Administrative Forms/Notices
Please refer to the below Communication Guide to contact the appropriate vendor or provider of service when you have questions or need assistance. HealthSCOPE Benefits only submits enrollment to the other carriers and cannot respond to inquiries concerning those program benefits. By contacting the appropriate vendor directly you will receive more timely assistance with your question.
COMMUNICATION GUIDE FOR MEMBERS
EMPLOYEES: The New Employee Enrollee Form is to be used when you are enrolling in any of the medical, dental, vision or life programs for the first time, OR if you are currently enrolled and wish to drop coverage of any of the available products. (Note: Please be sure all forms are completed in their entirety, signed and dated. If enrolling dependents, their date of birth and SSN are required for enrollment.)
If you did not enroll in the life insurance when first eligible all amounts are subject to medical underwriting. You will need to complete an Evidence of Insurability form that can be found under Voluntary Benefits / Life Insurance.
EMPLOYEES: The Change Enrollment form is to be used when you are currently enrolled in any of the medical, dental, vision or life programs and wish to make changes during the Open Enrollment period, at the time of a Special Enrollment Event, or a Qualifying Change in Status. See the Plan Document for details on when you may enroll. (Note: Please be sure all forms are completed in their entirety, signed and dated. If enrolling dependents, their date of birth and SSN are required for enrollment.)
EMPLOYEES: The below Disabled Dependent Certification forms are required if you are requesting to continue coverage beyond the limiting age of 26 for an eligible dependent child who is mentally or physically incapable of sustaining his or her own living, provided the child is unmarried and suffered such incapacity prior to attaining the limiting age. The BCBS form must be completed to continue health plan coverage. The MetLife form must be completed to continue the voluntary dental and/or vision plans.
BCBS-IL Disabled Dependent Certification
MetLife Disabled Dependent Certification
General COBRA Notice: This Notice applies if you are enrolled for coverage under a group health plan offered by the Trust. This notice has important information about your right to COBRA Continuation Coverage, explaining when it may become available to you and your family, and what you need to do to protect your right to get it.