Page 10 - 2015 Four Seasons Non-Medical Enrollment Guide
P. 10
Special Notices
Becoming Eligible for Changing Your Coverage
Assistance Through a Although Four Seasons pays the greater portion of your healthcare premiums, you
share some of the cost. When you choose healthcare insurance, your contributions are
State Children’s Health
automatically deducted from each paycheck before any taxes are withheld—which
Insurance Plan means that you save on taxes. This arrangement is called a “125C Plan.”
If you or your dependents are By participating in a 125C Plan (i.e., contributing on a before tax basis), you cannot
eligible for premium assistance cancel or change medical and dental coverage for you or your covered dependents
under Medicaid or CHIP, Four for the full 2015 calendar year unless you have a “qualiied life event” (described below)
Seasons is required to permit that affects you, your spouse or domestic partner, or dependent(s).
you and your dependents to
enroll in Four Seasons medical If you have a qualiied life event, you must log on to
coverage as long as you and https://fsbeneits.fourseasons.com or call the My Four Seasons Beneits Center at 1-866-
your dependents are eligible, 672-0435 (toll free) to make changes within 30 days of the event. If you fail to do so,
but not already enrolled. you will not be able to make changes until the next open enrollment period (or future
qualiied life event, if earlier).
This is called a “special
enrollment” opportunity, and you Examples of a “Change in Status”
must request coverage within
60 days of being determined The beneit change you make must be consistent with the status change. For example,
eligible for Medicaid or CHIP if you get married, you may add your spouse to your medical coverage. You will need
premium assistance. to provide proof of your status change. Examples of satisfactory proof include a birth
certiicate, marriage certiicate, divorce decree, domestic partner afidavit, etc.
Premium Assistance z Change in Legal Marital Status—you are married, divorced, legally separated; your
Under Medicaid and marriage is annulled; your spouse dies; you add a domestic partner or end such a
relationship
the Children’s Health z Change in Number of Dependents—you or your spouse gives birth or adopts a child;
Insurance Program (CHIP)
a child is placed with you for adoption; your child or spouse or domestic partner dies
This notice is not included in the z Change in Your or Your Spouse’s Employment Status—you leave Four Seasons or
Open Enrollment Guide as it was begin work for Four Seasons; your spouse leaves his/her employer or begins a new
mailed to your home on job; you or your spouse start or return from an unpaid leave of absence (i.e., Family
October 1, 2014. For a copy of and Medical Leave)
the notice in English or Spanish, z Change in Dependent Eligibility—your dependent child reaches the maximum age
please log on to the My Four (26 years) allowable under the plan
Seasons Beneits website at z Change in Health Coverage—a signiicant change in your health coverage or that
https://fsbeneits.fourseasons. of your spouse or domestic partner (e.g., plan beneits, cost of coverage increase,
com. Then, click on the Forms loss of coverage)
and Materials tab. To request for
Colour Elements a printed copy to be mailed z Change of Your Work Site—or that of your spouse or domestic partner, resulting in a
to your home, call the My change of beneits offered
Four Seasons Beneits Center at z Change Due to Relocation—of your residence to outside the plan’s service area
1-866-672-0435 (toll z Qualiied Medical Child Support Order—requires you to provide coverage for a
free). dependent child
Logo & Logo Variations
z You Qualify for Special Enrollment Rights—under the Health Insurance Portability and
Accountability Act (HIPAA) 10
My Four Seasons BENEFITS My Four Seasons
BENEFITS
Icon Image Elements Font Elements
Tandelle
Century Gothic
Becoming Eligible for Changing Your Coverage
Assistance Through a Although Four Seasons pays the greater portion of your healthcare premiums, you
share some of the cost. When you choose healthcare insurance, your contributions are
State Children’s Health
automatically deducted from each paycheck before any taxes are withheld—which
Insurance Plan means that you save on taxes. This arrangement is called a “125C Plan.”
If you or your dependents are By participating in a 125C Plan (i.e., contributing on a before tax basis), you cannot
eligible for premium assistance cancel or change medical and dental coverage for you or your covered dependents
under Medicaid or CHIP, Four for the full 2015 calendar year unless you have a “qualiied life event” (described below)
Seasons is required to permit that affects you, your spouse or domestic partner, or dependent(s).
you and your dependents to
enroll in Four Seasons medical If you have a qualiied life event, you must log on to
coverage as long as you and https://fsbeneits.fourseasons.com or call the My Four Seasons Beneits Center at 1-866-
your dependents are eligible, 672-0435 (toll free) to make changes within 30 days of the event. If you fail to do so,
but not already enrolled. you will not be able to make changes until the next open enrollment period (or future
qualiied life event, if earlier).
This is called a “special
enrollment” opportunity, and you Examples of a “Change in Status”
must request coverage within
60 days of being determined The beneit change you make must be consistent with the status change. For example,
eligible for Medicaid or CHIP if you get married, you may add your spouse to your medical coverage. You will need
premium assistance. to provide proof of your status change. Examples of satisfactory proof include a birth
certiicate, marriage certiicate, divorce decree, domestic partner afidavit, etc.
Premium Assistance z Change in Legal Marital Status—you are married, divorced, legally separated; your
Under Medicaid and marriage is annulled; your spouse dies; you add a domestic partner or end such a
relationship
the Children’s Health z Change in Number of Dependents—you or your spouse gives birth or adopts a child;
Insurance Program (CHIP)
a child is placed with you for adoption; your child or spouse or domestic partner dies
This notice is not included in the z Change in Your or Your Spouse’s Employment Status—you leave Four Seasons or
Open Enrollment Guide as it was begin work for Four Seasons; your spouse leaves his/her employer or begins a new
mailed to your home on job; you or your spouse start or return from an unpaid leave of absence (i.e., Family
October 1, 2014. For a copy of and Medical Leave)
the notice in English or Spanish, z Change in Dependent Eligibility—your dependent child reaches the maximum age
please log on to the My Four (26 years) allowable under the plan
Seasons Beneits website at z Change in Health Coverage—a signiicant change in your health coverage or that
https://fsbeneits.fourseasons. of your spouse or domestic partner (e.g., plan beneits, cost of coverage increase,
com. Then, click on the Forms loss of coverage)
and Materials tab. To request for
Colour Elements a printed copy to be mailed z Change of Your Work Site—or that of your spouse or domestic partner, resulting in a
to your home, call the My change of beneits offered
Four Seasons Beneits Center at z Change Due to Relocation—of your residence to outside the plan’s service area
1-866-672-0435 (toll z Qualiied Medical Child Support Order—requires you to provide coverage for a
free). dependent child
Logo & Logo Variations
z You Qualify for Special Enrollment Rights—under the Health Insurance Portability and
Accountability Act (HIPAA) 10
My Four Seasons BENEFITS My Four Seasons
BENEFITS
Icon Image Elements Font Elements
Tandelle
Century Gothic
