Change Form Logo

  • Page 1 - Opening Page - City/Town selection; Employee Name; Form Action

  • Employee Benefits Online Change Form

    This form is HIPAA compliant.  The data you enter will be stored confidentially and securely.

  •   You may experience a delay while the Benefits Administrator and Email fields populate.
  • The email address above will receive your request.
  • Image-1152

  • This option is for the Covered Person (see image above) who appears on the city/town's EB Invoice, and is making a benefit change. Use this option if:

    • You have no covered dependents and are dropping medical, dental, and/or vision coverage.
    • You are an active employee already enrolled in basic or voluntary life through MMIA and enrolling in medical, dental, and/or vision coverage due to a qualifying event (documentation of the event will be required).
    • You are reducing the enrollment level of at least one benefit, but leaving others the same (example: you are enrolled in full family coverage for medical, dental, and vision and change to full family medical, and participant-only dental and vision).

     

    Prior to completing this form, we recommend you confirm this is the correct option with your benefits administrator.

  • {citytown}  {group}

    {employeeName}

    Benefit Review - {actionFor}

  •  - -

  • This request has already been completed and the is record is locked.  If you believe it was approved or declined in error, please contact Nikki Willoughby for additional assistance.

  • Page 2 - Replace Card; Update Address

  • Employee Benefits Online Change Form

  • {action866} for {employeeretireeName3}, {citytown}

  • ***Replacement ID cards take up to 4 weeks to be received at the address above.***

  • Page 3 - Active to Retiree Status

     

  • Employee Benefits Online Change Form

  • {action866} for {employeeretireeName3}, {citytown}

  • Your basic life and AD&D coverage ends when you retire.  If basic dependent life is also offered, that benefit ends at retirement as well.

  • If you are enrolled in Voluntary Life (and/or Voluntary AD&D) the coverage ends for you and any covered dependent at retirement. 

  •  - -

  • Upon retirement from the {citytown}, you may elect to make changes to your benefits. 

    Retirees and/or covered spouses are not eligible to keep medical coverage once they turn 65.  Coverage automatically ends for the individual on the last day of the month in which they turn 65.  You may continue existing dental and/or vision coverage.

    *A retiree must meet minimum eligibility requirements, which are typically 5 years of service and at least 50 years of age.

     

  • Retirees over age 65 may not continue medical coverage through MMIA, but may elect to keep dental and/or vision if offered by the city through MMIA.  If the employee's spouse is currently participating in the medical plan, they will be allowed to continue coverage until they reach age 65.

    **The spouse of a retiree must complete a benefit enrollment form in order to continue medical coverage once the retiree's coverage ends upon reaching age 65**

     

    *A retiree must meet minimum eligibility requirements, which are typically 5 years of service and at least 50 years of age.

  • Retirees over age 65 may not continue medical coverage through MMIA.  If the employee's spouse is currently participating in the medical plan, they will be allowed to continue coverage until they reach age 65.

    **The spouse of a retiree must complete a benefit enrollment form in order to continue medical coverage once the retiree's coverage ends upon reaching age 65**

     

    *A retiree must meet minimum eligibility requirements, which are typically 5 years of service and at least 50 years of age.

  • Retirees under the age of 65 may continue medical coverage, but a covered dependent over age 65 cannot continue medical coverage through MMIA.  Regardless of age, retirees and their dependents may elect to keep dental and/or vision if offered by the city through MMIA.  

     

    *A retiree must meet minimum eligibility requirements, which are typically 5 years of service and at least 50 years of age.

  • Retirees under the age of 65 may continue medical coverage, but a covered dependent over age 65 cannot continue medical coverage through MMIA.

    *A retiree must meet minimum eligibility requirements, which are typically 5 years of service and at least 50 years of age.

  • Retirees and covered dependents over the age of 65 may not continue medical coverage.  Regardless of age, retirees and their dependents may elect to keep dental and/or vision if offered by the city through MMIA.  

    Your medical coverage will automatically terminate at the end of the month in which you retire.

     

    *A retiree must meet minimum eligibility requirements, which are typically 5 years of service and at least 50 years of age.

  • As a retiree, once you drop coverage, you may not re-enroll for that benefit.

  • Your spouse is over the age of 65, and is not eligible to continue medical coverage once you retire.  Please correct the selection above.

  • Medical Plan Choices:

    {formMedical}

  • *The custom medical plan is not available to you.*  Please select a medical plan from the list available to you from the Medical Plan Choices above.

  • Page 4 - Add/Drop Dependent

  • Employee Benefits Online Change Form

  • {action866} for {employeeretireeName3}, {citytown}

  • To include dependents due to marriage, adoption, loss of previous coverage, or court order, you will need to submit supporting documents (such as a marriage certificate, certificate of prior coverage, or court documents). If the information comes from your previous insurance provider, it must specify the date when the coverage ended. Please ensure you provide the necessary documentation to your Benefits Administrator for final approval of this request.

    When adding dependents, the coverage and any plan changes are effective on the qualifying event date.
  • Since the baby's mother is not covered by your MMIA Medical plan, a copy of the birth certificate is required to enroll the newborn.  Please provide a copy of the birth certificate to your Benefits Administrator for final approval of this request.
  • The qualifying event date is the date of marriage, the date of birth or adoption, the date of retirement, the date the judge signed the order, or the date the other coverage was lost. Please enter that date in the "Qualifying Event Date" field.
  •  - -
  • When removing a dependent child who is turning 26, their benefits will end the last day of the month in which they turn 26. They will be offered COBRA.
  • When removing a dependent, their benefits end on the last day of the month in which request was approved. 
  • If you are only dropping medical, dental and vision coverage for your dependent and need to keep the voluntary life coverage (if enrolled), please use the back button and select "Change - Primary particiapnt's benefit selections". 
  •  - -
  •  - -
  •  - -
  •  - -
  •  - -
  • Remove Dependent(s) from Benefits:

    This process removes the listed dependent from ALL coverages.  If you only need to remove the dependent from some of the coverages, please use the back button and select "Change - Primary participant's benefit selections".

  •  Enrollment is automatic for Basic Term Life and AD&D paid 100% by your employer
  • Basic Term Life and AD&D Volume
    {basicLife500}
  • Basic Dependent Term Life Volume
    {basicDependent501}

  • **OPTIONAL** To update your beneficiary form, please provide the completed and signed beneficiary form to your benefits administrator.  It will be submitted securely to MMIA when your change request is approved.

  • Page 5 - Dependents

  • Employee Benefits Online Change Form

  • {action866} for {employeeretireeName3}, {citytown}

  • If you don't have the baby's SSN yet, please enter 000-00-0000.  You will need to provide the child's information once you receive it.

  • Complete this page for any dependent you are adding to medical, dental, and/ or vision due to the qualifying event.  If enrolling your spouse, common-law spouse, or domestic partner add them as the first dependent.

  • Dependent 1
  •  - -
  • Domestic Partners are allowed on the plan as long as the completed affidavit is provided to your benefits administrator with this enrollment.  Click on this link to access the appropriate form. 
     
  • Common-Law spouses are allowed on the plan as long as the completed affidavit is provided to your benefits administrator with this enrollment.  Click on this link to access the appropriate form. 
  • Dependent 2
  •  - -
  • Dependent 3
  •  - -
  • Dependent 4
  •  - -
  • Dependent 5
  •  - -
  • Dependent 6
  •  - -
  • Dependent 7
  •  - -

  • Page 6 - Add/Remove Dependent Benefit Selections

  • {action866} for {employeeretireeName3}, {citytown}

  •  Available Benefits for the current plan year:
     

  • Employee Benefits Online Change Form

  • Medical Plan Choices:

    {formMedical}

  • *The custom medical plan is not available to you.*  Please select a medical plan from the list available to you from the Medical Plan Choices above.

  • Waiver of Medical/Prescription Coverage

    • I am waiving medical coverage for myself and any eligible dependent.
    • I understand that this waiver of coverage may affect the ability to obtain coverage at a later date.

  • Page 7 - Change Benefit Selections

  • Employee Benefits Online Change Form

  • {action866} for {employeeretireeName3}, {citytown}

    {whatIs}

  •  - -

  • Benefit changes are effective on the first day of the month.  If you select any other date, the change will be effective on the first day of the next month.

    If this change is to correct benefit selections for initial enrollment or due to a qualifying event, the effective date will be the same as the date of the qualifying event.

    You may not select a date more than 31 days in the past.

  •  Available Benefits for the current plan year:

  • Medical Plan Choices:

    {formMedical}

  • *The custom medical plan is not available to you.*  Please select a medical plan from the list available to you from the Medical Plan Options above.

  • Depending upon the qualifying event, you may not be eligible for a change to your medical plan. If you choose a medical plan that is different than your currently enrolled plan, and the change to the plan is not allowed, you will be contacted by your benefit administrator.

  • Waiver of Medical/Prescription Coverage

    • I am waiving medical coverage for myself and any eligible dependent.
    • I understand that this waiver of coverage may affect the ability to obtain coverage at a later date.
  •  Enrollment is automatic for Basic Term Life and AD&D paid 100% by your employer
  • Basic Term Life and AD&D Volume
    {basicLife500}
  • Basic Dependent Term Life Volume
    {basicDependent501}

  • You may wish to provide an updated beneficiary form to your benefits administrator.  It will be submitted securely to MMIA when your enrollment request is approved.

  •   Voluntary Term Life is offered and premiums are paid entirely by the employee.

  • Page 8 - Voluntary Life

  • Employee Benefits Online Change Form

  • {action866} for {employeeretireeName3}, {citytown}

  •  Voluntary Term Life & AD&D

    The {citytown} offers Voluntary Term Life and AD&D coverage.  The employee pays this benefit 100%.  Additional details on this coverage can be found in the Voluntary Term Life and AD&D Summary. 

    Coverage Amount: The maximum amount an employee can apply for is 5x their salary up to the maximum of $500,000. Employees may purchase benefits increments of $5,000. Spouses may receive coverage, up to 100% of the employee amount, not to exceed $500,000.

    Guaranteed Issue: Up to $350,000 for employees; $50,000 for spouses. Amounts over the Guaranteed Issue require a completed Evidence of Insurability (EOI) form. 

    Monthly Premium Rates per Thousand: Rates are age-banded for voluntary life and are shown below. AD&D rates are $0.05 per thousand for all ages. Volumes can be selected separately for voluntary life and AD&D coverage.

    Dependent Child Benefit: Employees can cover their child(ren) in increments of $1,000, a minimum of $2,000 up to a maximum of $10,000. The cost is the same for one child or multiple children. The rate is $0.12 per $1,000 of coverage and employee coverage is required.  AD&D coverage is not available for children. Eligible children must be less than 26 years of age.

     

    **If adding or changing this coverage you must complete the Voluntary Life Enrollment Form and provide it to your benefits administrator to be submitted to MMIA upon approval of this request.

     
     
  • Maximum Voluntary Life Volume available to you is {maximumLife}

  • Voluntary Spouse benefits are only available if the employee elects the same coverage at an equal or greater value.

  • Voluntary Dependent Life is available only to dependent children under the age 26.

  • You are requesting Voluntary Life coverage which requires an Evidence of Insurability form to be completed and provided to your benefits administrator.  Additional review by the underwriters is required before the coverage is approved.  You will be contacted if the request is declined or if more information is needed.

  • Page 9 - Summary of Benefit enrollment/changes

  • Employee Benefits Online Change Form

  • This is a summary of the benefits you have elected.

  • {action866} for {employeeretireeName3}, {citytown}

  • Add Dependent(s) - {addDependents}
             
    Name Relationship Date of Birth Gender Social Security Number
    {dependentName} {relationship} {dateOf} {gender529} {ssn}
    {dependentName533} {input532} {input534} {input535} {input536}
    {input539} {input538} {input540} {input541} {input542}
    {input545} {input544} {input546} {input547} {input548}
    {input551} {input550} {input552} {input553} {input554}
    {input557} {input556} {input558} {input559} {input560}
    {input563} {input562} {input564} {input565} {input566}
  • Drop Dependent(s) - {removeDependents}
    Dependents to remove from all coverages (medical/dental/vision/voluntary life):
    {enterThe}
    {removeDep} {lastDay}{dateDependent}{dateOf1092}{dateDivorce}{dateDependent1168}
    {removeDependent}
    {adddropChange}
     
  • Change Primary Participant's Benefits
    Effective Date of Change {effectiveDate}
    Benefit changes are effective on the first day of the month. If you select any other date, the change will be effective on the first day of the next month.
  • Active to Retiree Status
    Retirement Date {whatIs823}
    {changeBenefits1166}
     
    {age65}
    {basicLife1060}
    {volLife1061}
     
  •  Benefit Selections
     Medical Plan Medical Dental Vision
    {medPlan} {medCoverage} {dentalFor} {visionFor}
    {medWaiver}
  • City/Town-Paid Basic Term Life Insurance
    Employee's basic life coverage volume is {basicLife500}.  {basicDependent}
  • Employee-Paid Voluntary Term Life Insurance
    Voluntary Life Coverage: {changeVoluntary}
  •  Employee-Paid Voluntary Term Life Insurance
      Employee Spouse Dependent
    Voluntary Life {volLife761} {volSpouse763} {volDep771}
    Voluntary AD&D {volAdampd} {volSpouse764} Not Available

  • Page 10 - Signature Page

  • Employee Benefits Online Change Form

  • {action866} for {employeeretireeName3}, {citytown}

  • Participant Authorization
    I hereby request coverage for myself and my dependent(s) listed on this enrollment application who are currently enrolled or may become eligible for coverage under the plan agreement purchased by the Montana Municipal Interlocal Authority (MMIA). I agree that my dependents and I will comply with the following:
    ~ That we will be bound by the terms and conditions of the Group Agreement, as it may be amended;
    ~ That all providers that have rendered services to me and my dependents are authorized to make medical information and records regarding such services available to the Plan and their providers who, in turn, may share such records among themselves; and,
    ~ That I shall assist the Plan in the completion and submission of consents, releases, assignments, and any other documents related to the protection of the Plan’s rights under the Group Agreement including, but not limited to, the coordination of benefits with other health benefit plans, insurance policies or Medicare.
    I understand that I am responsible for notifying the Plan within 31 days of any changes in my or my dependent(s)’ eligibility status, such as change of address, birth, adoption of a child, marriage, divorce, termination, or additional coverages.

  • Statement of HIPAA Portability Rights

    IMPORTANT – KEEP THIS CERTIFICATE. This certificate is evidence of your coverage under this plan. Under a federal law known as HIPAA, you may need evidence of your coverage to help you get special enrollment in another plan or to get certain types of individual health coverage.
    Right to get special enrollment in another plan. Under HIPAA, if you lose your group health plan coverage, you may be able to get into another group health plan for which you are eligible (such as a spouse's plan), even if the plan generally does not accept late enrollees if you request enrollment within 30 days. (Additional special enrollment rights are triggered by marriage, birth, adoption, and placement for adoption.)
      -Therefore, once your coverage ends, if you are eligible for coverage in another plan (such as a spouse's plan), you should request special enrollment as soon as possible.
    Prohibition against discrimination based on a health factor. Under HIPAA, a group health plan may not keep you (or your dependents) out of the plan based on anything related to your health. Also, a group health plan may not charge you (or your dependents) more for coverage, based on health, than the amount charged a similarly situated individual.
    State flexibility. This certificate describes minimum HIPAA protections under federal law. States may require insurers and HMOs to provide additional protections to individuals in that state.
    For more information. If you have questions about your HIPAA rights, you may contact your state insurance department or the U.S. Department of Labor, Employee Benefits Security Administration (EBSA) toll-free at 1-866-444-3272 (for free HIPAA publications ask for publications concerning changes in health care laws). You may also contact the CMS publication hotline at 1-800-633-4227 (ask for “Protecting Your Health Insurance Coverage”). These publications and other useful information are also available on the Internet at: http://www.dol.gov/ebsa, the DOL's interactive web pages - Health Elaws

     

  •  - -

  • By selecting "No" above your request will not be processed. Please reach out to the benefits contact for {citytown} to answer any questions or address any concerns you have.

  • Employee Benefits Online Change Form

  • Please click on the "Submit Request" button below. 

    This will complete your portion of the process.

    Fill Again
     
    Edit Submission
     
     
    •  
      Open Enrollment Address Update - {group}/{name}.pdf
      Download PDF
       
    •  
      Open Enrollment Change - {name}.pdf
      Download PDF
       
    •  
      Open Enrollment Summary - {name}.pdf
      Download PDF
       
    •  
      Open Enrollment Medical Waiver - {name}.pdf
      Download PDF
       
    •  
      Open Enrollment Change - {group}/{name}.pdf
      Download PDF
       

  • You may wish to submit an updated Beneficiary Form. Please provide the completed form to your benefits administrator.

    Fill Again
     
    Edit Submission
     
     
    •  
      Open Enrollment Address Update - {group}/{name}.pdf
      Download PDF
       
    •  
      Open Enrollment Change - {name}.pdf
      Download PDF
       
    •  
      Open Enrollment Summary - {name}.pdf
      Download PDF
       
    •  
      Open Enrollment Medical Waiver - {name}.pdf
      Download PDF
       
    •  
      Open Enrollment Change - {group}/{name}.pdf
      Download PDF
       

  • Your request requires a Domestic Partnership Affidavit.  Please provide the completed form to your benefits administrator.

    Fill Again
     
    Edit Submission
     
     
    •  
      Open Enrollment Address Update - {group}/{name}.pdf
      Download PDF
       
    •  
      Open Enrollment Change - {name}.pdf
      Download PDF
       
    •  
      Open Enrollment Summary - {name}.pdf
      Download PDF
       
    •  
      Open Enrollment Medical Waiver - {name}.pdf
      Download PDF
       
    •  
      Open Enrollment Change - {group}/{name}.pdf
      Download PDF
       

  • Your request requires a Common Law Affidavit.  Please provide the completed form to your benefits administrator.

    Fill Again
     
    Edit Submission
     
     
    •  
      Open Enrollment Address Update - {group}/{name}.pdf
      Download PDF
       
    •  
      Open Enrollment Change - {name}.pdf
      Download PDF
       
    •  
      Open Enrollment Summary - {name}.pdf
      Download PDF
       
    •  
      Open Enrollment Medical Waiver - {name}.pdf
      Download PDF
       
    •  
      Open Enrollment Change - {group}/{name}.pdf
      Download PDF
       

  • Your request requires a Voluntary Life Form.  Please provide the completed form to your benefits administrator.

    Fill Again
     
    Edit Submission
     
     
    •  
      Open Enrollment Address Update - {group}/{name}.pdf
      Download PDF
       
    •  
      Open Enrollment Change - {name}.pdf
      Download PDF
       
    •  
      Open Enrollment Summary - {name}.pdf
      Download PDF
       
    •  
      Open Enrollment Medical Waiver - {name}.pdf
      Download PDF
       
    •  
      Open Enrollment Change - {group}/{name}.pdf
      Download PDF
       

  • Your request requires an Evidence of Insurability Form.  Please provide the completed form to your benefits administrator.

    Fill Again
     
    Edit Submission
     
     
    •  
      Open Enrollment Address Update - {group}/{name}.pdf
      Download PDF
       
    •  
      Open Enrollment Change - {name}.pdf
      Download PDF
       
    •  
      Open Enrollment Summary - {name}.pdf
      Download PDF
       
    •  
      Open Enrollment Medical Waiver - {name}.pdf
      Download PDF
       
    •  
      Open Enrollment Change - {group}/{name}.pdf
      Download PDF
       

  • Your request requires a copy of the marriage license.  Please provide this document to your benefits administrator.

    Fill Again
     
    Edit Submission
     
     
    •  
      Open Enrollment Address Update - {group}/{name}.pdf
      Download PDF
       
    •  
      Open Enrollment Change - {name}.pdf
      Download PDF
       
    •  
      Open Enrollment Summary - {name}.pdf
      Download PDF
       
    •  
      Open Enrollment Medical Waiver - {name}.pdf
      Download PDF
       
    •  
      Open Enrollment Change - {group}/{name}.pdf
      Download PDF
       

  • Your request requires a copy of the birth certificate since the baby's mother is not participating in the medical coverage.  Please provide this document to your benefits administrator.

    Fill Again
     
    Edit Submission
     
     
    •  
      Open Enrollment Address Update - {group}/{name}.pdf
      Download PDF
       
    •  
      Open Enrollment Change - {name}.pdf
      Download PDF
       
    •  
      Open Enrollment Summary - {name}.pdf
      Download PDF
       
    •  
      Open Enrollment Medical Waiver - {name}.pdf
      Download PDF
       
    •  
      Open Enrollment Change - {group}/{name}.pdf
      Download PDF
       

  • Your request requires a copy of the court-ordered medical support document.  Please provide this document to your benefits administrator.

    Fill Again
     
    Edit Submission
     
     
    •  
      Open Enrollment Address Update - {group}/{name}.pdf
      Download PDF
       
    •  
      Open Enrollment Change - {name}.pdf
      Download PDF
       
    •  
      Open Enrollment Summary - {name}.pdf
      Download PDF
       
    •  
      Open Enrollment Medical Waiver - {name}.pdf
      Download PDF
       
    •  
      Open Enrollment Change - {group}/{name}.pdf
      Download PDF
       

  • Your request requires a copy of the adoption record.  Please provide this document to your benefits administrator.

    Fill Again
     
    Edit Submission
     
     
    •  
      Open Enrollment Address Update - {group}/{name}.pdf
      Download PDF
       
    •  
      Open Enrollment Change - {name}.pdf
      Download PDF
       
    •  
      Open Enrollment Summary - {name}.pdf
      Download PDF
       
    •  
      Open Enrollment Medical Waiver - {name}.pdf
      Download PDF
       
    •  
      Open Enrollment Change - {group}/{name}.pdf
      Download PDF
       

  • Your request requires a certificate of prior coverage listing the individuals covered and the date the coverage ended.  Please provide this document to your benefits administrator.

    Fill Again
     
    Edit Submission
     
     
    •  
      Open Enrollment Address Update - {group}/{name}.pdf
      Download PDF
       
    •  
      Open Enrollment Change - {name}.pdf
      Download PDF
       
    •  
      Open Enrollment Summary - {name}.pdf
      Download PDF
       
    •  
      Open Enrollment Medical Waiver - {name}.pdf
      Download PDF
       
    •  
      Open Enrollment Change - {group}/{name}.pdf
      Download PDF
       

  •  

    Your request contains errors.  Please contact your benefit administrator for additional information or instructions on how to complete your request.  Clicking the button below will reset the page

  • Page 13 - Approval Page

  • {citytown}  {group}

    {employeeName}

    Benefit Review - {actionFor}

  • Browse Files
    Cancelof
  • Browse Files
    Cancelof
  • Browse Files
    Cancelof
  • Browse Files
    Cancelof
  • Browse Files
    Cancelof
  • Browse Files
    Cancelof
  • Browse Files
    Cancelof

  • Page 14 - ID Request/Personal Info Update Approval Page

  • Please click on the "Submit Request" button below. 

    This will complete your portion of the process.

    Fill Again
     
    Edit Submission
     
     
    •  
      Open Enrollment Address Update - {group}/{name}.pdf
      Download PDF
       
    •  
      Open Enrollment Change - {name}.pdf
      Download PDF
       
    •  
      Open Enrollment Summary - {name}.pdf
      Download PDF
       
    •  
      Open Enrollment Medical Waiver - {name}.pdf
      Download PDF
       
    •  
      Open Enrollment Change - {group}/{name}.pdf
      Download PDF
       

  • All of these fields are hidden from view on the form - they are used to fill, calculate, or perform some other function "behind the scenes" of the actual form

  • Page 1 - Opening Page - City/Town selection; Employee Name; Form Action

  • Page 3 - Active to Retiree

  • Page 4 - Add/Drop

  • Page 5 - Dependents

  • Page 6 - Benefit Selections

  • Page 7 - Voluntary Life

  • Should be Empty: