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

{citytown}  {group}

{employeeName}

Benefit Review - {actionFor}

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

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.

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.

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".

Enrollment is automatic for Basic Term Life and AD&D paid 100% by your employer

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.

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.

**ERROR**

{citytown} bundles benefits so your coverage selections must be at the same level.

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.

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

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

This is a summary of the benefits you have elected.

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}

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.

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

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

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

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

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.

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

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

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.

Page 13 - Approval Page