The University of Toledo

2011 Open Enrollment HSC Non-Union Employees

All forms included in this link are fillable forms.  Please read all instructions and complete, print and sign all appropriate forms applicable to your personal circumstances.     

All completed forms must be returned in one packet to the Human Resources Department no later than 5 PM on Monday, November 15, 2010.  Please return forms using only one of the following methods to prevent duplicate copies:

• Drop off to the HR office or at one of the scheduled table times (for a complete schedule, click here)
• Fax to (419) 530-1492 (please keep your fax confirmation as your receipt)
• Mail to Mail Stop 205 (please note that we will not be able to confirm that your paperwork has been received, so please keep a copy of your records)

1. Healthcare Election Form:  If you are not making changes to your current elections, you do not need to complete the Healthcare Election Form.  If you are making changes to your current elections, electing new coverage, or adding dependents to your coverage the first form you must complete is the Healthcare Election Form.  Please complete all applicable information and list all dependents to be covered on any of your elections.  Please note if you choose the MMO CDHP plan, then the HSA Form must also be completed. 

• Spouses and dependents who have missing information, including social security number, will not be enrolled in coverage.  If your spouse/dependent does not have a social security number, please indicate on the form the reason that a social security number is not available.
• Does your spouse or dependent have a different address from you?  If yes, please indicate their address on page 2 of this form. 
• Does your spouse or dependent have other medical/prescription drug coverage?  If yes, you must include that information as well on page 2 of this form.
• If you are adding a spouse or dependent to your coverage, please provide a copy of your marriage certificate and/or your children's birth certificates. 

2. Health Savings Account (HSA) Form:  Are you currently enrolled or did you elect the Medical Mutual CDHP?  If no, continue to #3.  If yes, please complete this form and return it to Human Resources.

3. Spousal / Domestic Partner Healthcare Eligibility Affidavit:   Do you currently cover or did you enroll a Spouse or Domestic Partner on your Paramount ES plan?  If no, continue to #4.  If yes, complete Sections A & B of this form, print the form and have your spouse’s employer complete Section C.  Once all appropriate sections are completed and signed, this form must be returned to Human Resources. 

4. Dependent Affidavit:  Are any of your dependent children age 19 or older?  If no, continue to #5.  If yes, please complete and print this form for each dependent over age 19 and return to Human Resources.

5. Chard Snyder Flexible Spending Account Enrollment Form:  Do you wish to enroll/re-enroll in a medical or dependent care flexible spending account for 2011?  If no, continue to #6.  If yes, complete the FSA enrollment form and return to Human Resources.   

6. Term Form: If you wish to waive coverage for 2011 or need to remove a Spouse, Domestic Partner or Dependent Child from coverage please complete this form and return to Human Resources.

Again, all completed forms must be returned in one packet to the Human Resources Department located in the Transportation Center or at Mail Stop 205 no later than 5 p.m. on Monday, November 15, 2010.

Required Legal Notifications:  UT is required to provide employees the following legal notifications annually. This is for informational purposes only.

University of Toledo - Grandfathered Plan Status

The University of Toledo believes this plan is a “grandfathered health plan” under the Patient Protection and Affordable Care Act (the Affordable Care Act).  As permitted by the Affordable Care Act, a grandfathered health plan can preserve certain basic health coverage that was already in effect when that law was enacted.  Being a grandfathered health plan means that your plan may not include certain consumer protections of the Affordable Care Act that apply to other plans, for example, the requirement for the provision of preventive health services without any cost sharing.  However, grandfathered health plans must comply with certain other consumer protections in the Affordable Care Act, for example, the elimination of lifetime limits on benefits. 

Questions regarding which protections apply and which protections do not apply to a grandfathered health plan and what might cause a plan to change from grandfathered health plan status can be directed to the plan administrator at 419-530-4747. 

Social Security Number Required

Due to recent regulation changes, you must provide a Social Security Number (SSN) to the UT Benefits Department for each dependent you wish to enroll in the Plan to satisfy federal reporting requirements. This condition allows UT to comply with a Medicare law requiring health plan administrators to electronically report data for covered plan participants to the Centers for Medicare and Medicaid Services (CMS).

Spouses, same and opposite sex domestic partners are not eligible to begin coverage until a SSN has been provided as part of enrollment.  Coverage for dependent children will begin upon enrollment.  However, if a child’s SSN is not received within 90 days of enrollment, coverage for the child will be terminated retroactive to the date coverage began.  You may be required to reimburse the Plan for any expenses for which benefits were paid on behalf of an otherwise ineligible dependent. 

Medicare Part D Notice

HIPAA Privacy Notice

Michelle's Law

Children's Health Insurance Program Reauthorization Act

Women's Health & Cancer Rights Act    

Adult Child FAQs