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<ul><li><p>2018 OPEN ENROLLMENT </p><p>PRINTABLE INDEX OF FORMS AND NOTICES Health Insurance Enrollment Form (80/20 Plan, High Deductible Plan, Dental &amp; </p><p>Vision) </p><p> Health Savings Account (HSA) Application (ONLY for use if enrolling in the High </p><p>Deductible Health Plan) </p><p> HSA Terms, Conditions &amp; Signature Page </p><p> HSA Frequently Asked Questions (FAQs) </p><p> HSA Worksheet </p><p> Health Insurance Waiver </p><p> Affidavit of Declaration of Financial Interdependence </p><p> Extension of Dependent Coverage Form </p><p> Medicare Secondary Payer Employee Status Form </p><p>Health Reimbursement Arrangement (HRA) Forms HRA Enrollment Form </p><p> HRA Attestation Form </p><p> HRA Flow Chart </p><p> HRA Claim Form </p><p>Notices Summary of Benefits and Coverage (Anthem: AFSCME, CODE, NON, BT, Police </p><p>hires after 9/8/16, Fire hired after 4/27/16) </p><p> Summary of Benefits and Coverage (Anthem: Police hired before 9/8/16 and Fire </p><p>hired before 4/27/16) </p><p> Summary of Benefits and Coverage (High Deductible Plan with HSA) </p><p> Summary of Benefits and Coverage (Integrated HRA) </p><p> Womens Health and Cancer Rights &amp; Special Enrollment </p><p> Michelles Law &amp; Grandfather Status Notice </p><p> Childrens Health Insurance Program (CHIP) Notice </p><p> COBRA Notice Letter </p><p> Notice of City of Cincinnatis Health Plan Privacy Practices (HIPAA) </p><p> Medicare Part D Notice of Creditable Coverage </p><p> *NEW* EEOC Notice Regarding Wellness Programs </p><p> *NEW* Notice Regarding Wellness Program Spouse/Dependent Authorization </p><p> Glossary of Medical Terms </p><p>http://www.cincinnati-oh.gov/finance/assets/File/Risk/Health%20Form%202018.pdfhttp://www.cincinnati-oh.gov/finance/assets/File/Risk/HSA%20Bank%20Application.pdfhttp://www.cincinnati-oh.gov/finance/assets/File/Risk/HSA%20Terms%20%26%20Conditions.pdfhttp://www.cincinnati-oh.gov/finance/assets/File/Risk/HSA%20FAQs.pdfhttp://www.cincinnati-oh.gov/finance/assets/File/Risk/HSA%20Worksheet%202018.pdfhttp://www.cincinnati-oh.gov/finance/assets/File/Risk/Health%20Insurance%20Waiver%20Form%202018.pdfhttp://www.cincinnati-oh.gov/finance/assets/File/Risk/Affidavit%20of%20Declaration%20of%20Financial%20Interdependence.pdfhttp://www.cincinnati-oh.gov/finance/assets/File/Risk/State%20of%20Ohio%20Extension%20of%20Dependent%20Coverage%20Form.pdfhttp://www.cincinnati-oh.gov/finance/assets/File/Risk/Medicare%20Secondary%20Payer%20-%20Employee%20Status%20Form.pdfhttp://cincinnati-oh.gov/finance/assets/File/Risk/2017%20HRA%20Enrollment%20Form%208-23-16.pdfhttp://www.cincinnati-oh.gov/finance/assets/File/Risk/HRA%20Attestation.pdfhttp://www.cincinnati-oh.gov/finance/assets/File/Risk/HRA%20Benefit%20Flow%20Chart%20Final.pdfhttp://www.cincinnati-oh.gov/finance/assets/File/Risk/HRA%20Claim%20Form%20-%202018%20Final.pdfhttp://www.cincinnati-oh.gov/finance/assets/File/Risk/SBC%202018%20-%20Non-Rep%2C%20AFSCME%2C%20CODE%2C%20BT%2C%20Police-post%2C%20Fire-post.pdfhttp://www.cincinnati-oh.gov/finance/assets/File/Risk/SBC%202018%20-%20Fire%20(hired%20pre)%20Police%20(hired%20pre).pdfhttp://www.cincinnati-oh.gov/finance/assets/File/Risk/SBC%202018%20-%20HDHP.pdfhttp://www.cincinnati-oh.gov/finance/assets/File/Risk/HRA%20COC%20SBC%202018.pdfhttp://www.cincinnati-oh.gov/finance/assets/File/Risk/Women's%20Health%2C%20Cancer%20Rights%2C%20Special%20Enrollment.pdfhttp://www.cincinnati-oh.gov/finance/assets/File/Risk/Michelle's%20Law%20and%20Grandfather%20Notice.pdfhttp://www.cincinnati-oh.gov/finance/assets/File/Risk/CHIP%20Notice%202017.pdfhttps://cincinnati-oh.gov/finance/assets/File/Risk/COBRA%20Notice%2010-9-17.pdfhttps://cincinnati-oh.gov/finance/assets/File/Risk/COBRA%20Notice%2010-9-17.pdfhttp://www.cincinnati-oh.gov/finance/assets/File/Risk/NOTICE%20of%20City's%20Privacy%20Practices.pdfhttp://www.cincinnati-oh.gov/finance/assets/File/Risk/Notice%20of%20Creditable%20Coverage%20Rx%20-%202018.pdfhttp://www.cincinnati-oh.gov/finance/assets/File/Risk/EEOC%20Notice%20on%20Wellness%20Programs.pdfhttp://www.cincinnati-oh.gov/finance/assets/File/Risk/Notice%20on%20Wellness%20Programs_Spousal%20Authorization.pdfhttp://www.cincinnati-oh.gov/finance/assets/File/Risk/Glossary%20of%20Health%20Coverage%20and%20Medical%20Terms(1).pdf</p></li><li><p>Risk Use Only: </p><p>Effective Date of </p><p>Waiver </p><p>Health Insurance Waiver Form </p><p>Please circle your union: AFSCME BUILDING TRADES CODE FIRE NON-REPRESENTED POLICE Name Employee ID# __ SS# Department/Division </p><p>Present coverage: [ ] Anthem 80/20 </p><p>[ ] Single </p><p>[ ] Family [ ] Anthem High Deductible Plan &amp; HSA </p><p>[ ] Single </p><p>[ ] Family [ ] HRA </p><p>[ ] Single </p><p>[ ] Family [ ] Do not presently have insurance with the city </p><p> I would like to waive: [ ] Health Insurance [ ] Dental Insurance* [ ] Vision Insurance* </p><p>Effective Date: ________________________________ </p><p>Reason for waiving coverage: </p><p>Currently have insurance through </p><p>[ ] Spouse/Equal Partners employer </p><p>[ ] Another City employee </p><p>[ ] City of Cincinnati Retirement </p><p>[ ] Other Insurance Carrier ID # EP/Spouses SS# I hereby waive the insurance coverage, as indicated above, through the City of Cincinnati. I understand by waiving this coverage, I will not be able to re-enroll until the City of Cincinnatis </p><p>Open Enrollment or unless I have a qualifying event or lose my other insurance coverage. Signature Date *FOP and AFSCME union employees need to contact their union regarding dental and vision benefits. *Management employees dental and vision benefits are 100% employer paid. Form IN </p><p>Revised 08/2017 </p></li><li><p> J&amp;K Third Party Administrator </p><p>Integrated HRA Enrollment Form City of Cincinnati Employees EMPLOYER INFORMATION </p><p>Employer Name: City of Cincinnati </p><p>Please send completed enrollment forms and information to: </p><p>City of Cincinnati Risk Management - 805 Central Avenue, Suite 100 - Cincinnati, OH 45202 </p><p>Fax: 513.352.3761 / Email: Phyliss.Ward@Cincinnati-oh.gov For Questions Call: 877-872-4232 or email CinciHRA@JandKcons.com </p><p>I am enrolling in the Integrated HRA for: Single Family </p><p>PARTICIPANT INFORMATION </p><p>Employee Name: </p><p>Birthdate: </p><p>Hire Date: </p><p>Social Security No: Employee ID No.: Gender: M F </p><p>Date Eligible for HRA: </p><p>Home Street Address: </p><p>City: State: Zip Code: </p><p>Home Phone: Work Phone: Cell Phone: </p><p>Email Address: Fire, Police or Union Affiliation: </p><p> SPOUSE INFORMATION </p><p>Spouse Name: </p><p>Birthdate: Gender: M F </p><p>Social Security No: Spouses Employer: </p><p>Spouses Pay Period for Health Premium Contribution: Monthly Semi-Monthly Bi-Weekly Weekly </p><p>Spouses Health Premium Contribution Pay Period: ** INCLUDE DOCUMENTATION, I.E. PAYSTUB OR BENEFIT STATEMENT </p><p>Are Spouses Health Premium Contribution / Deductions: Before Taxes (OR) After Taxes </p><p>* Contribution per pay period should include the cost for Medical only; Dental &amp; Vision are not covered under this plan. </p><p>If submitting a spousal paystub, please circle the contribution/deduction amount on the submitted paystub. DO NOT BLACKOUT THE PAY PERIOD. </p><p>** Send a copy of your spouses paystub that shows the NEW contribution/deduction amount for the effective date listed above. This amount should reflect the cost of adding you and/or any dependents to the spouses plan. Please indicate if the medical deduction DOES NOT come out of every paycheck. Some </p><p>may be only once a month or the first two pays of each month. </p><p>* If your spouses plan has a High Deductible with an HSA, Health Savings Account, you are not eligible to participate in the Integrated HRA, unless the </p><p>spouses employer allows your spouse to drop the HSA portion of the plan. If your primary health insurance coverage is through Medicare, Tricare, or </p><p>any City of Cincinnati sponsored health plan you are not eligible for the Integrated HRA. </p><p>***You must provide proof of dependent eligibility i.e. marriage certificate, birth certificate, etc.*** </p><p>DEPENDENT INFORMATION: (Attach a separate sheet if additional space is needed for additional dependents) </p><p>Name: Date of Birth: Gender: Male Female </p><p>Social Security No: Name: Date of Birth: Gender: Male Female </p><p>Social Security No: Name: Date of Birth: Gender: Male Female </p><p>Social Security No: </p><p>PARTICIPANT AUTHORIZATION </p><p>I hereby authorize the City of Cincinnati to enroll me into the employer sponsored Integrated HRA. I agree to comply with the terms and conditions of the </p><p>plan. I understand that if the health premium contributions are deducted on an After-Tax Basis, this will result in all premium reimbursements being income </p><p>tax free. However, if the contributions are on a Pre-Tax Basis, the premium reimbursements will be fully taxable. In either case, the deductible, co-pay and </p><p>co-insurance reimbursements will remain tax free. I further understand that if any current contributions are made to an HDHP/HSA, I am not eligible to </p><p>participate in the Integrated HRA offered through the City of Cincinnati. </p><p>Employee Signature: Date: </p><p>mailto:Phyliss.Ward@Cincinnati-oh.govmailto:CinciHRA@JandKcons.com</p></li><li><p>ATTESTATION OF ENROLLMENT CITY OF CINCINNATI EMPLOYEES </p><p>IN A NON-CITY OF CINCINNATI EMPLOYER GROUP HEALTH PLAN </p><p>Return form to: Risk Management, 805 Central Avenue, Suite 100 Employee Name: Work Phone: </p><p> City Employee ID: Email: </p><p>This form applies to individuals who participate in the Integrated HRA and hereby waive </p><p>enrollment in the City of Cincinnati Anthem 80/20 medical plan. </p><p> To participate in this program, employees, spouses/equal partners, and dependents must provide proof of </p><p>enrollment in a non-City of Cincinnati employer group health plan. By signing below, I, a City </p><p>Employee, certify that: </p><p> The City of Cincinnati has offered me a group health plan (the Anthem 80/20 plan) that provides </p><p>minimum value within the meaning of section 36B(c)(2)(C)(ii) of the Internal Revenue Code </p><p>(basically a plan rated bronze or better under the Patient Protection and Affordable Care Act of </p><p>2010). </p><p> I am enrolled in a group health plan of another employer (such as my spouse/equal partners </p><p>employer) that provides minimum value within the meaning of section 36B(c)(2)(C)(ii) of the </p><p>Internal Revenue Code (basically, bronze or higher) and that does not consist solely of a health </p><p>reimbursement arrangement (HRA) under the Internal Revenue Code (that is, a plan that </p><p>reimburses health care expenses only up to a dollar limit). </p><p> I understand that by enrolling in this HRA, I am waiving participation in the City of Cincinnati </p><p>Anthem 80/20 Plan. </p><p> For confirmation that the other plan meets the IRS's definition of minimum value and does not consist </p><p>solely of an HRA, please contact the benefits coordinator at the other employer </p><p>Employee Signature Date </p><p>Spouses Signature Date </p><p> HRA information contact: </p><p>J &amp; K CONSULTANTS, INC. </p><p>2605 Nicholson Rd., Suite 1140 </p><p>Sewickley, PA 15143 </p><p>Toll Free Phone: 877-872-4232 </p><p>CinciHRA@JandKcons.com </p><p>Toll Free Fax: 877-599-3724 </p><p>Coc.JandKcons.com </p><p>mailto:CinciHRA@JandKcons.com</p></li><li><p>2018 City of Cincinnati Employee HRA Benefit </p><p>Review this Flow Chart to determine if you are eligible to enroll in the HRA </p><p> I have access to an alternate (non-city sponsored) Group </p><p>Health Plan </p><p>Helpful Definitions </p><p>HRA: Health Reimbursement Arrangement. Reimburses employees and dependents for eligible health care expenses and premium expenses incurred under non City sponsored group health coverage. </p><p> Yes. </p><p>Continue to see if you are eligible to enroll in the HRA </p><p>I am currently enrolled in the City Sponsored Group Anthem </p><p>80/20 Health Plan </p><p>OR </p><p>I am a New Employee </p><p>Yes. </p><p>I am eligible to enroll in he HRA </p><p> * Only the employee and the </p><p>dependents currently covered by the Anthem 80/20 Plan are eligible to be </p><p>enrolled into the HRA </p><p>No. </p><p>I am not Eligible to enroll in the HRA and must remain or enroll in the City Sponsored Group Anthem </p><p>80/20 Health Plan </p><p>I am NOT currently enrolled in the City Sponsored Group Anthem 80/20 </p><p>Health Plan for Single or Family Coverage </p><p>No. </p><p>I am not eligible to enroll in the HRA </p><p>Alternate Group Health Plan: Means any group health coverage, (other than a medical plan sponsored by the City of Cincinnati) available to an Employee, such as through the Employees spouse/equal partner, another employer of the Employee, or group coverage available to the Employee from any other source including but not limited to eligible retiree benefit programs, other than Medicare, Tricare or the City Retirement System. </p><p>Health Care Expenses: Deductibles, Co-Pays and Co-Insurance for eligible expenses incurred under the alternate group plan. </p><p>Premiums: Amount deducted from your spouse/equal partner's pay for the alternative group plan that is reimbursable in an amount that exceeds the cost of the premium that you would pay on the Citys plan. If the cost of your alternate coverage increases due to dependent additions, you will receive a reimbursement. If there is no premium increase, you will not receive a </p><p>Note: If at any point an employee loses access to their alternate group health plan - a Qualifying Event - they will be able to enroll in the City Anthem 80/20 Health Plan </p><p> This plan is administered by J&amp;K Consultants, 2605 Nicholson Rd., Suite 1140, Sewickley, PA 15143 </p><p>877-872-4232 (Toll Free Office) 877-599-3724 (Toll Free Fax ) CinciHRA@JandKcons.com </p><p>How Does the HRA Work? </p><p>reimbursement. </p><p>Calendar Year Maximum: The maximum amount that will be reimbursed for health care expenses and premiums are: </p><p>$5,000/Single </p><p>$14,300 /Family </p><p>Enroll Incur File Get Reimbursed </p><p>Enroll in the alternate Group Health Plan. </p><p>Complete the Citys HRA Enrollment Form. </p><p>Complete the Citys Attestation Form. </p><p>Provide proof of your alternate plan in order to receive premium reimbursements. </p><p>Use HRA ID Card to pay out of pocket expenses at the point of service. </p><p>Doctors visits </p><p>Prescriptions </p><p>Preventive Screenings </p><p>Urgent care </p><p>Treatments </p><p>Procedures </p><p>Surgeries </p><p>ETC. </p><p>Present your alternate health plan Health Insurance ID Card. </p><p>Next, present your HRA ID Card for Co-pays, Deductibles and Out of Pockets. </p><p>Your Provider will first file claims with your alternate Health Plan. </p><p>After your provider has received payment for the claim filed, any eligible expense will then be filed by your provider and paid by the HRA Plan. </p><p>Most claims will be paid directly to the provider through use of the ID card. If YOU pay an out of pocket eligible expense, you can always submit a paper claim for reimbursement. (Some pharmacies such as Walgreens, CVS and Mail Order Facilities will not accept the HRA ID Card and will require you to file a paper claim.)You will get a check mailed to your home. </p><p>Premium reimbursements will be issued to you through your City paycheck. If your premium contributions are after tax, you will get a check mailed to your home. </p><p>mailto:CinciHRA@JandKcons.com</p></li><li><p>Following are important notices regarding your health benefits. These notices are intended to </p><p>make you aware of certain rights and obligations under the benefits plan. </p><p> Womens Health and Cancer Rights Act of 1998 (W HCRA) </p><p>If you have had or are going to have a mastectomy, you may be entitled to certain benefits under </p><p>the Womens Health and Cancer Rights Act of...</p></li></ul>


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