WMCHealth Logo

HealthAlliance of the Hudson Valley

Enrollment/Change Form - Benefits Elections/Changes

Plan Year Effective: 2024
SECTION 1:  EMPLOYEE INFORMATION








MM/DD/YYYY

MM/DD/YYYY








SECTION 2:  BENEFIT ELECTION

I understand that if I do not enroll in the Biometric Screening Program by this deadline, my monthly premiums will be increased to the rate in 2023 had I not participated in the Premium Reduction.












Provide insured name, ID number, effective date of coverage, name of other insurance carrier.
Medicare eligibility is determined by age and specific qualifying conditions for active employees, retirees, and covered dependents. Generally, individuals become eligible for Medicare benefits when they turn 65, qualify for disability benefits through Social Security, or have a qualifying medical condition like End-Stage Renal Disease (ESRD). If employees are age 65 and still actively working, and the age or disability criteria do not apply, they can apply for Medicare upon the conclusion of their employment. Details on eligibility criteria and the application process are available on the Medicare website (www.medicare.gov) or by contacting the Social Security Administration. It is important to notify your employer promptly if you are enrolled in Medicare to prevent potential claims issue.

Supplemental Life Insurance, Long Term Disability Insurance, and Voluntary benefits:

Please click here to elect your supplemental life insurance, long term disability insurance, and voluntary benefit options through Lincoln Financial Group.

$
$
DEPENDENT COVERAGE INFORMATION
_______________________________________________________________________________________
*Dependents eligible for coverage may not qualify for all Plan benefits -- check federal IRS requirements, especially before submitting claims.*
   
______________________________________________________________________________________




MM/DD/YYYY



SECTION 4: ACKNOWLEDGMENT
Election of Pre-Tax Premium Deduction:  As an eligible participant in the Flexible Benefits Plan, you have the ability to pay for your employee premiums for health coverage with Pre-tax dollars under IRC Section 125.  Although paying for the premiums with Pre-Tax dollars will reduce your net out of pocket costs, you may elect to pay your premiums with After-Tax dollars.  Accordingly, please choose the indicated tax treatment for your payroll deductions for your health coverage.  Any supplemental life, disability or voluntary overages are paid with After-Tax dollars.

If you elect to waive or opt-out of coverage, do NOT complete the following.

I am enrolling for coverage in the Health Alliance of the Hudson Valley health plan and understand the premiums will be deducted from my regular payroll check automatically.  I am electing that these premium deductions be based upon my election below:
My signature indicates acceptance of the terms and conditions below:
 


·       I understand that I cannot change or revoke this salary reduction agreement related to the payment of plan premiums at any time during the Plan Year unless I have a change in family status or a member of your family or you have a change of employment status.  


·   I understand that the medical coverage offered by my employer meets the minimum essential value and is considered affordable coverage under IRC 4980Hn and that I may not be eligible for premium tax credits (subsidy) under IRC 36B.


·     If the required contributions for the selected benefits are increased or decreased (due to change in status for example) while this agreement remains in effect, your election will automatically be adjusted to reflect that increase or decrease.

·      Prior to the first day of each Plan Year, you will be offered the opportunity to change your benefit election for the following Plan Year. If you do not complete and return a new election form at that time, you will be treated as having elected to continue your benefit coverage and amount of payroll deduction then in effect applied for the new Plan Year.


·       The Plan Administrator may reduce or cancel your pre-tax deduction or otherwise modify this agreement in the event it would be necessary in order to satisfy certain provisions of the Internal Revenue Code.

·     Neither FICA (Federal Insurance Contributions Act) nor FUTA (Federal Unemployment Tax Act) taxes are payable on the amount of pre-tax salary reduction used to pay health premiums. As a result, Social Security Benefits and Unemployment benefits could be reduced as a result of your pre-tax election. WMC-NY, Inc. cannot provide you tax advice.

      THIS AGREEMENT IS SUBJECT TO THE TERMS OF WMCHEALTH'S FLEXIBLE BENEFITS PLAN AS AMENDED FROM TIME TO TIME AS IN EFFECT, AND SHALL BE GOVERNED BY AND CONSTRUED IN ACCORDANCE WITH APPLICABLE LAWS AND REVOKES ANY PRIOR ELECTION AND SALARY REDUCTION PREMIUM CONVERSION AGREEMENT RELATING TO SUCH PLAN.

       If you currently contribute (or will contribute) towards your heath care coverage through bi-weekly payroll contributions and need to enroll in coverage or make a change to your benefits due to a family status change, you must notify the Benefits Office within 30 days of your date of hire or the event.  Otherwise, you must wait to make the change until the regular annual Open enrollment period for a January 1st effective date.

       I certify that all the information is correct.  Any misstatements, misrepresentations, fraud or omissions may result in legal, criminal or disciplinary action and/or claim denial and/or plan termination for me and/or my dependents(s).  For those coverages I have selected, I authorize my employer to make the required deductions.  I understand that if any benefit payments are paid/received for persons who do not meet the definition criteria for a dependent, I will be responsible for reimbursing premiums paid by my employer and all my claims payments.

E-SIGNATURE
I understand that my electronic signature below has the same force and effect as my written signature.