HR-461 (4/17) 1

Retiree Medical & Dental Enrollment and Change Form Action requested due to: (check all that apply)

2a. Medical Plan:

1. Your Information (Please print clearly)

3a. Level of Medical Coverage 3b. Level of Dental Coverage

To ensure your request is processed as quickly as possible, please read the instructions and important information below: y If enrolling for coverage as a newly retired employee, you must submit this form within 30 calendar days of your date of

retirement. Coverage will then take effect on the first day of the month following your date of retirement. If your date of retirement is the first day of the month, coverage will become effective on that date.

y If requesting a change in enrollment due to a family status change or qualifying event, your request must be submitted within 30 calendar days of the status change or qualifying event, with changes in coverage effective the first day of the month after the qualifying event. You will need to supply the required supporting documentation. Find a complete list of documenta-tion requirements at www.fcps.edu; search keywords "Dependent eligibility".

Retirement* Transfer from Active Status (previously retired) Add Dependents Cancel Coverage (Cannot be reinstated) Drop Dependents

Death of Retiree/Employee (surviving spouse) Change Plans (Due to Medicare Eligibility) Change Plans (Due to Moving Out of Service Area) Open Enrollment Other (please describe):

Your Name (Last, First, Middle)

Your Home Address (street and apt. number)

City, State, Zip Code

E-mail Address

Date of Birth

Social Security Number (SSN) or Employee ID Number

Retirement Date

Home Phone

Alternate Phone

Cancel or Decline MedicalNote: Coverage can never be reinstated.

2b. Dental Plan:

Individual (No Medicare)

Mini-Family (You + 1) (No one has Medicare)

Family (You + 2 or more) (No one has Medicare)

Medicare Individual Medicare Mini-Family

(Both have Medicare) 1 Individual + 1 Medicare Mini-Family + 1 Medicare Family w/Medicare

(1 or more has Medicare)

*If you are declining medical or dental coverage as a new retiree, please see section 10, Deferred Health Option (DHO) on page 4.

Not Eligible

Must have been enrolled in coverage for 60 consecutive months immediately prior to my retirement.

Aetna PPO

Aetna DNOIf electing the DNO plan, you MUST contact Aetna Dental to designate a primary care dentist number (PCD).

Aetna/Innovation Health (Available to all eligible retirees)

CareFirst BlueChoice Advantage (Available to eligible retirees/dependents not eligible for Medicare)

Kaiser Permanente (Must reside in KP service area)

Kaiser Permanente Medicare (Must reside in KP Medicare service area)

Cancel or Decline DentalNote: Coverage can never be reinstated.

Not Eligible

Individual

Mini-Family (You + 1)

Family (You + 2 or more)

Are you the surviving spouse of an FCPS employee/retiree?If yes, please provide the name and SSN of the employee/retiree:

Yes No

(Additional form required, please contact HRConnection@fcps.edu)

For Benefits Office Use Only: Coverage Dates 5 Continuous Years? Direct Bill HL Annuity Deduction HL HL Deduction Amount Medical to yes no Direct Bill DN Annuity Deduction DN DN Deduction Amount Dental to yes no

2 HR-461 (4/17)

Last 4 digits of SSN __________________________

5. Dependent Enrollment Information (List only the names of those individuals you wish to ADD to coverage. To drop dependents use box 6. Skip to section 7 if no dependents.)

Name (Last, First, MI) andSocial Security Number (see box 9)

Gender, Relationship, and D.O.B. Plans to Enroll In

Medicare Info(Attach copy of Medicare card. If you are not enrolled in Medicare, please skip this section.)

Dependent Name

SSN Date of Birth (MM/DD/YYYY)

Medical Only

Dental Only

Both Medical & Dental

Medicare Effective Date: Part A ____________________________________

Part B ____________________________________

HIC# ____________________________________

Dependent Name

SSN Date of Birth (MM/DD/YYYY)

Medical Only

Dental Only

Both Medical & Dental

Medicare Effective Date: Part A ____________________________________

Part B ____________________________________

HIC# ____________________________________

Dependent Name

SSN Date of Birth (MM/DD/YYYY)

Medical Only

Dental Only

Both Medical & Dental

Medicare Effective Date: Part A ____________________________________

Part B ____________________________________

HIC# ____________________________________

Dependent Name

SSN Date of Birth (MM/DD/YYYY)

Medical Only

Dental Only

Both Medical & Dental

Medicare Effective Date: Part A ____________________________________

Part B ____________________________________

HIC# ____________________________________

6. Remove Dependents Complete only if YOU, the retiree, are retaining coverage and are requesting to remove the dependent(s) listed below from FCPS medical and/or dental coverage.

Name (Last, First, MI) Relationship Remove from

Date of Birth (MM/DD/YYYY)

Medical Only Dental Only Both Medical & Dental

Date of Birth (MM/DD/YYYY)

Medical Only Dental Only Both Medical & Dental

Date of Birth (MM/DD/YYYY)

Medical Only Dental Only Both Medical & Dental

Date of Birth (MM/DD/YYYY)

Medical Only Dental Only Both Medical & Dental

4. If you are electing FCPS Medical coverage, are you eligible for Medicare due to age or disability? Note: If not enrolling in FCPS medical coverage, go to Section 5 (if electing dental) or Section 7.

Yes No

If Yes, please provide your Medicare Claim Number: Part A Effective Date: Part B Effective Date:Please attach a copy of your card to this form.

I understand that it is my responsibility (and the responsibility of my covered dependents) to apply for Medicare when first eligible and provide a copy of my Medicare card to the Office of Benefit Services within 30 calendar days of receipt. Failure to apply for Medicare, including Medicare eligibility due to disability, will result in my claims paying as if Medicare were in place.Retiree Initials

Female Male

Spouse Child

Female Male

Spouse Child

Female Male

Spouse Child

Female Male

Spouse Child

Spouse Child

Spouse Child

Spouse Child

Spouse Child

HR-461 (4/17) 3

7. Acceptance or Opt Out

8. Submission

9. Notes

I hereby apply for or opt out of coverage on behalf of myself and each eligible dependent. I understand that coverage will be provided according to the terms and conditions of the contract between the insurance carrier(s) and Fairfax County Public Schools (FCPS), and applicable FCPS directives. I understand that I cannot cancel or change this election unless I experience a qualifying change in status or Special Enrollment Right under the Health Insurance Portability & Accountability Act (HIPAA), and that I must notify the Office of Benefit Services in the De-partment of Human Resources within 30 calendar days of any change in status which would cause any of my covered dependents to cease to be eligible for benefits under the health or dental plans due to the dependents death or loss of eligibility. If I fail to notify the Office of Benefit Services by filing the appropriate forms, I will be responsible for any claims and/or premiums paid on behalf of any individual who ceased to be eligible for benefits under the policy. It is my responsibility to keep informed of any changes to the plan that might affect my eligibility or my dependent(s) eligibility. I understand that once I cancel my medical, dental, or DHO coverage, I am not eligible to reenroll or change this election. I under-stand if I experience a qualifying change in status, that I must notify the Office of Benefit Services in the Department of Human Resources within 30 calendar days of any change in status which would cause any of my covered dependents to cease to be eligible for benefits under the health or dental plans. These qualifying events include eligibility for Medicare, the death of spouse, di-vorce (or legal separation in states where permitted), termination of employment (or termination of spouse's employment) that results in a change in eligibility, significant increase in cost of coverage, and/or loss of eligibility under spouse's health and/or dental plan. See the FCPS Retiree Benefits Handbook for more information.I understand that by completing and signing this enrollment form, I am making a binding election with regard to my benefits and that I am authorizing FCPS to take the necessary deduction from my retirement annuity to pay my share of the cost of coverage, including any retroactive deductions if required. If my retirement annuity will not accommodate the deduction, I will pay for my health benefits premiums by personal check. I also authorize deductions in future plan years unless I request an authorized change in my election.

Retiree Name (Last, First, M):__________________________________________________________________________

Retiree Signature: ________________________________________________ Date:__________________________

Scan and e-mail form to: HRConnection@fcps.edu

Or fax to: Office of Benefit Services at 571-423-5000

Or mail to: Department of Human Resources Office of Benefit Services, Suite 2700 8115 Gatehouse Road Falls Church, VA 22042

Remember to keep a copy of this form for your records. If you fax this form, also keep a copy of your fax machines transmission report as documentation that we received the form by the deadline. Forms that are received after applicable deadlines cannot be accepted.

Patient Protection and Affordable Care Act: Reporting requirements of the Patient Protection and Affordable Care Act require employers to file an annual report with the IRS that includes Social Security numbers (SSNs) for all individuals, including spouses, and dependent children enrolled in employer- sponsored medical plans (IRC Section 6055). This information will assist the IRS in determining whether individuals have secured health coverage to satisfy the individual mandate. You will be required to provide FCPS with the SSNs of all covered dependents to comply with this requirement. Medicare, Medicaid and SCHIP Extension Act of 2007: Medicare, Medicaid and SCHIP Extension Act of 2007, 42 U.S.C. 1395y (b) (7) & (8), mandates employers to submit SSNs of all medical plan enrollees who are age 45 and over or are Medicare eligible regardless of age to the Center for Medicare and Medicaid Services.

Questions?Contact the HR Client Service Center at 571-423-3000 or 1-800-831-4331 or

e-mail your questions to HRConnection@fcps.edu.

Last 4 digits of SSN __________________________

4 HR-461 (4/17)

Employee Name

Date of Birth

E-mail Address

I understand that by taking advantage of this one-time enrollment opportunity and enrolling in the Deferred Health Option (DHO), I may be able to enroll myself and my eligible dependents, if any, in an FCPS retiree medical and/or dental plan at a later date if I lose similar coverage for one of the following qualifying events:

y death of spouse

y divorce (or legal separation in states where permitted)

y termination of employment (or termination of spouse's employment) that results in a change in eligibility

y significant increase in cost of coverage

y loss of eligibility under spouse's health and/or dental plan (such as becoming eligible for Medicare)

I further understand that I may only enroll in the type of plan (medical and/or dental) which was lost as a result of the qualifying event, and that FCPS eligibility rules are subject to change.

I hereby authorize the deduction of my DHO premiums from my annuity check. I understand that DHO payment by annuity deduction is required of all DHO participants whose annuity check is sufficient to pay the DHO cost per month.

If my annuity will not cover the deduction, I will make monthly DHO payments by personal check, made payable to Fairfax County Public Schools. I understand that FCPS will not send monthly billing reminders and that my participation in the DHO program is contingent upon timely premium payment to FCPS.

Retiree Signature: ________________________________________________ Date:_______________________

10. Deferred Health Option (DHO) Complete only if YOU, as a new retiree, wish to enroll in the Deferred Health Option (DHO) at time of retirement.

Last 4 digits of SSN __________________________

This program is available only to employees hired prior to July 1, 2005 (and eligible former employees who elected coverage during a special enrollment period in 2006). To participate in the DHO program, you must be covered under an FCPS medical and/or dental program at the time you retire and have been for sixty consecutive months immediately prior to retirement. If you choose to participate in DHO, you will pay a monthly premium to reserve the right to enroll in the FCPS retiree medical and/or dental plans in the future if you lose coverage through your spouse's plan as a result of a qualifying event (see details below).

Spouse Name

Date of Birth

E-mail Address

HR-461 (4/17) 5

Language Assistance Services

ENGLISHATTENTION: If you speak English, language assistance services, free of charge, are available to you. Call 571-423-3200.

AMHARIC () : , , , . 571-423-3200 .

ARABIC ().3200-423-571: .

BENGALI ()

: , , , . 571-423-3200 .

CHINESE ()571-423-3200

FRENCH (Franais)ATTENTION : Si vous parlez franais , les services d'assistance de langues, gratuitement , sont votre disposition. Appelez 571-423-3200 .

GERMAN (Deutsch)ACHTUNG: Wenn Sie Deutsch sprechen , Sprachassistenzdienste sind kostenlos, zur Verfgung. Rufen Sie 571-423-3200 .

HINDI ()

: , , : , 571-423-3200

IBO (Igbo asusu)Nt : br na na-ekwu okwu n'ala Igbo , ass aka r , n'efu , d ka g. Akp 571-423-3200 .

KOREAN () :,. 571-423-3200.

KRU (s-w-po-ny)D n k dy gbo: j k m s-w-po-ny j n, n, wuu k k po-po n m gbo kpa. 571-423-3200.

PERSIAN FARSI ().3200-423-571: .

RUSSIAN () : , , , . 571-423-3200 .

SPANISH (Espaol)ATENCIN : Si usted habla espaol, servicios de asistencia lingstica, de forma gratuita, estn disponibles para usted. Llame a 571-423-3200.

TAGALOG (Tagalog)PAUNAWA: Kung nagsasalita ka ng Tagalog, maaari kang gumamit ng mga serbisyo ng tulong sa wika nang walang bayad. Tumawag sa 571-423-3200.

URDU () .3200-423-571: .

VIETNAMESE (Ting Vit)Ch : Nu bn ni ting Vit , cc dch v h tr ngn ng , min ph, c sn cho bn . Gi 571-423-3200 .

YORUBA (d Yorb)AKIYESI: Bi o ba ns d Yorb f ni iranlw lori d wa fun yin o. pe r-ibanisr yi 571-423-3200.

FCPS health plans comply with applicable Federal civil rights laws, including Section 1557 of the Affordable Care Act (Nondiscrimination in Health Programs and Activities). In compliance with the Act, FCPS health plans do not exclude people or treat them differently because of race, color, national origin, age, disability, or sex. FCPS health plans also prohibit denial of health care or health coverage based on an individuals sex, including discrimination based on pregnancy, gender identity, and sex stereotyping. The Plan also provides important protections for individuals with disabilities and enhances language assistance for people with limited English proficiency. Each tagline listed below reads, "If you speak [native language], language assistance services, free of charge, are available to you. Call 571-423-3200."