Forms

2017-18 Plan Year New Member Enrollment Form – Use this form to enroll in benefits when first eligible.

2017-18 Plan Year Open Enrollment Form –Use this form to enroll in or change plans during Open Enrollment.

2017-18 Plan Year Midyear Change Form – Use this form to update your benefits within 31 days of experiencing a qualified status change (QSC) event. Review the Qualified Status Change Matrix for more information.

Qualified Status change (QSC) Matrix – A Qualified Status Change is a change in work or family status that allows limited mid-year changes to benefit plans that effect eligibility for coverage.  These changes are allowed outside of the annual open enrollment period.  All changes must be reported to the Entity within 31 days.  (or as specified in each section)

Eligibility and Dependent Eligibility – Make Sure Everyone You Cover Meets One of These Definitions

Affidavit of Domestic Partnership – To add a domestic partner by affidavit to your coverage, you must submit this affidavit to your educational entity within five business days of the electronic enrollment date or the date your enrollment form was received by your Educational Entity.

Termination of Domestic Partnership  - Submit completed form to your Educational Entity.

Appeal Form- You may appeal to OEBB about dependent eligibility decisions, enrollment errors and omissions, Healthy Futures, or missed enrollment timeline.

Link to Individual Medical Plans, Dental Plans, and Vision Plans

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