TML IEBP Paperwork Overview

Transcription

Wednesday, March 27, 2013
2:00 PM
How to Complete TML IEBP Paperwork
Please join us for an important review of enrollment, changes, and new hire
forms and paperwork. We will discuss the most common errors and
highlight required information.
Employee Healthcare
BENEFIT REMINDER
TML Intergovernmental Employee Benefits Pool (TML IEBP) would
like to encourage you to become familiar with your health care benefit
program. To assist you in this process, here are a few helpful tips:
* All new hires and their dependents covered under the TML IEBP
benefit plan must complete the enrollment paperwork and
submit it to their Employer for approval. The Employer will then
forward the enrollment information to TML IEBP.
* The completed and approved Enrollment Form must be received
at TML IEBP within 31 days of the date of hire. Please contact us
to ensure your eligibility paperwork has been received.
(800) 348-7879
Ask for the Billing & Eligibility Representative for your Employer
Visit our website at www.tmliebp.org
Sign up for a user name and password to log in to myTML IEBP
Take charge of your health with TML IEBP
1 8 2 1
R U T H E R F O R D L A N E , S U I T E
A U S T I N , T E X A S 7 8 7 5 4
3 0 0
PO Box 140167
Austin, Texas
78714-0167
Fax: (512) 719-6565
MEDICAL ENROLLMENT
EMPLOYEE BENEFITS ENROLLMENT RECORD
Employer
MEDICAL
MEDICAL ENROLLMENT FORM
Unique Identification #/Social Security #
Last Name
First Name
MI
Male
Single
Active
Date of Hire
Birth Date
Female
Married
Retired
Hours per week normally worked
Job Title
Covered by Employer’s Prior Carrier?
Yes or
EMPLOYEE COVERAGE INFORMATION
Employee Mailing Address
No
Coverage Effective Date
Prior Effective Date
Medical
Dental
Vision
Alternate Plan
Street
State
City
Zip Code
DEPENDENT/SPOUSE COVERAGE INFORMATION
E-mail
Relation to Employee Code: s = spouse; nc = natural child; ac = adopted child;
sc = step child; fc = foster child; gc = grandchild; lg = legal guardian/conservator;
co = court ordered health coverage
 Only the dependents listed below will have the coverage selected.
 The term dependent will not include any person who is eligible for
coverage as an employee. Children may be covered under only one
Employee’s plan.
Select
Coverage
Last Name
First Name
MI
Medical
Dental
Vision
Medical
Dental
Vision
Medical
Dental
Vision
Phone
Sex
Birth Date
Social
Security #
Lives with
Employee
Who is legally obligated to
carry dependent coverage
Relation
Code
Yes
No
Yes
No
Yes
No
1. Are you, your spouse or your children who are covered under a TML IEBP health plan also covered under another medical, dental or vision plan?
2. Are the above covered dependents required by court order or decree to be covered under another medical, dental or vision plan?
Yes
Yes
No
No
If yes, please submit legal document.
I hereby request the coverage indicated, provided that I am or become eligible,
and certify that the above information is correct.
Employer Accepted
Notes
By
Date
Employee Signature
Date
I hereby decline any medical, dental, or vision coverage through the TML
Intergovernmental Employee Benefits Pool for my dependents or myself effective as
of the date of my signature below. I acknowledge that if I make any future
application for coverage for my dependents or myself through my current employer,
then all persons enrolled at that future time shall be considered as late entrants and
their coverage shall be subject to limitations for pre-existing conditions. I affirm that
neither my employer nor any other entity has offered any financial or other
incentive in consideration for my declination of this coverage.
Legal/Business - Declination is due to:
 Employer pays less than 75% of employee medical rates
 Employer offers an HMO plan and 80% of Pool participation requirement is met
 Employee is accessing spouse’s plan and has submitted plan name, contact person &
employer of plan information.
 An employee who is accessing a parental healthcare plan to the attained age of twentysix will not be required to obtain TML IEBP benefits to meet the 100% participation
requirement.
 TriCare/Champus Coverage
 Retiree Benefits from prior employment
Employee Signature
Plan Name
Date
Employer
Forms Guide
(Rev 8-3-12)
Contact Person
______
Page 5 of 47
Standard Insurance Company
Enrollment and Change Form
APPLICANT
Mark all boxes and complete all sections that apply. Return completed form to your Human Resources Department.
Your Name (Last, First, Middle)
Group Name
Your Address
City
Your Soc. Sec. No.
Employer Name
Group Number(s)
State
Date of Birth
Male
Female
Zip
Job Title/Occupation
LIFE
Check with your Human Resources Department about coverage options available to you and Evidence of Insurability requirements.
Life Insurance
Life with AD&D Employer Paid
Additional/Optional Life with AD&D (actives)
You may choose one from the following plan options.
½ Times Annual Salary
1 Times Annual Salary
1 ½ Times Annual Salary
2 ½ Times Annual Salary
Dependents Life Insurance
Dependents Life Insurance
Voluntary AD&D Insurance
You may choose one from the following plan options.
Employee Only
Employee and Family Your requested amount $
RETIREE LIFE
Check with your Human Resources Department about coverage options available to you and Evidence of Insurability requirements.
Retiree Life Insurance
Retiree Life ($2,000)
Retiree Additional Life Insurance
Retiree Additional Life
$
(maximum of $10,000)
Retiree Dependents Life Insurance
Retiree Dependents Life Insurance
Address
Soc. Sec. No
Relationship
% of Benefit
Contingent – Full Name
Address
Soc. Sec. No
Relationship
% of Benefit
CHANGE
Primary – Full Name
Use this section only when you wish to make a change after insurance becomes effective. Complete all boxes and sections that apply.
SIGNATURE
BENEFICIARY
This designation applies to Life/Life with AD&D Insurance available through your Employer, if any. Designations are not valid unless signed,
dated and delivered to the Employer during your lifetime. See page 2 for further information.
I wish to make the choices indicated on this form. If electing coverage, I authorize deductions from my wages to cover my contribution, if
required, toward the cost of insurance. I understand that my deduction amount will change if my coverage or costs change.
Add Dependent
Delete Dependent
Date of add/delete
Member/Employee Signature Required
Name Change
Former name
Beneficiary Change
Other
Date (Mo/Day/Yr)
Human Resources Department – Complete this section. Retain form for your records and send a copy to TML IEBP, PO Box
140167, Austin, TX 78714-0167
Employer Accepted
Date of Hire/Rehire Hrs. Worked Per Wk
Earnings $
Per:
Yr
Initials:
Date:
Life Enrollment & Change Form
(PY 11-12)
1 | Page
PO Box 140167
Austin, Texas
78714-0167
Fax: (512) 719-6565
Employer
MEDICAL CHANGE-TERM FORM
Last Name
PLEASE MARK CHANGE DESIRED
First Name
Yes
No
MI
Add Coverage Indicated Below
(former name)
Name Change
Medicare Eligible
MEDICAL REQUEST FOR CHANGE-TERM
EMPLOYEE BENEFITS ENROLLMENT RECORD
Address Change
If Yes, Medicare (HIC) Number
Employee Mailing Address
Coverage Effective Date
Drop Coverage Indicated Below
Retired
Date of Retirement
Medicare Effective Date
Street
State
City
Zip Code
DEPENDENT/SPOUSE COVERAGE INFORMATION
E-mail
Relation to Employee Code: s = spouse; nc = natural child; ac = adopted child;
sc = step child; fc = foster child; gc = grandchild; lg = legal guardian/conservator;
co = court ordered health coverage
 Only the dependents listed below will have the coverage selected.
 The term dependent will not include any person who is eligible for
coverage as an employee. Children may be covered under only one
Employee’s plan.
Select
Coverage
Last Name
First Name
MI
Medical
Dental
Vision
Medical
Dental
Vision
Medical
Dental
Vision
Phone
Sex
Birth Date
Social
Security #
Lives with
Employee
Who is legally obligated to
carry dependent coverage
Relation
Code
Yes
No
Yes
No
Yes
No
1. Are you, your spouse or your children who are covered under a TML IEBP health plan also covered under another medical, dental or vision plan?
2. Are the above covered dependents required by court order or decree to be covered under another medical, dental or vision plan?
Yes
Yes
No
No
If yes, please submit legal document.
I hereby request the coverage indicated, provided that I am or become eligible,
and certify that the above information is correct.
Employee Signature
Date
Employer Accepted
By
Date
Reason for Add or Change
Notes
I hereby decline any medical, dental, or vision coverage through the TML
Intergovernmental Employee Benefits Pool for my dependents or myself effective as
of the date of my signature below. I acknowledge that if I make any future
application for coverage for my dependents or myself through my current employer,
then all persons enrolled at that future time shall be considered as late entrants and
their coverage shall be subject to limitations for pre-existing conditions. I affirm that
neither my employer nor any other entity has offered any financial or other
incentive in consideration for my declination of this coverage.
Legal/Business - Declination is due to:
 Employer pays less than 75% of employee medical rates
 Employer offers an HMO plan and 80% of Pool participation requirement is met
 Employee is accessing spouse’s plan and has submitted plan name, contact person &
employer of plan information.
 An employee who is accessing a parental healthcare plan to the attained age of twentysix will not be required to obtain TML IEBP benefits to meet the 100% participation
requirement.
 TriCare/Champus Coverage
 Retiree Benefits from prior employment
Employee Signature
Plan Name
Date
Employer
Forms Guide
(Rev 8-3-12)
Contact Person
______
Page 6 of 47
Comprehensive Eligibility
Tip Sheet
Managing the Integrity of the Healthcare Dollar
Please note, effective January 1, 2013, new hires will be required to provide documentation to support dependent eligibility enrollment criteria within thirty-one (31) days
from their hire date. Dependents will not be enrolled until documentation is provided. If the documentation is not received within the thirty one (31) days of hire,
enrollment will not occur until the next open enrollment or special enrollment period occurs. Effective September 1, 2013 and plan year’s thereafter, TML IEBP will require
the appropriate documentation on all active, Continuation of Coverage, pre sixty-five and post sixty-five plan participants and their dependents.
Dependent Documentation Requirements for Benefits Enrollment, Change, and Termination Adding
Dependent Coverage -- A Social Security Number is required for all dependents covered under the
group medical, dental &/or vision plan.
Type of Dependent
Spouse
Natural Child - to attained age 26
Step Child - to attained age 26
Adopted Child - to attained age 26
Foster Child - to attained age 26
Other Child - to attained age 26
Grandchild - to attained age 26
Incapacitated Child
Qualifying Event
Divorce - Drop spouse and their
child(ren)
Court Ordered Coverage/Benefits Add Dependent Child(ren)
Court Order Expires - Drop
Dependent Child(ren)
Ineligibility under Medicaid or SCHIP
Supporting Documentation (copies acceptable)
Marriage License, Certificate of Informal Marriage (issued by
county clerk's office), or Joint Tax Return
Birth Certificate
Birth Certificate and Divorce Decree (signed by Judge), Custodial
Orders (signed by Judge), or Attorney General (AG) Order PLUS
Marriage License, Certificate of Informal Marriage (issued by
county clerk's office), or Joint Tax Return indicating the
Employee is married to the child(ren) parent.
Birth Certificate and Court Issued Adoption Documents
Birth Certificate and Court Issued Foster Documents
Birth Certificate and Legal Guardianship/Conservatorship
Documents (signed by Judge)
Birth Certificate, Tax Records, and Legal
Guardianship/Conservatorship Documents (signed by Judge)
Birth Certificate and Social Security Disability Document
Divorce Decree (finalized, signed by Judge)
Birth Certificate and Divorce Decree (signed by Judge), Custodial
Orders (signed by Judge), or Attorney General Order
Attorney General Order (if an AG order is on file with TML IEBP
we must have a new order from AG office indicating child(ren)
may be dropped), Divorce Decree (signed by Judge), or
Custodial Orders (signed by Judge)
Copy of ineligibility letter with effective date from Medicaid or
TML Intergovernmental Employee Benefits Pool
www.tmliebp.org
Qualifying Event
- Add Dependent Child(ren)
Eligibility for Medicaid - Drop Spouse
&/or Dependent Child(ren)
Eligibility for Medicare - Drop Spouse
Eligibility for Other Coverage - Drop
Dependent Spouse &/or Child(ren)
Spouse Job Status Change - full time
to part time, unpaid leave of
absence, termination of
employment, significant change
(10% or more) in the benefit
coverage of your spouse's health
plan - Add Spouse & Dependent
Child(ren)
SCHIP, PLUS appropriate dependent child documentation listed
above
Copy of eligibility letter with effective date from Medicaid
Copy of eligibility letter (or Medicare Card) with effective date
from Medicare
Letter from Other Health Plan verifying enrollment
Documentation from their employer of the change with
effective date PLUS Marriage License, Certificate of Informal
Marriage (issued by county clerk's office), or Joint Tax Return
and appropriate child documentation listed above
Documentation Time Limits (If the documentation is not received within the below time limits
enrollment will not occur until the next open enrollment or special enrollment period occurs)
Event
New Hire
Initial Enrollment - New Group
Annual Open Enrollment - Based on
Group Anniversary
Qualifying Event
Deadline for Documentation
within 31 days of Date of Hire
within 31 days of the New Groups Effective Date
within 31 days of New Plan Year Effective Date
within 31 days of the Qualifying Event
(1.22.13)
OTHER INSURANCE/OTHER COVERAGE
INQUIRY FORM
OTHER INSURANCE/OTHER COVERAGE INQUIRY FORM
ENGLISH
This form is located on your Employer Custom Website under Online Forms.
In order to process your health claims, TML Intergovernmental Employee Benefits Pool (TML IEBP) requires information regarding
other health coverage. Health coverage includes Medical, Prescription, Dental and/or Vision coverage. Please promptly complete
and return this form to the address below to avoid delays in claim adjudication or provider prompt pay penalties.
FAILURE TO PROVIDE THIS INFORMATION
WILL RESULT IN CLAIM PROCESSING DELAYS
Mail to:
PO Box 149190
Austin, TX 78714-9190
Fax to:
Fax: (512) 719-6539
Online at: www.tmliebp.org/survey
For questions or assistance with this form call:
Customer Service: (800) 282-5385
If you have already completed or submitted this form to TML IEBP, please contact Customer Service for verification that your
completed form has been received before you resend.
Employee Name:
Member ID:
Employer Name:
Group #:
1.
Do you, your spouse or your dependents that are covered under your plan also have coverage through another medical,
Yes
No
prescription, dental or vision plan (currently or within the last 12 months)?
2.
Do you, your spouse or your dependents expect to be covered under an additional medical, prescription, dental or vision plan
during the next 12 months (i.e: resulting from a change in work status, marital status, open enrollment or Medicare
Yes
No
eligibility)?
If you have answered no to both questions, please sign the form and return it to the address indicated.
If you have answered Yes to either question #1 or #2, please complete the following information regarding the other plan coverage
(include details regarding all other plans on an additional form, if needed).
Effective date of other coverage:
Other coverage plan name:
Other coverage plan address:
Other coverage plan phone
number:
Other coverage plan number:
Other coverage benefit subscriber
name:
ID number:
date of birth:
relationship to TML IEBP covered
individual:
Termination date of other
coverage, (if applicable):
Forms Guide
(Rev 8-3-12)
Page 41 of 47
OTHER INSURANCE/OTHER COVERAGE
INQUIRY FORM
List everyone, (including yourself) covered under the other plan that is also covered under your employer plan:
Name
Types of Coverage*
Effective Date
Termination Date
*Types of Coverage: Medical, Prescription, Dental, Vision
Other Coverage Plan Details
Type of Plan
Type of Plan (continued)
Employer plan
PPO
HMO
High Deductible Health Plan with Health Savings Account (H.S.A.)
Health Reimbursement Plan/HRA (General Purpose)
Health Reimbursement Plan/HRA (Post Deductible - limited)
Section 125 Plan
Other _________________________________________
3.
Medicare
Medicaid
SCHIP
Individual plan
Are any of your dependents covered under more than one medical, prescription, dental or vision plan belonging to parents or
Yes
No
legal guardians who are divorced, separated or no longer living together?
If yes, list the dependents and answer question #4:
4.
Do any court documents exist that pertain to the parental responsibilities of your covered dependents?
Yes
No (if yes, please submit a copy of the entire court document if not previously submitted.)
I hereby certify that the above information is correct.
Employee Signature
Date
PLEASE NOTE: YOU WILL NEED TO COMPLETE A NEW “OTHER COVERAGE INQUIRY” FORM EACH TIME YOU OR YOUR
DEPENDENTS HAVE A CHANGE IN HEALTH BENEFIT COVERAGE.
Forms Guide
(Rev 8-3-12)
Page 42 of 47
Health Information Authorization Form
This form is located under the “Forms and Publications” section under Patient Protection/Privacy of Health Information.
Esta forma de autorización esta disponible en español. Llame al (800) 385-9952 o visite nuestra pagina de internet en www.tmliebp.org para
obtener la copia en español.
You must complete Sections 1, 2, and 8. If you leave a section blank, TML IEBP cannot accept your Authorization Form.
Your Information
Covered Employee Information
Your Name:
Covered Employee’s Name:
Date of Birth:
Employer’s Name:
Address:
Subscriber ID #:
Group #:
Daytime Phone #:
I authorize TML IEBP to release or disclose my personal health information as described below:
1)
Who do you want to access, get or receive your personal health information? (include name, address and/or phone number) For
example, if you want your husband or wife to have access to your personal health information, write his or her name here.
_________________________________________________________________________________________________________________
ONLINE ACCESS: If you want the person listed above to have online access to your claims information, he/she must be covered under a
TML IEBP health plan, have his/her own myTML IEBP online account, AND YOU MUST PROVIDE HIS/HER SUBSCRIBER ID #.
_________________________________________________________________________________________________________________
2)
What information do you want TML IEBP to release, give out or share? For example, you may want TML IEBP to give out all of your health
information or you may want us to give out information only about one date of service.
All my health information (as allowed by law)
Other (please specify): ____________________________________
3)
Purpose of Disclosure: Unless another purpose is listed here, this authorization is made at my request. ____________________________
4)
Expiration: Unless an earlier expiration date or expiration event is specified here, this authorization expires three years from the date this
authorization is signed. _____________________________________________________________________________________________
Federal law requires that your authorization include the following information on your rights under the Privacy Rule. Please read carefully.
5)
You may revoke or withdraw this authorization at any time by sending a letter to TML IEBP’s Privacy & Security Officer at the address
below. The withdrawal does not take effect until after TML IEBP receives and logs it and does not affect information released by TML IEBP
before logging your withdrawal.
6)
If you allow the release of your health information to a person other than a health plan or healthcare provider, that person may give your
information to someone else without your permission.
7)
TML IEBP cannot make you sign this authorization as a requirement for enrolling in the health plan or for benefits eligibility.
8)
Your Signature and Date. I approve the use and sharing of my health information as described in this authorization.
Your Signature: ________________________________________________
Date: ______________________________________
Please note that in the event of your death, this authorization will no longer be in effect. Only executors or court-appointed administrators
have authority to receive the personal health information of deceased individuals.
IF SOMEONE OTHER THAN THE COVERED INDIVIDUAL SIGNS THIS FORM, SECTION 9 MUST BE COMPLETED.
9)
Personal Representative Information. If you sign this form for someone else, you must tell us about your legal right to sign. For example,
if you sign for your son or daughter who is less than 18 years old, write “Parent of the minor child.” If you have a medical power of
attorney that allows you to make medical decisions for the individual, write “Medical power of attorney.” TML IEBP may require you to
send in legal papers that prove you have the right to sign for the individual. ___________________________________________________
_________________________________________________________________________________________________________________
Please mail your completed and signed form to:
www.tmliebp.org
TML IEBP
1821 Rutherford Lane, Suite 300
Austin, TX 78754-5151
Or FAX to: (512) 719-6539
Page 1
Health Information Authorization Form | (Rev 1.1.13)
Why Do I Need an Authorization Form?
This page answers commonly asked questions about the federal Privacy Rule, and lets you know when TML IEBP will need an
authorization form. If you have questions that are not answered here, call TML IEBP at (800) 282-5385.
Q: WHAT IS THE PRIVACY RULE?
A: The Privacy Rule is a federal law. It affects how TML IEBP, other health plans, healthcare providers and healthcare
clearinghouses (businesses that process health information) handle your health information.
TML IEBP’s Notice of Privacy Practices explains how the Privacy Rule affects you and your covered dependents. The Notice of
Privacy Practices is included in your enrollment information packet. The Privacy Rule is regulated by the U.S. Department of
Health and Human Services’ Office of Civil Rights. The Office of Civil Rights also has information on how the Privacy Rule affects
you available on their website at www.hhs.gov/ocr/hipaa.
Q: WHEN DO I NEED TO COMPLETE AN AUTHORIZATION FORM?
A: Generally, TML IEBP does not need an authorization to share information with other health plans or healthcare providers who
are subject to the Privacy Rule. However, you may want TML IEBP to disclose information to someone not subject to the Privacy
Rule. The following are some common examples of when you would need an authorization:
•
To Disclose Information to a Family Member: If you or a covered dependent is 18 years of age or older, TML IEBP cannot
disclose information on your claims, medical management, etc. to a family member. If you usually have a family member
handle your health claims or if you are used to handling the claims for all of your family, each covered individual who is 18
years of age or older will need to sign an authorization that specifies the family member(s) who may access information
held by TML IEBP.
•
To Disclose Information to a Patient Advocate: If you want someone to follow up on a claim for you or for a family
member (for example, someone in your employer’s benefit department), TML IEBP must have an authorization to release
information to your advocate. If the claim is on a family member and that family member is 18 years of age or older, the
family member must sign his or her own authorization.
•
For TML IEBP to Get Information: Sometimes TML IEBP needs additional information from a healthcare provider or
another person or organization before TML IEBP can make a decision on the benefits that are available to you. The Privacy
Rule allows healthcare providers and other organizations to release information to TML IEBP when TML IEBP needs the
information to make a payment decision. However, in some cases, a healthcare provider may have its own privacy policies
that are stricter than the Privacy Rule and require an authorization from the patient before releasing information to TML
IEBP. If this is the case, TML IEBP will notify you or your covered dependent of the need for an authorization.
Q: WHERE CAN I GET A BLANK AUTHORIZATION FORM?
A: A blank authorization is included in your enrollment information packet. You may make as many copies as you need. Also, the
authorization form is available online through myTML IEBP under Forms & Publications at www.tmliebp.org.
Q: WHAT IF I AM DISABLED AND UNABLE TO SIGN AN AUTHORIZATION?
A: If you become disabled and do not have an authorization on file or your authorization expired, TML IEBP will not release any
information to a family member unless they have legal authority to make healthcare decisions on your behalf. A spouse does not
have automatic authority to make healthcare decisions for you if you become disabled. As part of your disability planning, you
may want to consult an attorney about a Medical Power of Attorney. A Medical Power of Attorney allows you to specify a person
to make healthcare decisions for you in the event that you are disabled and unable to make decisions for yourself. A Medical
Power of Attorney is not valid until a physician certifies that you are not able to make your own healthcare decisions. Additional
information on a Medical Power of Attorney and the Texas statutory form is available through myTML IEBP under Forms &
Publications at www.tmliebp.org.
www.tmliebp.org
Page 2
CONTINUATION OF COVERAGE
QUALIFYING EVENT FORM
COC QUALIFYING EVENT FORM
TML IEBP Admin COC
Instructions for Benefit Administrator
Please complete the form below and fax to your Member Service Representative at (512) 719-6565.
* Important:
This notice must be sent to your Member Service Representative within one business day of a qualifying
event via fax. Please mail the original to: TML Intergovernmental Employee Benefits Pool
P.O. Box 140167, Austin, Texas 78714-0167
MEMBER INFORMATION
Group Name
____________________________________________
Contact _____________________________________________
Date
________________________
Phone
________________________
EMPLOYEE INFORMATION
Employee Name ____________________________________________
Employee ID/Social Security # ____________________
NOTICE INFORMATION
Please send a Continuation of Coverage notice to:
Employee
Dependent
Name
Address
City, State, Zip
Date of Qualifying Event
QUALIFYING EVENT - PLEASE CHECK ONE:
Termination
Death of EE
Divorce
*Retiree with no Retiree Coverage
Reduction in Hours
Dependent no longer eligible
Employee Medicare entitlement
Employee called to Active Duty
* If you do not have Retiree coverage - coverage will be terminated.
* If you have Retiree coverage - you need to submit a “Request for Change” form.
NON QUALIFYING EVENT INFORMATION
If the individual was terminated due to gross misconduct, the termination is not a qualifying event. Please inform TML IEBP that
termination was due to gross misconduct by checking this box.
FAMILY MEMBERS COVERED - PLEASE CHECK ONE:
Spouse
Children
Did the Employee participate in Flex?
Transparency to Healthcare Benefits Guide PY12-13
(Rev 8-29-12)
Yes
No
Page 44 of 75
TML Intergovernmental
Employee Benefits Pool
Austin, Texas
EMPLOYER’S TERMINATION
NOTICE
Return To:
PO Box 140167
Austin, Texas 78714-0167
Employer:
T=Terminat
e
Coverage
Social Security
Number
Employer Representative Signature
Employee Name
(Last, First, MI)
Title
Reason
Terminatio
n
Date
Date
Administrative Manual 2001
Sample Forms - Section VIII – Page 12
From: tmlmail
Sent: Monday, February 04, 2013 2:57 PM
To: tmlmail
Subject: TML IEBP Annual Eligibility Audit
The TML Intergovernmental Employee Benefits Pool (TML IEBP) website has been updated with a listing of
all active employees and dependents currently enrolled as of February 1, 2013. Please review this listing
with attention to the following:
Are all benefit eligible employees, dependents (and elected officials, if applicable) listed?
Are any terminated and/or ineligible employees or dependents still on the list?
Are the employees on the list actively at work, accessing continuation of coverage or enrolled as a pre
sixty-five retiree?
Remember, TML IEBP requires 100% of all benefit eligible employees be enrolled in either the medical
plan or the alternate plan, unless one of the four scenarios applies:
If an individual is covered under TriCare/Champus coverage (Tricare individuals cannot enroll in the
alternate plan);
If an individual is covered under their spouse’s plan;
If an individual is hired to work for a political subdivision and is able to access a prior employer’s
retirement benefit plan; or
If an individual is on a parental plan until attained age twenty-six (26).
If you identify any benefit eligible employees/dependents (working at least twenty (20) hours per week
and receiving all benefits including but not limited to vacation, sick leave and pension) that are missing
from the list, please submit an online Employee Benefits Enrollment Record for review. If a terminated
employee is still listed, please submit an online Member Change Form with information regarding their
termination. All corrections submitted regarding benefit eligibility are subject to TML IEBP administrative
guidelines. Please refer to the current Benefit Plan document for details.
TML IEBP has attached a document with instructions for performing this audit online. The audit and any
eligibility changes identified should be completed electronically no later than March 31, 2013.
Please note, effective January 1, 2013, new hires will be required to provide documentation to support
dependent eligibility enrollment criteria within thirty-one (31) days from their hire date. Dependents will
not be enrolled until documentation is provided. If the documentation is not received within the thirtyone (31) days of hire, enrollment will not occur until the next open enrollment or special enrollment
period occurs. Effective September 1, 2013 and plan years thereafter, TML IEBP will require the
appropriate documentation on all active, Continuation of Coverage, pre sixty-five and post sixty five plan
participants and their dependents. A Comprehensive Personal Health Organizer is now available on our
website. Login to www.tmliebp.org and select “My Benefits.” Then click on the link called
“Comprehensive Personal Health Organizer.”
Thank you in advance for assisting us in maintaining an accurate database.
Respectfully,
Susan Smith, Executive Director
ONLINE AUDIT INSTRUCTIONS
1. Go to the TML IEBP website at www.tmliebp.org.
Use your .work account to gain access
to myTML IEBP.
If you need help with your password,
please call your B&E Representative at
800.348.7879.
2. Once logged in, you will see a drop down
navigation item labeled Eligibility Reports. Hover
over that item and click on the Annual Eligibility
Audit link.
3. A list of your group’s eligibility will be displayed. Please review this list to make sure it is accurate.
If an individual is listed that is not eligible for coverage, uncheck the check box in the Eligible for Benefits
column.
If an individual is missing from the list, check the box that states Check here if anyone’s eligibility is missing.
Employee
SSN
Employee Employee Dep
First
Last
Code
Dep SSN
Dep
First
Dep
Last
Status Job Title
123-15-6789
John
Brown
e
123-45-6789 John Brown Active Manager
123-15-6789
John
Brown
s
987-65-4321 Jane Brown Active
123-15-6789
John
Brown
1
555-11-9999 Julie Brown Active
123-15-6789
Susie
Smith
e
246-80-2468 Susie Smith Active
Officer
Hire
Date
Eligible
For
Benefits
5/1/07
1/1/09
Check here if anyone's eligibility is missing:
Submit
4. Once you have completed the eligibility review, click the Submit button at the bottom of the screen.
5. Once you click the Submit button, a confirmation message will appear.
Click the Confirm button if you are satisfied with the eligibility list and the changes you made (if any).
Click the Return to Eligibility button if you want to review your eligibility list again.
6. If you did not make any changes to your eligibility, no further action is needed.
7. If you indicated that there was incorrect or missing eligibility, you will receive a message stating that you will be
redirected to our Employer’s Only website to make changes. Click the OK button on this message box.
Please contact your B&E Representative at 800-348-7879 if you have any questions or problems.
PO Box 140167
Austin, Texas 78714
Fax: (512) 719-6505
PLEASE USE
BLACK INK ONLY
Employer Medical Benefit
Annual Enrollment Audit Confirmation Document
TML Intergovernmental Employee Benefits Pool (TML IEBP) is requesting that you conduct an audit regarding
the employees and dependents that are accessing your Employer Medical Benefit Plan. Once the audit has
been conducted, please execute this audit confirmation document.
If there are errors identified, please attach the appropriate enrollment and/or termination forms to the
confirmation audit document.
TML IEBP should receive this information by April 1, 2013.
Your time in this matter is appreciated.
Respectfully,
Susan L. Smith
Executive Director
Confirmation that the Employer Medical Benefit Annual Enrollment Audit has been conducted:
Name:
Title:
Date:
Employer:
Rerate Notice and Benefit Verification Form
City ofTurkey
Somewhere
Plan Year 2012-2013 (12 Months)
Original
Rates are subject to change if there is any legislation passed during the plan year affecting benefits.
Supplemental benefits cannot be accessed without accessing the TML IEBP Medical Benefit Plan
Medical
Select one of the following options for Medical
Employer Group Medical Plan
Plan
Benefit
Percent
In Net
Ded
Out Net
Ded
In Net
OOP
Office
Visit
XRay &
Rates
Lab in OV
Current
New
Employee 195% of
Subsidy
Employee
P85-150-20-Mac A
80/50
$1500
$1750
$2000
$15
No
Employee
$496.98
$571.52
$571.52
$1,114.46
Spouse:
$504.66
$580.36
$580.36
$1,131.70
Child(ren): $376.34
$432.80
$432.80
$843.96
Alternate Plan I
Family
$1,138.82 $1,309.64 $1,309.64 $2,553.80
Employee
$496.98
$571.52
$571.52
$1,114.46
Consumer Centered Pool Plans/Restat Card Program Mac A
Plan
Benefit In Net
Percent Ded
Out Net
Ded
In Net
OOP
Office
Visit
XRay &
Rates
Lab in OV
New
Emp
Subsidy
195% of
Employee
P85-20-25
80/50
$450
$2500
$30
No
Employee
$697.00
$697.00
$1,359.14
Spouse:
$707.76
$707.76
$1,380.14
Child(ren):
$527.80
$527.80
$1,029.20
Family
$1,597.14 $1,597.14 $3,114.42
Employee
$666.60
$666.60
$1,299.82
Spouse:
$676.90
$676.90
$1,319.90
Child(ren):
$504.78
$504.78
$984.30
Family
$1,527.46 $1,527.46 $2,978.50
Employee
$572.02
$572.02
$1,115.40
Spouse:
$580.84
$580.84
$1,132.64
Child(ren):
$433.14
$433.14
$844.64
Family
$1,310.72 $1,310.72 $2,555.90
Employee
$535.34
$535.34
$1,043.86
Spouse:
$543.58
$543.58
$1,060.00
Child(ren):
$405.38
$405.38
$790.50
Family
$1,226.66 $1,226.66 $2,391.98
Employee
$498.32
$498.32
$971.68
Spouse:
$506.00
$506.00
$986.70
Child(ren):
$377.34
$377.34
$735.82
Family
$1,141.84 $1,141.84 $2,226.58
Employee
$476.88
$476.88
$929.94
Spouse:
$484.28
$484.28
$944.30
Child(ren):
$361.12
$361.12
$704.22
Family
$1,092.78 $1,092.78 $2,130.90
Employee
$457.08
$457.08
$891.30
Spouse:
$464.14
$464.14
$905.08
Child(ren):
$346.14
$346.14
$674.96
Family
$1,047.38 $1,047.38 $2,042.40
Employee
$430.86
$430.86
$840.20
Spouse:
$437.54
$437.54
$853.16
Child(ren):
$326.28
$326.28
$636.26
Family
$987.34
$987.34
$1,925.28
P75-0-30
P85-50-20
P85-50-30
P85-75-30
P85-100-30
P85-150-40
P85-250-30
Page 1 of 5
70/50
80/50
80/50
80/50
80/50
80/50
80/50
$200
$0
$500
$500
$750
$1000
$1500
$2500
$250
$750
$750
$1000
$1250
$1750
$2750
$3000
$2000
$3000
$3000
$3000
$4000
$3000
N/A
N/A
N/A
N/A
N/A
N/A
N/A
No
No
No
No
No
No
No
PTURKEY0 - Nov-01
Monthly Defined Contribution
Due to the employer customization regarding defined contribution amount for employees, part-time employees that meet the definition of an
active employee (an Employee who works at least twenty (20) hours per week or is accessing vacation, sick or paid/unpaid Family Medical
Leave Act of 1993 (FMLA) and is receiving the same benefits as all other employees) and/or dependents, TML Intergovernmental Employee
Benefits Pool requests the below information to ensure accurate information is maintained in the enrollment, eligibility and billing adjudication
system.
Employer Funded Defined Contribution
Dependent Additional Employer Funding
Employee
Active Employees
Spouse
Amount
Amount
Child
% of Rate
Amount
% of Rate
Family
Amount
% of Rate
Full-Time
$________
$________ or _______%
$________ or _______%
$________ or ________%
Part-Time
$________
$________ or _______%
$________ or _______%
$________ or ________%
$________
$________ or _______%
$________ or _______%
$________ or ________%
Retirees
Additional Employer Funding for HRA, FSA or HSA (Example criteria: 100% participation in Employer Fair; Receipt of Healthy Initiative Payment)
HRA
$_________
Criteria:_________________________________________________________________
Employer Contribution to FSA
$_________
Criteria:_________________________________________________________________
Employer Contribution to HSA
$_________
Criteria:_________________________________________________________________
NOTE: If you have funding requirements that cannot be specified in the above form, please contact your Billing & Eligibility Representative.
Dental Plan
No Dental Coverage
Vision Plan
No Vision Coverage
Pre-65 Retiree Medical
Select one of the following options for Pre-65 Retiree Medical
Retirees within Manual
Retirees at 195% of Active Plan
Pre Sixty-five Pool Benefits
No Retiree Coverage Offered
Pre-65 Retiree Dental
No Pre-65 Retiree Dental Coverage
Pre-65 Retiree Vision
No Pre-65 Retiree Vision Coverage
Page 2 of 5
PTURKEY0 - Nov-01
LTD
No LTD Coverage
STD
No STD Coverage
Plan 11 ($20,000)
Current Rate
New Rate
Life:
$0.400
$0.400
AD&D:
$0.035
$0.035
Dependent Life: Plan 3 ($10,000/$2,000)
Current Rate
New Rate
$2.76 per
dependent unit
$2.76 per
dependent unit
Voluntary AD&D
No Voluntary AD&D Coverage
Additional Employee Life and AD&D
Age of Employee
Current Rate per $1000
New Rate per $1000
Under 30
0.061
0.061
30 - 34
0.069
0.069
35 - 39
0.100
0.100
40 - 44
0.130
0.130
45 - 49
0.198
0.198
50 - 54
0.332
0.332
55 - 59
0.595
0.595
60 - 64
0.913
0.913
65 - 69
1.513
1.513
70 and over
2.431
2.431
Page 3 of 5
PTURKEY0 - Nov-01
Basic & Additional Retiree Life
Age of Employee
Current Rate per $1000
New Rate per $1000
Under 45
0.228
0.228
45 - 49
0.329
0.329
50 - 54
0.519
0.519
55 - 59
0.873
0.873
60 - 64
1.240
1.240
65 - 69
1.961
1.961
70 - 74
3.226
3.226
75 - 79
5.376
5.376
80 - 84
8.223
8.223
85 - 89
12.587
12.587
90 - 94
18.342
18.342
95 and over
37.823
37.823
Continuation of Coverage (COC)
No COC Admin
Benefit Waiting Period
30 days after date of hire
Medical Network
Choice Plus
Flex, HRA, HSA & RRA
Flex Admin
HRA Admin
HSA Admin
RRA Admin
No
No
No
No
Select one of the following options for Flex:
Select one or all of the following options for HRA, HSA & RRA:
Debit Card Flex ($3.70 per participant per month)
HRA ($3.70 per participant per month - debit card only
Paper Flex ($5 per participant per month)
HSA ($3.70 per participant per month - debit card only
RRA ($3.70 per participant per month - debit card only
If employer accesses Debit Card Flex and/or HRA, HSA or RRA, only one charge of $3.70 per participant per month will be incurred.
Medication Therapy Management Program
Maximum Allowable Cost (MAC A)
If a brand name drug is dispensed and a generic alternate drug exists, the Covered Individual pays the difference between the brand name and generic
price in addition to the appropriate copayment for the brand name. The cost difference between the brand name and generic price does not apply to any
individual deductibles or out of pocket amounts. The MAC differential applies to all prescriptions purchased through this program when a generic alternate
is available.
Maximum Allowable Cost (MAC C)
Covered Individual will pay the appropriate copayment amount of the prescription.
Prescription Clinical Program
Refer to Medication Therapy Management Guide for information on step therapy, prior authorization, cost share, generic, best brand, non best brand, align
and broad network plan guidelines.
Page 4 of 5
PTURKEY0 - Nov-01
Employee Cost Share Copay Information
Retail: Covered
Individual OOP
Mail/Maintenance up to 84/90 day
dispensement or
Specialty/Biotech/Biosimilar Rx up to 34
day dispensement: Covered Individual
OOP
Prescribed Over the Counter Alternatives:
Non-Sedating Antihistamines (Claritin®, Claritin-D®, Alavert®, Allegra®, AllegraD®, Zyrtec®, Zyrtec-D®) per prescription
Stomach and Ulcer (Prilosec®, Prevacid®, Zegerid®) per prescription
Smoking Cessation (Nicorette Gum) Quantity Limit - 3 boxes per plan year
Aspirin, Folic Acid, Fluoride Chemoprevention Supplements, Iron Deficiency
Supplements
$0.00
N/A
Value Tiered 34 day generic dispensement
$0.00
N/A
Value Tiered 84-90 day generic dispensement
$9.00
N/A
Generic
$10.00
$25.00
Best Brand Price List
$38.00
$95.00
Non-Best Brand Price List
$60.00
$150.00
Cost Share
$120.00
$300.00
Specialty/Biotech Prescriptions
N/A
$100.00 up to 34 day dispensement
Biosimilar Prescriptions
N/A
$75.00 up to 34 day dispensement
Signature Section
The entity named on this Rerate and Benefit Verification Form desires large claim information as specified in Article 21.49-15 of the Insurance Code in
Section 2.(2), to be for individual claims that reach or exceed $35,000 during the plan year. This information is considered confidential for purposes of
Chapter 552 of the Local Government Code.
The rates are based on May census information. If the census changes by more than 10%, TML IEBP reserves the right to revise rates due to census
change and underwriting impact.
Employer Group Medical Plan
Tax ID Number
Page 5 of 5
OR
Consumer Centered Pool Plans
Authorized Signature
Date
PTURKEY0 - Nov-01
www.tmliebp.org
CONTINUATION OF COVERAGE ADMINISTRATIVE AGREEMENT
City of Somewhere
January 2013
WHEREAS, the undersigned Employer is an Employer Member of the TML Intergovernmental Employee Benefits Pool
(hereinafter referred to as the “Pool”);
WHEREAS, the undersigned Employer sponsors an employee benefit plan;
WHEREAS, the undersigned Employer is responsible for the administration of its employee benefit plan as the Plan
Administrator; and
WHEREAS, the undersigned Employer wants the Pool to assist the Employer in complying with the requirements of
Continuation of Coverage as required by Federal law.
NOW THEREFORE, in consideration of the promises, mutual covenants and agreements contained herein, the undersigned
Employer and the Pool agree as follows:
I.
Effective Date
As of the first day of January, 2013, the Pool will commence Continuation of Coverage administration for the
undersigned Employer for all qualifying events occurring thereafter and during the term of this agreement.
II.
Employer Duties
1.
The undersigned Employer will notify the Pool’s Billing/Eligibility Representative assigned to the Employer via
FAX or Telephone (with a written follow up) within one (1) business day of a qualifying event, as defined by the
Continuation of Coverage statute and its amendments, or a termination for gross misconduct of a Covered
Employee for which the Employer has knowledge. Examples of qualifying events include termination; lump sum
or severance settlement; resignation; death; retirement if the employee does not enroll for retiree coverage
when offered under the Employer’s benefit plan; reduction in hours (including reduction to zero hours), call to
duty for military service and absence from work for an injury or illness after all earned sick leave, vacation leave
and FMLA has been exhausted.
2.
The undersigned Employer will distribute Attachment A, which advises each Covered Individual of their rights
and responsibilities under Continuation of Coverage. The Employer will certify through a letter to the Pool that
the Attachment A was distributed to all Covered Individuals as of the date the Pool commenced Continuation of
Coverage Administration.
3.
The undersigned Employer will distribute Attachment A to all employees who become covered by the
Employer’s benefit plan after the date the Pool commenced Continuation of Coverage administration and
include verification of the distribution with the enrollment card when it is submitted to the Pool.
4.
The undersigned Employer will notify the Pool via FAX or Telephone (with a written follow-up) within one (1)
business day of gaining knowledge that a Covered Individual has legally separated, divorced or is no longer
eligible for coverage e.g. a child is eligible for coverage under a health plan offered by the child's employer or
the Covered employee or dependent is voluntarily dropped from coverage.
5.
The undersigned Employer will notify the Pool at least ten (10) business days prior to any open enrollment
period. The notice to the Pool will include the dates of the open enrollment.
6.
The undersigned Employer will immediately notify the Pool of any suspected claim, demand or suit arising from
the administration of Continuation of Coverage.
COC Agreement
(PY12-13)
Page 1
www.tmliebp.org
7.
III.
To the extent allowed by law, the undersigned Employer will indemnify and hold harmless the Pool and its
officers, agents, employees and representatives from all suits, actions, losses, damages (including punitive
damages), claims or liability of any type, including without limiting the generality of the foregoing all expenses
of litigation, court costs, and attorney’s fees, resulting from the failure of the undersigned Employer to give any
notice required by this Agreement. The undersigned Employer will fund this obligation out of current revenues
in the year the obligation is determined or will levy a tax to fund the obligation if current revenues are
insufficient.
Pool Duties
1.
The Pool staff will monitor changes in Continuation of Coverage and the case law which develops interpreting
Continuation of Coverage.
2.
The Pool will provide election notices within 14 days of the receipt of notices of qualifying events sent by the
Employer.
3.
The Pool will provide the appropriate notification letters to the employee or their dependent(s) as required by
Continuation of Coverage statutes. These letters may include any or all of the following:
a.
benefit availability - initial notice, enrollment card and cost;
b.
confirmation of enrollment and payment coupons
c.
notice of termination letters:

Failure to reply

Failure to make initial payment

Failure to make regular payment

End of eligibility (no longer qualified)

End of eligibility period
d.
open enrollment
e.
contribution change and revised payment coupons
f.
conversion to an individual policy
g.
Medicare eligibility
h.
verification of incapacitated child status
4.
The Pool will provide the Continuation of Coverage participants with ID cards, a benefit booklet, and other
materials as the need may arise.
5.
The Pool will maintain records that all required notifications were sent and copies are available to the Employer
upon request.
6.
The Pool will collect the required contributions at the maximum amount allowed by law. Upon notice for the
Employer under II.1., the Pool has fourteen (14) days to send the Continuation of Coverage notice. Once the
election notice is mailed the qualifying beneficiary has sixty (60) days to elect Continuation of Coverage. If the
qualified beneficiary elects Continuation of Coverage the qualified beneficiary has forty-five (45) days from
election to make the first payment. If partial payments are made and the payment deficiency is insignificant,
Pool contacts the qualified beneficiary for full payment. The qualified beneficiary has thirty (30) days from
deficiency notification to make payment. Insignificant payment deficiency is $50 or 10% of amount due.
7.
The Pool will periodically provide the Employer, for their review, with the text of the letter and notices to be
used in administering this Agreement. The Pool maintains final authority over the text of these letters and
notices. The Pool reserves unto itself the right to modify the letters and notices as may be required pursuant to
the Continuation of Coverage statute, any applicable case law and to promote the efficient administration of the
Agreement.
COC Agreement
(PY12-13)
Page 2
www.tmliebp.org
IV.
8.
As allowed by law, the Pool will indemnify, defend, reimburse, and hold harmless the Employer and its
employees from any and all liabilities, claims, demands, or suits arising from or related to the provision of
Continuation of Coverage administrative services unless those liabilities, claims, demands, or suits arise out of
the Employer’s failure to give any notice as required in II, 1, 2, 3, 4, 5 and 6 of this Agreement. The foregoing
reimbursement obligation shall specifically include any medical claim costs incurred by the Pool because of the
failure of the Employer to give any notice of an employee termination or other qualifying event. This notice is
required by the agreement or by law. The Pool, upon notice by the Employer will immediately investigate,
handle, respond to and defend any such claims, demands or suits at the Employer’s sole expense. If the liability,
claim, demand or suit is based on negligence this contract of indemnity shall apply and the negligence of the
Employer and the Pool will be on a percentage basis as in a pure comparative negligence situation under the
law.
9.
The Pool’s responsibilities under this contract are for Continuation of Coverage that the Employer is required to
provide under Federal law, and does not have any responsibility for other benefits such as group life insurance
or disability.
Notice
Any notice to be given under this Agreement, other than those in II, 1, 2, 3, 4 and 5 of this Agreement, shall be
deemed given and received on the first to occur of the following: (a) actual receipt by the party to be notified; or (b)
five days after deposit of such notice in the US Mail system if sent by Certified Mail, Return Receipt Requested,
postage prepaid, and addressed to the party to be notified at the address of such party set forth below or as
designated from time to time in writing by giving not less than ten days in advance notice to the other party. The
initial addresses for the Pool and Employer shall be as follows:
Address of Pool
Executive Director
Texas Municipal Center
1821 Rutherford Lane, Suite 300
Austin, Texas 78754-5151
V.
Compensation
1.
The Employer will pay the Pool a one-time $50.00 set up fee and a $0.50 Per Participant Per Month fee for each
participating participant per month that enrolls in Continuation of Coverage.
2.
VI.
Address of Employer
Other special services which may be requested by the Employer but are not contained in this Agreement will be
billed at a mutually agreeable hourly rate.
Miscellaneous Provisions
1.
This Agreement represents the complete understanding of the parties and may not be modified or amended
without the written agreement of both parties.
2.
The parties agree that venue for any dispute arising under the terms of this Agreement shall be in Austin, Travis
County, Texas.
3.
The parties agree that venue for any dispute arising out of the performance under their Agreement shall be in
Austin, Travis County, Texas.
4.
In performing the administrative services under this Agreement, the Pool may rely without qualification on the
information provided by the Employer.
COC Agreement
(PY12-13)
Page 3
www.tmliebp.org
VII.
5.
The Pool agrees to take over the remaining Continuation of Coverage administration for any of the Employer’s
current Continuation of Coverage participants, without Employer compensation, so long as the Employer
furnishes the information necessary to effectuate the transfer.
6.
This Agreement is entire as to all of the performance to be rendered under it. If any term or provision of this
Agreement is held by a court of competent jurisdiction to be invalid, void or unenforceable, the remainder of
the provision of this Agreement shall be void and of no force and effect.
7.
It is understood that the Pool will charge the Continuation of Coverage participant the administration fee
allowed by the Continuation of Coverage statute.
Termination
1.
Term of this initial Agreement shall be from its effective date through December 31, 2013, at 12:00 a.m. The
Employer may annually renew the Agreement for the subsequent twelve (12) month period by executing and
returning the Pool’s rerate notice and benefit selection for each year.
2.
Either party may terminate this Agreement at anytime by giving the other party written notice at least thirty
(30) days prior to the specified date.
3.
This Agreement terminates, without further notice, on the date the undersigned Employer is no longer an
Employer of the Pool.
4.
All records in possession of the Pool relating to Continuation of Coverage administration at termination of the
Agreement will be transferred to the Employer within forty-five (45) business days.
5.
Should this Agreement terminate for any reason it does not relieve either party of their duties nor obligations
during the period when this Agreement was in full force and effect.
This Agreement is entered into for the Employer under authorization of
, at a duly called meeting
by:
held on
(Signature)
City of Somewhere
(Employer/Group Name)
(Authorized Official Title)
(Date)
This Agreement Entered Into and Accepted By:
TML INTERGOVERNMENTAL EMPLOYEE BENEFITS POOL
BY:
TITLE:
Executive Director
COC Agreement
(PY12-13)
at Austin, Texas
(Date)
Page 4
Go Green Benefit Rerate
Mailing Options Form
TML Intergovernmental Employee Benefits Pool is providing two options for the 2012-2013 Benefit Plan Year “Go Green”
Campaign. Per feedback from the TML IEBP membership, electronic access has been redesigned so the information is easily
accessible on your employer custom website.
As an Employer, you may choose Option I or Option II:
Option I – Receive ALL TML IEBP health plan documents on paper. Plan options must be available to eligible employee
population thirty (30) days prior to effective date or seven (7) working days after benefit plan options employer election
was complete.
Option II – Fund Contact E-Friendly Resource Guide and Employee E-Friendly Employee Resource Guide for every covered
individual.
Please send an additional Fund Contact E-Friendly Resource Guide
Please select your option above, sign below and return this sheet to TML IEBP by August 13, 2012. Your time in this matter is
appreciated. Fax: 512-719-6509 or Mail: TML IEBP, 1821 Rutherford Lane, Suite 300 Austin, Texas 78754.
Employer Name:
Phone Number:
Signature:
Printed Name:
Date:
Listed below are the items via electronic access on your employer custom website:
Employee E-Friendly Resource Guide
Healthy Initiatives Information
• Personal Health Record
o Biometric Screenings
o Health Power Assessment
• Healthy Living Guides Handout
• Healthy Living Fact Sheets
Prescription Information
• Summary of Prescription Benefit Changes
• Medication Therapy Management Guide
• Align Network
• Clinical Prior Authorization Document
• Step Therapy Program Document
• Cost Share Drugs Document
• Rx Flowsheet
• Specialty Rx/Biotech Prescriptions/High Deductible HSA
Wellness Drug List
Medical Benefit Book/Summary of Benefit and Language Changes
(Employer Specific)
• Medical Plan
Dental Benefit Book/Summary of Benefit and Language
Changes/Schedule of Dental Benefits (Employer Specific)
• Dental II
• Dental III
• Dental IV
Vision Benefit Book/Summary of Benefit and Language
Vision Benefit Book/Summary of Benefit and Language
Changes/Schedule of Vision Benefits (Employer Specific)
• Vision A
• Vision B
Alternate Plan Book/Summary of Changes (Employer Specific)
Section 125 (Flex) Benefit Book/Summary of Changes (Employer
Specific)
www.tmliebp.org
HRA-RRA
Summary of Changes (Employer Specific)
•
•
Initial
Notices Guides
•
• •Notice of Limitation on Coverage of Pre-Existing Conditions
• •Medicaid and CHIP Notice
• •Notice of Benefits for Mastectomy and Breast Reconstruction
• •Notice of Special Enrollment Opportunities
• •Wellness Benefit Initial Notice
• •Early Retiree Reinsurance Program
•
Open
Enrollment Resources
•
• •Six Ways to Understand Open Enrollment
• •Employee Enrollment Important Reminder Notice
• •Notice of Privacy Practices
• •BPS (MBI) Debit Card Flyer (Consumer Driven Product)
•
Retiree
Guide (Employer Specific)
•
• •Pre Sixty-five Creditable Coverage Prescription Reminder Letter
• •TML IEBP Pre Sixty-five Benefit Pool Options
• •UnitedHealthcare Post Sixty-five Benefit Options
• •Medicare Eligibility, Enrollment, and Entitlement
• •Sample Retiree Resolution/Ordinance
•
Political
Subdivision MemberCentric Guide
•
• •Consumer Centered Health Plan Overview
o Centered Pool Plan Options (Employer Specific)
• Consumer
o
• High Deductible
Health Plan Access
o
• High Deductible
Health Plan Diagram
o
• High Deductible
HSA Wellness Drug List
o Management Tips
• Benefits Card
o
Medical
Intelligence Health and Wellness Guide
•
• •Healthy Living Guides Handout
• •Healthy Living Fact Sheet
• •Healthy Living Letter Campaign
• •Fecal Occult Information
• •Health Power Assessment
• •Personal Health Record/Biometric Screenings
Page 1 of 2
Go Green Benefit Rerate Mailing Options Form PY12-13 | (Rev 7.11.12)
Provider Relations Guide
• Benefits Overview
• Provider Coding Guidelines
• Sample Options Network or Choice Network ID Card
• Sample Explanation of Benefit (EOB)
• Choice Plus Network
• Options PPO Network
• Public/Private Alliance
Forms Guide (Sample of ALL Forms)
www.tmliebp.org
Transparency
to Healthcare Benefits Guide
•
• • Patient Advocacy Policy
• • Healthcare Reform Definitions
• • Sample Choice Network ID Card
• • Sample Explanation of Benefit (EOB)
• • Internal and External Appeal Options
• • Claim and Billing Facts
• • Employee Audit Tool
• Continuation of Coverage
• Employee Enrollment Important Reminder Notice
Page 2 of 2
Enrollment Forms:




FSA
POP
HRA
HRA-HSA
PO Box 140167
Austin, Texas
78714-0167
Fax: (512) 719-6565
PREMIUM ONLY EMPLOYEE ENROLLMENT FORM
SECTION 125 PREMIUM ONLY PLAN ENROLLMENT FORM
Employer Name
Employer Group #
Employee Name
Employee Phone Number
Employee E-mail
Street Address
City
State
Zip Code
Mailing Address
City
State
Zip Code
Date of Birth
Spouse Name (First, M.I.)
Check One
Male
Female
Date of Birth
Check One
Single
Married
Check here if new
Check here if new
Date Employed
Widowed
Divorced
I request that my salary be reduced as follows:
Annually
Dependent Name (First, M.I.)
Date of Birth
Date of Birth
Date of Birth
Date of Birth
Monthly
Contribution for Medical Coverage
$
$
Contribution for Dental Coverage
$
$
$
$
$
$
Other Contributions (SPECIFY)
Total Authorized Reductions
AUTHORIZATION: I certify the above information to be correct and true to the best of my knowledge and that any children listed are dependents
under Section 152 of the Internal Revenue Code. I understand that any amounts remaining in my account(s) not used for expenses incurred during
the plan year will be forfeited in accordance with current plan provisions and tax laws. I also understand that the Flexible Spending reduction(s) will
be in effect for the plan year and cannot be revoked unless I experience a change in my family status, significant change in cost or coverage of my
health plan or my spouse’s health plan or separation from service as prescribed by IRS rules. If a change in family status occurs, you have 31 days
from the occurrence to change or revoke your election. Furthermore, I hereby authorize my employer to transfer my required health benefits
contribution on a monthly basis to the TML Intergovernmental Employee Benefits Pool. I agree to only submit claims which qualify as medical
expenses under Section 213, Internal Revenue Code or dependent care expenses under Section 129, Internal Revenue Code.
Employee Signature
Date
The benefits of the plan have been thoroughly explained to me and I decline to participate.
Employee Signature
Forms Guide
(Rev 8-3-12)
Date
Page 26 of 47
PO Box 140167
Austin, Texas
78714-0167
Fax: (512) 719-6565
EMPLOYEE ENROLLMENT FORM
SECTION 125 FLEX
SECTION 125 FLEX ENROLLMENT FORM
Employer Name
Employer Group #
Employee Name
Employee Phone Number
Employee E-mail
Street Address
City
State
Zip Code
Mailing Address
City
State
Zip Code
Date of Birth
Check One
Male
Female
Date of Birth
Check One
Single
Married
Check here if new
Check here if new
Date Employed
Widowed
Divorced
I request that my salary be reduced as follows:
Annually
Date of Birth
Date of Birth
Date of Birth
Date of Birth
Monthly
Contribution for Medical Coverage
$
$
Contribution for Dental Coverage
$
$
$
$
Unreimbursed Healthcare Expenses
$
$
Dependent Care Expense
$
$
Total Authorized Reductions
$
$
Other Contributions (SPECIFY)
AUTHORIZATION: I certify the above information to be correct and true to the best of my knowledge and that any children listed are dependents under Section 152 of
the Internal Revenue Code. I understand that any amounts remaining in my account(s) not used for expenses incurred during the plan year will be forfeited in
accordance with current plan provisions and tax laws. I also understand that the Flexible Spending reduction(s) will be in effect for the plan year and cannot be
revoked unless I experience a change in my family status, significant change in cost or coverage of my health plan or my spouse’s health plan or separation from
service as prescribed by IRS rules. If a change in family status occurs, you have 31 days from the occurrence to change or revoke your election. Furthermore, I hereby
authorize my employer to transfer my required health benefits contribution on a monthly basis to the TML Intergovernmental Employee Benefits Pool. I agree to only
submit claims which qualify as medical expenses under Section 213, Internal Revenue Code or dependent care expenses under Section 129, Internal Revenue Code.
I accept:
Employee Signature
Pre-tax Premium Only
FSA
DCA
Date
Employee Signature
Forms Guide
(Rev 8-3-12)
Date
Page 20 of 47
PO Box 140167
Austin, Texas
78714-0167
Fax: (512) 719-6565
HEALTH REIMBURSEMENT ACCOUNT (HRA)
HRA ENROLLMENT FORM
Employer Name
Employer Group #
Employee Name
Street Address
City
State
Check here if new
E-mail Address
Phone
Date of Birth
Zip Code
Check One
Male
Female
Check One
Single
Married
Date Employed
Widowed
Divorced
Date of Birth
Annually
Date of Birth
Date of Birth
Date of Birth
Date of Birth
Employer Contribution for Health
Reimbursement Account
$
Monthly
$
I certify the above information to be correct and true to the best of my knowledge and that any child(ren)
listed are dependents under Section 152 of the Internal Revenue Code.
Employer Accepted
By
Employee Signature
Date
Date
Employee Signature
Forms Guide
(Rev 8-3-12)
Date
Page 11 of 47
PO Box 140167
Austin, Texas
78714-0167
Fax: (512) 719-6565
CC EMPLOYEE ENROLLMENT FORM
CONSUMER CENTERED HRA-HSA ENROLLMENT FORM
Employer Name
Employer Group #
Employee Name
Street Address
City
State
Zip Code
Check here if new
Mailing Address
City
State
Zip Code
Check here if new
Phone
Date of Birth
Dependent Name
(First, M.I.)
E-mail Address
Check One
Male
Check One
Single
Female
Date of Birth
Date of Birth
Date Employed
Widowed
Married
Divorced
Date of Birth
Date of Birth
Date of Birth
Date of Birth
HRA OPTION
Annually
Employer Contribution for Health Reimbursement Arrangement
$
Monthly
$
HSA OPTION
I elect to contribute to my HSA with a pre-tax salary reduction through my employer’s Section 125 Cafeteria Plan, and authorize my employer
to deduct the amounts as indicated from my salary and forward the funds to HSA Bank to deposit in my HSA.
Total Annual Employee Contribution: $_______
Date of first HSA contribution: ____/____/____
Total Annual Employer Contribution (if applicable): $_______
(Date must be on or after the first day of your HSA-compatible
health plan coverage or the first day of opening your HSA,
whichever is later. Leaving the date blank will authorize your
employer to determine the date on your behalf.)
Note: Your Total Annual Employee Election along with contributions from any other sources, including your employer, may not exceed the Annual
Maximum Contribution amount set by the IRS. Contribution limits can be found at: www.hsabank.com or by visiting the IRS site at:
www.irs.gov.
I do not want to contribute to my HSA through a pre-tax salary reduction. I understand that I can make after-tax contributions to my HSA
online - through Internet Banking (https://secure.hsabank.com/ibanking/), or by mailing a check with a contribution form.
By my signature below, I certify that I have enrolled, or plan to enroll, in an HSA-compatible health plan and that I am not covered under any other
plan that would disqualify me from opening or contributing to my HSA. I understand that this form is provided for convenience purposes and that
HSA Bank will not initiate contributions to my HSA, but will allow my employer or their authorized agent to initiate contributions to my account.
I also certify the above information to be correct and true to the best of my knowledge and that any child(ren) listed are dependents under Section
152 of the Internal Revenue Code.
Employer Accepted
Employee Signature
Date
By
Date
Please return this form to your employer.
Consumer Centered Enrollment Form (PY12-13)
(Rev 11.13.12)
PO Box 140167
Austin, Texas
78714-0167
Fax: (512) 719-6565
HEALTH SAVINGS ACCOUNT (HSA)
HSA ENROLLMENT FORM
Employer Name
Employer Group #
Employee Name
Street Address
City
State
Zip Code
Check here if new
E-mail Address
Phone
Date of Birth
Check One
Male
Female
Check One
Single
Married
Date Employed
Widowed
Divorced
Date of Birth
Date of Birth
Date of Birth
Date of Birth
Date of Birth
Date of Birth
OPTION ONE
I elect to contribute to my HSA with a pre-tax salary reduction through my employer’s Section 125 Cafeteria Plan, and
authorize my employer to deduct the amounts as indicated from my salary and forward the funds to HSA Bank to deposit in my
HSA.
Total Annual Employee Contribution: $_______
Date of first HSA contribution: ____/____/____
Total Annual Employer Contribution (if applicable): $_______
(Date must be on or after the first day of your HSA-compatible
health plan coverage or the first day of opening your HSA, whichever
is later. Leaving the date blank will authorize your employer to
determine the date on your behalf.)
Note: Your Total Annual Employee Election along with contributions from any other sources, including your employer, may not exceed the Annual
Maximum Contribution amount set by the IRS. Contribution limits can be found at: www.hsabank.com or by visiting the IRS site at:
www.irs.gov.
Employee Signature
Date
OPTION TWO
I DO NOT want to contribute to my HSA through a pre-tax salary reduction. I understand that I can make after-tax
contributions to my HSA online - through Internet Banking (https://secure.hsabank.com/ibanking/), or by mailing a check with
a contribution form.
Employee Signature
Date
By my signature below, I certify that I have enrolled, or plan to enroll, in an HSA-compatible health plan and that I am not covered
under any other plan that would disqualify me from opening or contributing to my HSA. I understand that this form is provided for
convenience purposes and that HSA Bank will not initiate contributions to my HSA, but will allow my employer or their authorized
agent to initiate contributions to my account.
Employee Signature
Date
Please return this form to your employer.
Forms Guide
(Rev 8-3-12)
Page 18 of 47
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Transcription

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