SIMPSON  COLLEGE
MEDICAL INSURANCE WAIVER INCENTIVE PLAN
MEMORANDUM

           Simpson College offers a waiver plan to its employees to help eliminate duplicate health insurance coverage.  In return, as an incentive, the College will reimburse the employee $900.00 payable in June 2010. The employee may also choose to use the $75.00 per month as an additional contribution to their TIAA-CREF retirement plan or for dental/vision insurance premiums.

          If an employee becomes ineligible for benefits during the policy year, the annual reimbursement will be prorated for the number of months of completed service.

 Important!

The waiver of health insurance benefits can be elected only upon your initial eligibility into the plan.  If you choose to voluntarily waive coverage, re-entry into our health insurance plan can only be allowed via a "Special Enrollment".  You and/or your Dependent(s) may qualify for Special Enrollment under the following three conditions:

1.  Loss of Other Coverage - You and/or your Dependent(s) were covered under another group health plan, or had other health insurance coverage at the time of initial eligibility and declined enrollment solely due to the other coverage; and the other coverage terminated due to loss of eligibility (including loss due to divorce or legal separation, death, termination of employment or reduction in work hours), or due to termination of employer contributions (or, if the other coverage was under a COBRA or state continuation provision, due to exhaustion of the continuation).  "Loss of eligibility" does not include a loss due to failure of the individual to pay premiums on a timely basis or termination of coverage for cause (such as making a fraudulent claim or an intentional misrepresentation of a material fact in connection with the health coverage).  "Employer contributions" include contributions by any current or former employer (of the individual or another person) that is contributing to the coverage of the individual.  Request for enrollment under this condition must be made within 31 days after termination of other health coverage.
   
2. Newly Acquired Dependent(s) - You are already enrolled under your employer's health plan (or are eligible to be enrolled but have not enrolled during a previous enrollment period), and a person becomes your Dependent through marriage, birth, adoption or placement for adoption.  Request for enrollment under this condition must be made within 31 days after the later of:
   
   
   • The date of the marriage, birth, adoption or placement for adoption; or
     
   • The date Dependent health coverage is available to you under the plan provided you are enrolled (or eligible to be enrolled, but have not enrolled during a previous enrollment period).
     
     
3. Court Ordered Coverage - You are enrolled under your employer's health plan and a court or administrative order is issued that required you to provided health coverage for a Dependent child.  A request for enrollment under this condition must be made within 31 days after the court or administrative order is issued.

 Please sign to waive coverage and return to Human Resources, or call ext. #1511 with any questions.
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MEDICAL WAIVER

 

My medical insurance carrier is ___________________ from  _______________.
                                                  (Insurance group name)            (Company name)

Please waive my medical insurance coverage carried by Simpson College, from July 1, 2009 through June 30, 2010.

(Check all that apply)

___ I request that my refund be contributed to my dental/vision insurance.

___ I request that my refund be contributed to my TIAA-CREF retirement account.

___ I request a refund in June 2010.

 

          ______________________________
                   Employee Signature                 Date

 

          ______________________________
Print Name