2025 SSM Benefits Enrollment Form
(Employee benefits information collected via this form is kept confidential and can only be viewed by Human Resources.)
Name
*
First Name
Last Name
Email
*
Medical Insurance Election
*
Select from the Dropdown
Medical Coverage Waived
POS-HSA - Employee-Only Coverage
POS-HSA - Employee+Spouse Coverage
POS-HSA - Employee+Child Coverage
POS-HSA - Employee+Children Coverage
POS-HSA - Employee+Family Coverage
POS-HRA - Employee-Only Coverage
POS-HRA - Employee+Spouse Coverage
POS-HRA - Employee+Child Coverage
POS-HRA - Employee+Children Coverage
POS-HRA - Employee+Family Coverage
Vision Insurance Election
*
Select from the Dropdown
Vision Coverage Waived
Employee-Only Coverage
Employee+Spouse Coverage
Employee+Child Coverage
Employee+Children Coverage
Employee+Children Coverage
Employee+Family Coverage
Dental Insurance Election
*
Select from the Dropdown
Dental Coverage Waived
Employee-Only Coverage
Employee+Spouse Coverage
Employee+Child Coverage
Employee+Children Coverage
Employee+Family Coverage
Health Savings Account Annual Election Amount
Available ONLY if you enroll in the POS-HSA. Employee-Only Coverage: Enter a maximum value of 3800 (4800 if over age 55). Employee+Dependent Coverage: Enter a maximum value of 7550 (8550 if over age 55). Leave blank to waive enrollment.
Health Savings Account Bi-Weekly Deduction Amount
Healthcare Flexible Spending Account Annual Election Amount
Enter a value from 100 to 3300. Leave blank to waive enrollment.
Healthcare Flexible Spending Account Bi-Weekly Deduction Amount
Dependent Care Flexible Spending Account Annual Election Amount
Enter a value from 100 to 5000. Leave blank to waive enrollment.
Dependent Care Flexible Spending Account Bi-Weekly Deduction Amount
Estimated Total Benefit Cost
Note: The Estimated Total Benefit Cost does not include the cost of vacation buy/sell or supplemental life insurance benefits. Refer to your Personal Benefit Report for costs associated with these benefits.
Vacation Buy/Sell
Select from the Dropdown
Buy 1 Day
Buy 2 Days
Buy 3 Days
Buy 4 Days
Buy 5 Days
Sell 1 Day
Sell 2 Days
Sell 3 Days
Sell 4 Days
Sell 5 Days
Plan Provisions and Acknowledgement
HIPAA Special Enrollment Rights Notice If you are declining enrollment for yourself or your dependents (including your spouse) because you have other medical, dental, or vision insurance coverage, you may be able to enroll yourself or your dependents in these plans if you or your dependents lose eligibility for the other coverage, provided that you request enrollment within 30 days after the other coverage ends. In addition, if you gain a new dependent as the result of a marriage, birth, adoption, or placement for adoption, you may be able to enroll yourself or your dependents, provided that you request enrollment within 30 days after the marriage, birth, adoption, or placement for adoption. I understand that by signing and submitting this form I am making my benefits elections for the 2025 plan year (January 1, 2025 – December 31, 2025), and for subsequent plan years if I do not actively make an election during the next open enrollment period. I further understand that I may not be permitted to change my benefits elections until the next open enrollment period except in the case of a qualified life event. I authorize SSM to deduct from or credit to my pay amounts owed for the benefits I have elected for the 2025 plan year and for future plan years. Should my employment with SSM end, I authorize the deduction from my final pay for any outstanding amount representing the benefits I have received but for which I have not yet paid. I understand that if I enroll in the PPO-HSA I am not permitted to make contributions to the HSA if I am: a) covered under another medical plan that is not also a qualified high deductible health plan (QHDHP); or b) if I am enrolled in Medicare Part A and/or Medicare Part B. Finally, I understand the IRS "use it or lose it" regulations regarding certain benefits included in the Plan.
Submit
Should be Empty: