Flexible Benefits  

Plan Summary 

January 1 – December 31, 2019  

            Revised 11/15/2018 

 

                         

 

 

 

 

 

 

 

 

 

 

 This Flexible Benefits Plan Summary is a summary description of benefits under the Flexible Benefits Plan. It is not a contract setting forth all terms and conditions for the determination of eligibility and the payment of benefits by the Flexible Benefits Administrator, or its designee. Such provisions are contained within the Plan Document of the Flexible Benefits Plan for the State of Louisiana. Oversight responsibility is assigned to the Division of Administration, Office of Group Benefits (OGB). OGB retains the right to amend any aspect of any plan, to discontinue contributions, and to terminate any plan at OGB’s discretion, and in accordance with applicable laws.   

 

For Eligible Employees in the Following Payroll Systems. This list is current as of November 15, 2018. As Participant Employers may be added or deleted throughout the Plan Year, please confirm with OGB whether your employer participates in the Flexible Benefits Plan. Administration - HCM (HR) System

Boards and Commissions Louisiana Board of Examiners of Nursing Facility Administrators Louisiana State Board of Cosmetology Louisiana Board of Massage Therapy Louisiana State Board of Medical Examiners Louisiana Board of Nursing Louisiana State Board of Social Work Examiners Louisiana Board of Physical Therapy Examiners Louisiana State Board of Wholesale Drug Distributors Louisiana Cemetery Board Louisiana State Licensing Board of Contractors Louisiana Motor Vehicle Commission Louisiana Used Motor Vehicle Commission Louisiana Patient’s Compensation Fund Metropolitan Human Services District Louisiana Pilotage Fee Commission New Orleans City Park Louisiana Private Security Examiners New Orleans Redevelopment Authority Louisiana Professional Engineering and Land Surveying Board New Orleans Regional Planning Commission Louisiana State Board of Certified Public Accountants State Plumbing Board of Louisiana U.S.S. Kidd Commission

Charter Schools and School Boards Beekman Charter School Louisiana Key Academy Cameron Parish School Board Maxine Gardina Charter School D’Arbonne Woods Charter School Northeast Claiborne Charter School Delhi Charter School Slaughter Community Charter School Delta Charter School Special Education District 1 East Carroll Parish School Board Tallulah Charter School Glencoe Charter School Colleges and Universities Baton Rouge Community College McNeese State University Bossier Parish Community College Nicholls State University Delgado Community College Southeastern Louisiana University Grambling State University University of Louisiana at Lafayette Louisiana Community and Technical College System University of Louisiana at Monroe Louisiana Tech University University of New Orleans

Housing Authorities

East Baton Rouge Parish Housing Authority Louisiana Housing Corporation and Finance Agency Housing Authority of Jefferson Parish Ruston Housing Authority Housing Authority of New Orleans

Judicial Branch Criminal District Court of New Orleans Jefferson Parish Judges Eighteenth Judicial District Court Louisiana Law Institute Fifth Circuit Court of Appeal Office of the Judicial Administrator Florida Parishes Juvenile Justice Commission Second Circuit Court of Appeal Fourth Circuit Court of Appeal Supreme Court of Louisiana Fourth Judicial District Court Thirty-Seventh Judicial District Court

Twenty-Fourth Judicial District Court

Legislative Branch Legislative Budgetary Control Council Louisiana State Senate Legislative Fiscal Office Office of the Legislative Auditor

Levee Districts and Ports Atchafalaya Basin Levee District Orleans Levee District Caddo Levee District Sabine River Authority East Jefferson Levee District St. Bernard Port, Harbor and Terminal District Greater Lafourche Port Commission Southeast LA Flood Protection Authority East Lake Borgne Levee District – East The Port of Morgan City Natchitoches Levee and Drainage District The Port of South Louisiana Non-Flood Protection Asset Management Authority

Retirement Systems Firefighters Retirement System of Louisiana Louisiana State Police Retirement System Louisiana School Employees’ Retirement System Municipal Police Employees’ Retirement System Louisiana State Employees’ Retirement System Teachers’ Retirement System of Louisiana

 

OGB Flexible Benefits Plan Year January 1 through December 31, 2019

 

Introduction 

The State of Louisiana offers a Flexible Benefits Plan that gives you a way to take home more money in every paycheck! Your eligible premiums and contributions for dependent care and medical care are deducted from your gross salary – before taxes. If applicable, this might produce lower Social Security benefits. This means you may pay less in taxes and your spendable income increases.  

Benefit Options under the Flexible Benefits Plan 

Premium Conversion – allows you to pay the employee share of your eligible health coverage and life insurance premiums before taxes are calculated. By enrollment in an OGB health plan or term life insurance, Eligible Employees are automatically enrolled in the Flexible Benefits Plan and the Premium Conversion option.  Also, by enrolling in a voluntary product that is eligible for Premium Conversion (dental, vision, cancer, etc.), Eligible Employees are automatically enrolled in the Flexible Benefits Plan and the Premium Conversion option. Once enrolled in the Premium Conversion option, enrollment will automatically continue from year‐to‐year, unless the employee chooses to end participation in all coverage during Annual Enrollment, or in some cases, when experiencing an OGB Plan‐Recognized Qualified Life Event.  

General‐Purpose Health Care Flexible Spending Arrangement (GPFSA) – allows you to use pre‐tax dollars to pay eligible out‐of‐pocket medical, dental and vision care expenses for you, your spouse and/or your federal tax dependents – even if they are not covered by your health plan.  Employees cannot participate in the GPFSA and a Health Savings Account (HSA) at the same time.  

Limited‐Purpose Dental/Vision Flexible Spending Arrangement (LPFSA) – limited to eligible out‐of‐pocket dental and vision expenses only. 

o The LPFSA is available for all Eligible Employees, as defined in the Flexible Benefits Plan document, including employees enrolled in the Pelican HSA775 health plan option.  

o Employees cannot participate in both the GPFSA and the LPFSA at the same time. 

 

Dependent Care Flexible Spending Arrangement (DCFSA) – allows you to use pre‐tax dollars to pay eligible dependent care expenses for your child or for a spouse, parent or other dependent, who is incapable of self care.  

Health Savings Account (HSA) – allows you and your employer, if applicable, to contribute pre‐tax dollars to an OGB Health Savings Account. Eligible Employees can only contribute to the Health Savings Account option when they also choose the qualifying Pelican HSA775 health plan offered by the Office of Group Benefits and are not covered by any disqualifying non‐high‐deductible health plan. 

 Eligible Employees can participate in the General‐Purpose Health Care FSA option, the Limited‐Purpose Dental/Vision FSA option or the Dependent Care FSA option, even if they are not enrolled in an OGB health plan or the Premium Conversion option!   Eligibility Requirements for Flexible Benefits Plan Participation 

Enrollment in the Flexible Benefits Plan is limited to Eligible Employees, as defined in the Flexible Benefits Plan document.  

Rehired retirees who are employed as active full‐time employees are eligible for all options, except the Pelican HSA775, if they otherwise meet the definition of an Eligible Employee.   

Enrollment in the General‐Purpose FSA, Limited‐Purpose FSA and Dependent Care FSA is limited to Eligible Employees in a 

 

participating payroll system. Eligible Employees can enroll upon commencing employment during Annual Enrollment, or any special enrollment period announced by OGB, or, in some cases, after experiencing an OGB Plan‐Recognized Qualified Life Event. They must re‐enroll each year to continue participation and agree to pay the annual administrative fee ($34.80 for the 2019 Plan Year per each FSA, effective 01/01/2018, which is $2.90 per month per each FSA, which is $1.45 per pay period per each FSA). Failure to pay the administrative fee will result in denial of the privilege of participation in any of the FSAs. 

 

A plan member’s election to participate in the GPFSA, the LPFSA and/or the DCFSA is irrevocable for the duration of the Plan Year. (See the Health Care; Dependent Care; and Flexible Benefits Plan Documents; Article 4; located on the OGB website.) 

 

New hires who are Eligible Employees must enroll within their first thirty (30) days of employment. The participation will be effective the first of the month after the employee’s first full calendar month of employment. For example: if the hire date is August 20, the effective date is October 1.  

 

Employees who experience an OGB Plan‐Recognized Qualified Life Event must timely submit proper documents to their human resources department as indicated on the OGB Plan‐Recognized Qualified Life Event chart (see Exhibit 1). Human Resources will submit the documents and a completed GB‐01 form to OGB for processing. 

 To help HR personnel expedite issues, agencies must use the email addresses for the following subjects: Prudential Life Insurance –  PrudentialLifeIns@la.gov  Health Savings Accounts (HSA) – HealthSavingsAccounts@la.gov Flexible Spending Arrangements (FSA) –  FlexibleSpendingAccounts@la.gov  Statewide Products –  Statewideproducts@la.gov  COBRA and FSA COBRA –   COBRA@la.gov  Eligibility – Ogb.help@la.gov  

 Enrollment Requirements and Forms  If you are an Eligible Employee, you may enroll in one of three ways (effective for January 1, 2019):  1.)  Through the Annual Enrollment portal; 2.)  Through your Human Resources department; or 3.)  If you have experienced an OGB Plan‐Recognized Qualified Life Event, a qualified life event recognized by the Plan during the calendar year (outside of the Annual Enrollment period), you must contact your Human Resources department.  Enrollment forms are available from your human resources or payroll office.  To enroll, an Eligible Employee must complete and submit all appropriate enrollment forms to the human resources or payroll office.   The human resources or payroll office must complete all required payroll fields on the enrollment forms.   Note about the Flexible Spending Arrangement Enrollment/Stop Form – A copy of the GB‐02 Flexible Spending Arrangement Enrollment/Stop Form, completed during Annual Enrollment, does not need to be submitted to the Flexible Benefits Plan Administrator.  Non‐la.gov/HCM agencies can enroll their employees in a FSA through e‐Enrollment during Annual Enrollment.  Mid‐year enrollment or changes (for OGB Plan‐Recognized Qualified Life Events) ‐ Both la.gov/HCM and non‐la.gov/HCM agencies must submit mid‐year GB‐01 forms and supporting documentation to OGB.    

Current participants who want to  

continue participation:

Premium Conversion   No action necessary

Flexible Spending Arrangement options 

Must enroll each year 

Health Savings Account   Must enroll each year   

OGB Flexible Benefits Annual Enrollment               

October 1 through November 15, 2018

 

Less Taxes = More Spendable Income 

 Participation in the State of Louisiana Flexible Benefits Plan may help you pay less in taxes, which increases your spendable income. The examples below show how you can save.    

 

Example 1: Premium Conversion 

An Eligible Employee earns $2,000 per month and is in the 20% tax bracket.   With Flexible Benefits  Without Flexible 

Benefits 

Monthly Salary  $2,000.00  $2,000.00 

Pre‐Tax Health Plan Premium  ‐420.00  ‐0.00 

Taxable Income  $1,580.00  $2,000.00 

Taxes (20%)  ‐316.00  ‐400.00 

After‐Tax Premium  ‐0.00  ‐420.00 

Spendable Income  $1,264.00  $1,180.00 

$84 monthly savings x 12 months = $1,008.00 yearly savings     

Example 2: Premium Conversion and Dependent Care FSA 

An Eligible Employee earns $3,000 per month and is in the 25% tax bracket.   With Flexible Benefits  Without Flexible 

Benefits 

Monthly Salary  $3,000.00  $3,000.00 

Monthly Pre‐Tax Premium  ‐420.00  0.00 

Monthly DCFSA Deduction  ‐400.00  0.00 

Monthly DCFSA Administrative Fee  ‐3.00  0.00 

Monthly Taxable Income  $2,177.00  $3,000.00 

Monthly Taxes (25%)  ‐544.25  ‐750.00 

Monthly After‐Tax Premium  0.00  ‐420.00 

Monthly After‐Tax Dependent Care Cost 

0.00  ‐400.00 

Monthly Spendable Income  $1,632.75    $1,430.00 

$202.75 monthly savings x 12 months = $2,433.00 yearly savings               

 

Premium Conversion  

This benefit of the Flexible Benefits Plan allows you to pay eligible health coverage and insurance premiums before taxes are taken out of your salary. Your net income is increased because you pay lower taxes.   There is no administrative fee for participating in the Premium Conversion option. Once you enroll in this option, you will automatically continue in it from one year to the next year unless you choose to end participation. Currently participating employees who want to stop participation in the Flexible Benefits Plan for the upcoming plan year must complete and submit a GB‐02 Flexible Spending Arrangement Enrollment/Stop Form during Annual Enrollment to their human resources or payroll office. However, in discontinuing participation in Premium Conversion, you also are choosing to discontinue health coverage offered by the OGB.  

Who is eligible to participate? Eligible Employees (as defined in the Flexible Benefits Plan document) who are employed in one of the participating payroll systems are eligible to participate.  Products Eligible for Premium Conversion The following is a list of companies and the products they offer that are eligible for Premium Conversion through the HCM (ISIS/HR) payroll system. Other payroll systems may offer some of these products. Check with your human resources or payroll office to see which eligible products are offered through your payroll system.   

Products Eligible for Premium Conversion 

Office of Group Benefits  Pelican HRA1000; Pelican HSA775; Magnolia Local; 

Magnolia Local Plus; Magnolia Open Access; Vantage 

Medical Home HMO; Account Basic and Basic Plus 

Supplemental Term Life (Prudential) – employee only 

American Family Life Assurance (AFLAC)  Cancer 

Hospital Indemnity 

Intensive Care 

American Heritage Life Insurance Co.   Cancer 

American Public Life Insurance Co.   Dental 

Colonial Life and Accident Insurance Co.   Cancer                              Hospital Indemnity  

Delta Dental Insurance Co.   Dental 

Guaranty Assurance Co.   Dental (DINA) 

Guaranty Income Life  Dental (Q‐Dent) 

Loyal American Life Insurance Co.  Cancer                               Heart 

MS of A Dent‐All Plan, Inc.  Dental, Vision                 Teeth Whitening 

Rx                                        Weight Loss 

Hearing                             Massage Therapy 

Cosmetic Surgery          Health Care Supplements 

National Teachers Associates Life  Cancer                               Heart 

Starmount Life Insurance Co.  Dental                               Vision 

Trans America Life Insurance Co.  Cancer                               Heart 

 

 

  

 

Below are additional products eligible for Premium Conversion that are not offered through the la.gov/HCM payroll system but are offered through other payroll systems.  

 

Products Eligible for Premium Conversion (Not HCM) 

Allstate Corporation  Cancer 

American Family Life Assurance (AFLAC)  Dental                                 Vision 

American Public Life Insurance Co.  Cancer 

Ameritas Group  Dental 

Brokers National LIfe  Dental 

Crescent (Meritain Health)  Dental                                  Vision 

Davis  Vision 

Delta  Dental 

MetLife  Dental 

Spectera  Vision 

United Concordia Dental Insurance  Dental 

UnitedHealthcare  Vision 

VSP (Vision Service Plan Insurance Co.)  Vision 

 

 The Internal Revenue Service does not allow insurance products with cash value or return‐of‐premium riders to be included in the Premium Conversion option. 

 

 

  

             * To be eligible for reimbursement, some treatments, prescription 

drugs, or services deemed cosmetic in nature require written 

proof of medical necessity from your health care provider. 

*** The effective date for glasses and prosthetic devices is the 

date the item is available for pickup, not the date ordered. 

**** Verify with your health care provider (prior to the beginning of the upcoming plan year) that you are a suitable candidate for any surgical procedure before committing the money to your GPFSA. 

 

 

 

General‐Purpose Health Care Flexible Spending Arrangement (GPFSA)  Who is eligible to participate? Enrollment in the GPFSA is limited to Eligible Employees in a participating payroll system. Employees can enroll during Annual Enrollment, or, in some cases, after experiencing an OGB Plan‐Recognized Qualified Life Event. They must re‐enroll each year to continue participation and agree to pay the annual administrative fee. Failure to pay the administrative fee will result in denial of the privilege of participation in any of the FSAs.  New hires who are Eligible Employees must enroll within their first thirty (30) days of full‐time employment, and FTEs will be allowed an enrollment period as provided under applicable law. The participation will be effective the first of the month after the employee’s first full calendar month of employment. For example: if the hire date is August 20, the effective date is October 1.  Participation in the GPFSA ends on the date of termination of employment. FSA COBRA is available. 

Some Examples of Eligible Medical Expenses 

Acupuncture 

Ambulance service 

Chiropractic care 

Contact lenses (corrective ) * 

Dental fees 

Diagnostic tests 

Doctor fees 

Drug addiction or alcoholism treatment 

Drugs and medicines with a prescription 

Experimental medical treatment 

Eyeglasses *** 

Guide dogs 

Hearing aids and exams 

Injections and vaccines 

In‐vitro fertilization 

Nursing services * 

Optometrist fees 

Orthodontic treatment * 

Nicotine withdrawal prescription drugs 

Reconstructive surgery after mastectomy **** 

Smoking cessation programs 

Surgery **** 

Transportation for local medical care 

Wheelchairs 

Some Examples of Ineligible Medical Expenses 

Health premiums 

Health or fitness club membership fees, unless medically necessary 

Cosmetic surgery not deemed medically necessary to alleviate, mitigate, or prevent a medical condition 

Minimum Deposit  Maximum Deposit 

$600*  $2,700* *Unless otherwise required by the IRS for the 2019 Plan Year. 

 Administrator and VISA debit cards for GPFSA ‐ Discovery Benefits, Inc. is the third‐party administrator who will administer the Flexible Spending Arrangements for the Office of Group Benefits. Each participant in a GPFSA will receive a green Discovery Benefits VISA Benefits Debit Card, which can be used to pay providers who accept VISA for eligible expenses. The full amount of elected GPFSA funds are available immediately. The debit card is reloadable each year as long as the Employee re‐enrolls. The debit card will be replaced before the expiration date.   General‐Purpose Health Care FSA Reimbursement Claim Process GPFSA reimbursement request forms and guidelines for filing claims and receiving reimbursement are available on the OGB website under the Services/Flexible Benefits tab.   You can have immediate access to your FSA dollars with the FSA card and use the FSA card for purchases of non‐medicine items such as bandages, reading glasses and diabetes monitoring supplies. You must obtain a receipt and fax a copy of the receipt to the Flexible Benefits Plan administrator within two weeks upon request.  The FSA card may be used for over‐the‐counter purchases such as allergy and cold medicines, ointments and pain relievers. For prescription items, Participants must submit a doctor’s prescription, a claim form and an itemized receipt for each prescribed item purchased. Participants may only need to submit each prescription once during each plan year and can be reimbursed by check or by direct deposit.  The Grace Period modifies the IRS “use or lose” rule. Participants have until March 15 to incur eligible expenses for reimbursement from unused amounts remaining at the end of the immediately preceding plan year, which ends December 31. The Run‐Out Period is the time period after the end of the Grace Period, starting March 16 and ending April 30, during which participants can request reimbursement for eligible expenses incurred during the preceding plan year. Reimbursement requests must be received by April 30 to be paid from funds remaining at the end of the immediately preceding plan year. 

 

Limited‐Purpose Dental/Vision Flexible Spending Arrangement (LPFSA) 

 

Who is eligible to participate? Enrollment in the LPFSA is limited to Eligible Employees in a participating payroll system. Eligible Employees can enroll during Annual Enrollment, or in some circumstances when they experience an OGB Plan‐Recognized Qualified Life Event. They must re‐enroll each year to continue participation and agree to pay the annual administrative fee. Failure to pay the administrative fee will result in denial of the privilege of participation in any of the FSAs.  New hires who are Eligible Employees must enroll within their first thirty (30) days of full‐time employment.  FTEs may enroll during an enrollment period allowed by applicable law. The participation will be effective the first of the month after the employee’s first full calendar month of employment. For example: if the hire date is August 20, the effective date is October 1.  Participation in the LPFSA ends on the date of termination of employment. FSA COBRA is available.  

Minimum Deposit  Maximum Deposit 

$600*  $2,700* *Unless otherwise required by the IRS for the 2019 Plan Year. 

 The LPFSA is limited to eligible out‐of‐pocket dental and vision expenses only. Employees cannot participate in the GPFSA and LPFSA at the same time. However, an Eligible Employee who enrolls in the Pelican HSA775 health plan option can participate in the LPFSA.  Administrator and VISA debit card for LPFSA ‐ Discovery Benefits, Inc. is the third‐party administrator 

who will administer the Flexible Spending Arrangements for the Office of Group Benefits. Each participant in a LPFSA will receive a green Discovery Benefits VISA Benefits Debit Card, which can be used to pay providers who accept VISA for eligible expenses for LPFSA. The full amount of elected LPFSA funds are available immediately. The debit card is reloadable each year as long as the employee re‐enrolls. The debit card will be replaced before the expiration date.  Limited‐Purpose Dental/Vision FSA Reimbursement Claim Process LPFSA reimbursement request forms and guidelines for filing claims and receiving reimbursement are available on the OGB website under the Services/Flexible Benefits tab.  You must obtain a receipt and fax a copy of the receipt to the Flexible Benefits Plan administrator within two weeks upon request.  The Grace Period modifies the IRS “use or lose” rule. Participants have until March 15 to incur eligible expenses for reimbursement from unused amounts remaining at the end of the immediately preceding plan year, which ends December 31.  The Run‐Out Period is the time period after the end of the Grace Period, starting March 16 and ending April 30, during which participants can request reimbursement for eligible expenses incurred during the preceding plan year. Reimbursement requests must be received by April 30 to be paid from funds remaining at the end of the immediately preceding plan year. 

 

Qualified Reservist Distribution (QRD) 

for Eligible GPFSA or LPFSA Participants Called to Active Duty 

A Qualified Reservist Distribution (QRD) is a refund made to an employee of all or a portion of the balance remaining in 

the employee’s unused General‐Purpose Health Care Flexible Spending Arrangement (GPFSA) or Limited‐Purpose 

Dental/Vision Flexible Spending Arrangement (LPFSA) account. To qualify for a QRD, the employee must be a member 

of a reserve unit ordered to active duty for a period of 180 days or more, or for an indefinite period of time. The 

employee can request distribution during the period that begins with the date the order was given or he or she was 

called to active duty and ends on the last day of the Grace Period for the plan year. The amount of the distribution is 

limited to the amount contributed to the GPFSA or LPFSA as of the date of the QRD request, less any GPFSA or LPFSA 

reimbursements and prior QRDs. QRD request forms can be downloaded from the OGB website, under the Flexible 

Benefits home page. 

 

Dependent Care Flexible Spending Arrangement (DCFSA)  

Working parents with young children may benefit from the DCFSA. Many people are also caring for elderly or disabled dependents, who are unable to care for themselves. Child and elder care can be very expensive. With the Dependent Care FSA, you can redirect a part of your pay into a tax‐free account and then reimburse yourself for eligible expenses. You save money because taxes never need to be paid on the money set aside in the account. Dependent care expenses must meet IRS eligibility requirements. The expenses must be necessary for you to continue working. If married, you and your spouse must both be working, or your spouse must be a full‐time student or disabled. Reimbursed expenses cannot be deducted on your income tax return.  

Minimum Deposit  Maximum Deposit 

$600*  $5,000*, depending 

upon tax filing status 

*Unless otherwise required by the IRS for the 2019 Plan Year. 

 

Participants in the Dependent Care FSA must file IRS 

Form 2441 each year! 

 

 Who is eligible to participate? 

Eligible Employees of employers participating in one of the payroll systems listed at the beginning of this document, including rehired retirees who are employed as active, full‐time employees or FTEs  

Who are Eligible Dependents? 

Children under age 13 who reside in your household  

Adults or children who are physically or mentally incapable of self‐care and spend at least 8 hours a day in your household  

Examples of Eligible Expenses: 

Child care services inside the employee’s home or someone else’s home  

Charges by a licensed day care facility    

Adult day care in your home or someone else’s home 

Expenses for summer day camp 

 

Examples of Ineligible Expenses 

The following expenses are generally not eligible; however, if an expense is incident to, and cannot be separated from, the cost of caring for the qualified person, you can claim it: 

Deposits, registration fees, activity fees, 

books, T‐shirts or supplies 

Tuition, meals or diapers 

Transportation fees 

Learning disability schools 

Kindergarten tuition and fees 

 

How does the DCFSA work? 

You carefully estimate your dependent or elderly care expenses for the Flexible Benefits plan year (January 1 through December 31).  

Participation is effective the first of the month after the employee’s first full calendar month of employment.  

By completing a Flexible Spending Arrangement Enrollment/Stop Form, you will have money withheld from your paycheck. Deductions from your paycheck are deposited into your DCFSA account. If it is a recurring expense, the Recurring Dependent Care Request Form needs to be completed each plan year for expediting reimbursements.  

You submit a claim to be reimbursed for your expenses by the applicable deadline. As soon as you receive the necessary proof of your expenses, you can submit a claim for what you spent.   

You are reimbursed for each claim up to the amount in your DCFSA account.  

Expenses must be incurred before they can be reimbursed. 

 

 

Participation in the DCFSA ends on the date of termination of employment.  FSA COBRA is not available.  

How much can I contribute to a Dependent Care FSA? 

Deposits cannot exceed the established annual limits set by the Internal Revenue Service as listed below:  

o If you are married and filing jointly, or single and filing as head of household, the maximum contribution is $5,000.  

o If you are married and filing separately, or single, the maximum contribution is $2,500. 

 o If your spouse is a full‐time student or 

incapable of self‐care, the maximum contribution is $5,000.   

The maximum contribution applies to the taxable year 

and the Flexible Benefits Plan Year (January 1 through 

December 31). If an employee and spouse are enrolled 

in separate Dependent Care Flexible Spending 

Arrangements, they can both make contributions and 

submit claims, but the total for both cannot exceed 

$5,000. The minimum contribution per family is $600 

per Flexible Benefits Plan Year. Failure to pay the 

administrative fee will result in the denial of the 

privilege of participation in the DCFSA. 

 

Dependent Care FSA versus Child Care Tax Credit 

Generally, employees with an adjusted gross income of 

$25,000 or more may receive a larger tax savings from 

the Dependent Care FSA than the child care tax credit. 

However, individual circumstances (such as income, 

dependent care expenses and the number of 

dependents) affect any tax savings you receive. Consult 

your tax advisor to determine which choice is best for 

you. 

 Administrator and VISA debit card for DCFSA ‐ Discovery Benefits, Inc., DBI, is the third ‐party claims administrator of the Flexible Spending Arrangement for the Office of Group Benefits. Each participant in a DCFSA will receive a green Discovery Benefits VISA Debit Card, which can be used to pay providers who accept VISA for eligible expenses for a DCFSA. If your 

provider does not accept Visa, you can complete a reimbursement form and either mail/fax/upload to DBI for reimbursement of your expense.  

DCFSA funds are available upon deposit. The debit card is reloadable each year as long as the employee re‐enrolls. The debit card will be replaced before the expiration date.  

Dependent Care FSA Reimbursement Claim Process 

Reimbursement request forms and guidelines for filing 

claims and receiving reimbursement are available 

online on the OGB website, under the Services/ Flexible 

Benefits tab. 

 

To make this option as convenient as possible, OGB’s 

Flexible Spending Arrangement vendor offers a  

Recurring Expense Service. This service pre‐certifies 

your regularly recurring dependent care expenses. You 

should keep receipts in your home files in the event you 

are ever audited. If it is a recurring expense, the 

Recurring Dependent Care Request Form needs to be 

completed each year for expediting reimbursements.  

 

The Grace Period modifies the IRS “use or lose” rule. 

Participants have until March 15 to incur eligible 

expenses for reimbursement from unused amounts 

remaining at the end of the immediately preceding 

plan year, which ends December 31. 

 

The Run‐Out Period is the time period after the end of 

the Grace Period, starting March 16 and ending April 

30, during which participants can request 

reimbursement for eligible expenses incurred during 

the preceding plan year. Reimbursement requests 

must be received by April 30 to be paid from funds 

remaining at the end of the immediately preceding 

plan year. 

 

 

What You Should Know About IRS Rules and Regulations  

Elections are irrevocable unless you experience 

an OGB Plan‐Recognized Qualified Life Event, 

and your change in elections is consistent with 

the life event. Simply put, this means you cannot 

change the amount of your elections 

(participation or deductions from your paycheck) 

or your participation during the Flexible Benefits 

Plan Year unless you experience an OGB Plan‐

Recognized Qualified Life Event and your election 

change request is consistent with that event.  

 

OGB Plan‐Recognized Qualified Life Events are 

limited. Examples of OGB Plan‐Recognized 

Qualified Life Events are marriage; birth of a 

child; death of the employee or dependent; 

change in eligibility of a dependent; gain or loss of 

Medicaid eligibility; etc. (see the complete list in 

Exhibit 1). If you experience an OGB Plan‐

Recognized Qualified Life Event and wish to 

change your elections, you must submit a GB‐01 

form, along with proof of the qualified event, to 

your payroll office, or Human Resources office. 

It is to your advantage to submit your 

request as soon as possible after an OGB 

Plan‐Recognized Qualified Life Event 

occurs. (See Exhibit 1 for what 

constitutes a timely application for each 

individual qualified life event.) Changes 

must be reviewed and approved and will 

affect deductions from your future 

paychecks only. A request for an 

election change cannot be processed 

until you provide proof of the qualified 

life event.  

The OGB Plan‐Recognized Qualified 

Life Events (QLEs) are also located on 

the OGB website under Resources. 

 

 

 

 

Financial hardship is not an OGB Plan‐Recognized 

Qualified Life Event.  Financial hardship is not an 

OGB Plan‐Recognized Qualified Life Event that 

allows you to change your elections or cease or add 

participation in the Flexible Benefits Plan. Once you 

enroll in the Flexible Benefits Plan, you are bound 

by Flexible Benefits Plan rules and regulations. 

 

A change in elections must be consistent with the 

OGB Plan‐Recognized Qualified Life Event. For 

example, if a dependent becomes ineligible due to 

age, you can reduce your deductions from your 

future paychecks for that dependent only, but you 

cannot make other changes. 

 

Money left in your FSA cannot be refunded or 

rolled over. In accordance with the IRS “use or lose” 

rule, any money that remains in your GPFSA, LPFSA 

or DCFSA at the end of the Plan Year (including the 

Grace Period and the Run‐Out Period) is forfeited. 

The money will not be returned to you or carried 

over to the next Flexible Benefits plan year. Be sure 

to calculate your FSA contribution amount carefully 

each year. 

 

Each year in which you participate in a DCFSA, you 

must submit an IRS Form 2441. IRS Form 2441 must 

be attached to the tax return of any participant who 

receives DCFSA benefits or who files for a child‐care tax 

credit. 

 

 

 

 

 

 

 

 

 

 

Mid‐Year Election Changes  

 

Payroll deductions in the Premium Conversion, the 

General‐Purpose Health Care FSA, the Limited‐

Purpose Dental/Vision FSA, and the Dependent Care 

FSA options are irrevocable and locked in for the Plan 

Year and cannot be increased or decreased during 

the Flexible Benefits Plan Year, January 1 through 

December 31, unless you experience an OGB Plan‐

Recognized Qualified Life Event and your requested 

change is consistent with the qualified life event. 

 

Submittal of Change Forms and Documentation 

Request for changes to Flexible Benefits Plan elections 

are to be submitted to your human resources or payroll 

office on the GB‐01 form for the current Plan Year with 

appropriate documentation of the OGB Plan‐

Recognized Qualified Life Event. It is to your 

advantage to submit your request as soon as possible 

after an OGB Plan‐Recognized Qualified Life Event 

occurs.  

 

Changes cannot be made until the form and 

documentation have been received by your human 

resources or payroll office and the change is reviewed 

and approved. It is very important that the form and 

documentation be submitted in a timely manner for all 

OGB Plan‐Recognized Qualified Life Events during the 

Flexible Benefits Plan Year January 1 through 

December 31 (See Exhibit 1). 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

For human resources or payroll office only, the 

mailing address for submittal of forms and 

documentation is:  

Office of Group Benefits 

ATTN: Flexible Benefits Plan Administration 

P.O. Box 44036 

Baton Rouge, LA 70804 

 

See Exhibit 1 for a list of OGB Plan‐Recognized 

Qualified Life Events that allow you to make a mid‐

year change in your Flexible Benefits Plan elections 

and other pertinent information for each life event.  

The OGB Plan‐Recognized Qualified Life Events 

(QLEs) are also located on the OGB website under 

Resources. 

  

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Frequently Asked Questions  

How long do I have to submit my GB‐01 form?  You must make a request and submit your form and documentation of an OGB Plan‐Recognized Qualified Life Event to your human resources or payroll office in a timely manner after you experience a qualified life event. See Exhibit 1 for timeframes to submit documentation for each qualified life event. It is to your advantage to submit your request for an election change as soon as possible after experiencing the qualified life event.   If my employer knows I’m pregnant, won’t my baby be added to my coverage and my GB‐01 changed automatically? No. You must complete health coverage documents, including a GB‐01, and notify your human resources or payroll office in writing within 30 days of the child’s date of birth. In addition, if you want to pay the additional premium amount with pre‐tax dollars through the Flexible Benefits Plan, you must include that on the GB‐01 form with proof of the event, within the same 30‐day period. If approved, your election change will affect future paychecks only. Retroactive adjustments are not allowed, except for some HIPAA Special Enrollment Events.   If I’m dissatisfied with the service that I have received from a health plan or insurance company, can I drop my coverage and my Flexible Benefits Plan pre‐tax premium for that coverage?  No. Dissatisfaction with service is not an OGB Plan‐Recognized Qualified Life Event for an election change and cannot be used to change or reduce your premium election.  I did not enroll in the Flexible Benefits Plan during Annual Enrollment for this plan year.   

   However, my spouse recently lost his job and I will now be paying the health coverage premiums for my family. Can I enroll in the Flexible Benefits Plan and pay my premiums with pre‐tax dollars?  Yes. See Exhibit 1.  I am having financial difficulty and would like to  change my elections in the Flexible Benefits Plan. Can  I do that?    No. Financial difficulty is not an OGB Plan‐Recognized Qualified Life Event allowing an election change.   

Why does the Flexible Benefits Plan require an OGB  Plan‐Recognized Qualified Life Event to allow  changes to my coverage? It’s my money, isn’t it?  Yes, however, you paid your premiums on a pre‐tax  dollar basis, and IRS rules govern such pre‐tax dollar  contributions and plans.  I am divorced and have custody of my children,  although my former spouse claims them as  dependents on his tax return. Can I still participate in  the Dependent Care FSA?  

Yes. You don’t have to declare your children as dependents on your tax return to qualify for a Dependent Care FSA. However, you must be the custodial parent. (The child must reside with you for more than half the year.)  

If I enroll in the Flexible Benefits Plan, will I ever have  to pay taxes on the money I put into the plan?  No. As an IRS Section 125 benefit, it’s tax‐free. Your W‐2 form shows your gross income, less any amounts paid for a Flexible Benefits Plan benefit option. Flexible Benefits Plan contributions are reported as non‐taxable wages and income on your W‐2 form. If the IRS audits you, you will need to show total expenses and receipts from your service provider(s). Keep a copy of your reimbursement request forms and receipts for audit purposes.  

 

 

Notice of Administrator’s Capacity  

 

1. OGB has been authorized by the State of 

Louisiana to provide administrative services or 

to subcontract such services for the offered 

benefit plans (the “Administrator”). In some 

instances, OGB may also be authorized by one 

or more of the companies underwriting some of 

the benefits to provide certain services, 

including (but not limited to) marketing, billing 

and collection of premiums, processing claims 

payments and other services.  

 

2. The insurance companies noted in this 

Summary document have been approved by 

the State and are liable for the funds to pay 

your insurance claims.  The policyholder is the 

person or entity to which the insurance policy 

has been issued. The policyholder is identified 

on either the face page or schedule page of the 

policy or certificate.  The policyholder may or 

may not be you. 

 

3. The Administrator can rely on the direction, 

information or election of a Participant and 

shall not be responsible for any act or failure to 

act or lack of direction by a Participant. 

 

4. To the extent permitted by law, the 

Administrator shall not incur any liability for 

any acts or for failure to act except for its own 

willful misconduct or willful breach of the 

provisions of the Flexible Benefits Plan 

Document. 

 

5. If the Administrator is unable to reimburse any 

FSA Participant because the identity or 

whereabouts of such Participant cannot be 

ascertained, subsequent payments otherwise 

due to such Participant shall be forfeited after 

the end of the Run‐Out Period of the Flexible 

Benefits Plan Year. 

 

6. In the event of a mistake regarding the 

eligibility or participation of a Participant, or 

the allocations made to the account of any 

Participant, or the reimbursements paid or to 

be paid to a Participant or other person, the 

Administrator shall, to the extent possible and 

otherwise permissible, cause to be allocated or 

cause to be withheld or accelerated, or 

otherwise make adjustment of such amounts as 

will, in the Administrator’s judgment, accord to 

such Participant or other person the credits to 

the account or distributions to which he is 

properly entitled under this Flexible Benefits 

Plan. Such action by the Administrator may 

include withholding of any amounts due under 

the Flexible Benefits Plan or the employer from 

the salary paid by the employer.  

This notice advises Participants of the identity 

and relationship among the Administrator, the 

policyholder and the insurer.  

 

 

 

 

 

 

EXHIBIT “1” 

 

OGB PLAN‐RECOGNIZED 

QUALIFIED LIFE EVENTS 

 

 

 

QL

E

Cod

ePl

an R

ecog

nize

d Q

ualif

ied

Life

Eve

nt

Enr

olle

e ch

ange

req

uest

to

OG

B p

lan

AD

D o

r D

RO

P

Dea

dlin

e to

subm

it re

ques

t and

pro

vide

pr

oof d

ocum

ent

Proo

f or

docu

men

t re

quir

ed

Enr

olle

e al

low

ed

to c

hang

e (w

ho

mee

ts th

e el

igib

ility

de

finiti

on)

Eff

ectiv

e D

ate

of

Cha

nge

AD

D

Dep

ende

nt

YE

S or

NO

DR

OP

Dep

ende

nt

YE

S or

NO

DR

OP

Se

lf

Y

ES

or

NO

AD

D o

r D

RO

P M

edic

al

Cov

erag

e

CH

AN

GE

H

ealth

Pla

n Y

ES

or N

O

CO

BR

A

Eve

nt Y

ES

or N

O

Flex

ible

Sp

endi

ng P

lan

– H

ealth

Car

e

Flex

ible

Sp

endi

ng P

lan

- D

ep. C

are

A-1

Bir

thA

DD

App

licat

ion

mus

t be

mad

e w

ithin

30

days

of

cha

nge

in st

atus

Bir

th C

ertif

icat

e or

Bir

th

Let

ter

whi

ch in

clud

es

new

born

dat

a, a

nd

elig

ibili

ty d

ata

for

any

Em

ploy

ee, n

ew

baby

. Spo

use

may

be

adde

d as

a

resu

lt of

this

t

bt

l

Bab

y’s d

ate

of b

irth

if

App

licat

ion

for

enro

llmen

t is t

imel

y d

YE

SN

ON

OA

DD

YE

SN

OM

ay e

nrol

l or

can

incr

ease

am

ount

May

enr

oll o

r in

crea

se a

mou

nt

Off

ice

of G

roup

Ben

efits

Pla

n-R

ecog

nize

d Q

ualif

ied

Life

Eve

nts (

QL

E) 2

017

BIR

TH

/AD

OPT

ION

oc

age

stat

use

gb

tyda

tao

ay

new

ly-e

ligib

le p

erso

nsev

ent,

but

only

if

baby

is a

dded

.m

ade

aou

t

A-2

Ado

ptio

n or

pla

cem

ent f

or a

dopt

ion

AD

D

30 d

ays f

rom

the

effe

ctiv

e da

te o

f ad

optio

n/pl

acem

ent

for

adop

tion

Ado

ptio

n or

pla

cem

ent

for

adop

tion

lega

l do

cum

ent,

and

elig

ibili

ty

data

for

any

new

ly-

elig

ible

per

sons

Em

ploy

ee a

nd

adop

ted

child

; sp

ouse

may

be

adde

d as

a r

esul

t of

this

eve

nt b

ut

only

if c

hild

is

Eff

ectiv

e da

te o

f ad

optio

n or

pl

acem

ent f

or

adop

tion

if A

pplic

atio

n fo

r en

rollm

ent i

s tim

ely

YE

SN

ON

OA

DD

YE

SN

OM

ay e

nrol

l or

can

incr

ease

am

ount

May

enr

oll o

r in

crea

se a

mt i

f de

pend

ent c

are

expe

nses

in

crea

sed

adde

d.

mad

e

Pag

e 1

QL

E

Cod

ePl

an R

ecog

nize

d Q

ualif

ied

Life

Eve

nt

Enr

olle

e ch

ange

req

uest

to

OG

B p

lan

AD

D o

r D

RO

P

Dea

dlin

e to

subm

it re

ques

t and

pro

vide

pr

oof d

ocum

ent

Proo

f or

docu

men

t re

quir

ed

Enr

olle

e al

low

ed

to c

hang

e (w

ho

mee

ts th

e el

igib

ility

de

finiti

on)

Eff

ectiv

e D

ate

of

Cha

nge

AD

D

Dep

ende

nt

YE

S or

NO

DR

OP

Dep

ende

nt

YE

S or

NO

DR

OP

Se

lf

Y

ES

or

NO

AD

D o

r D

RO

P M

edic

al

Cov

erag

e

CH

AN

GE

H

ealth

Pla

n Y

ES

or N

O

CO

BR

A

Eve

nt Y

ES

or N

O

Flex

ible

Sp

endi

ng P

lan

– H

ealth

Car

e

Flex

ible

Sp

endi

ng P

lan

- D

ep. C

are

B-1

Dea

th o

f cov

ered

dep

ende

ntD

RO

P

60 d

ays f

rom

the

date

of d

eath

(OG

B

has t

he d

iscr

etio

n to

re

troa

ctiv

ely

term

inat

e co

vera

ge if

co

rrec

t pre

miu

m is

Cop

y of

cer

tifie

d de

ath

cert

ifica

te o

r ot

her

offic

iald

ocum

ent

Dep

ende

nt w

ho

died

. If s

pous

e di

es,

step

child

ren

mus

t be

End

of t

he m

onth

in

whi

ch th

e de

ath

occu

rsN

O

DR

OP

the

dece

ased

and

an

y st

epch

ildre

n w

hoar

eno

tN

O

DR

OP

for

the

dece

ased

de

pend

ent

oran

yN

O

Onl

y fo

r st

ep-

child

ren

if pa

rent

is

the

May

dec

reas

e am

ount

May

dro

p or

de

crea

se

amou

nt if

de

ceas

ed

DE

AT

H

Off

ice

of G

roup

Ben

efits

Pla

n-R

ecog

nize

d Q

ualif

ied

Life

Eve

nts (

QL

E) 2

017

pno

t tim

ely

paid

and

A

pplic

atio

n fo

r di

senr

ollm

ent i

s not

tim

ely

mad

e)

offic

ial d

ocum

ent

term

inat

ed a

nd

offe

red

CO

BR

A

cove

rage

.

occu

rsw

ho a

re n

ot

adop

ted

by

the

enro

llee

or a

ny

step

child

ren

onl

y

the

depe

nden

t w

ho d

ied

depe

nden

t is

child

B-2

Em

ploy

ee D

ecea

sed

DR

OP

30 d

ays f

rom

the

date

of d

eath

(OG

B

has t

he d

iscr

etio

n to

re

troa

ctiv

ely

term

inat

e co

vera

ge if

co

rrec

t pre

miu

m is

no

t tim

ely

paid

and

Cop

y of

cer

tifie

d de

ath

cert

ifica

te o

r ot

her

offic

ial d

ocum

ent

Em

ploy

ee a

nd

elig

ible

de

pend

ents

End

of m

onth

in

whi

ch E

mpl

oyee

’s

deat

h oc

curr

edN

/AY

ES

YE

SD

RO

PN

OY

ES

Aut

omat

ic

Can

cel o

n da

te

of d

eath

Aut

omat

ic

Can

cel o

n da

te

of d

eath

App

licat

ion

for

dise

nrol

lmen

t is n

ot

timel

y m

ade)

Pag

e 2

QL

E

Cod

ePl

an R

ecog

nize

d Q

ualif

ied

Life

Eve

nt

Enr

olle

e ch

ange

req

uest

to

OG

B p

lan

AD

D o

r D

RO

P

Dea

dlin

e to

subm

it re

ques

t and

pro

vide

pr

oof d

ocum

ent

Proo

f or

docu

men

t re

quir

ed

Enr

olle

e al

low

ed

to c

hang

e (w

ho

mee

ts th

e el

igib

ility

de

finiti

on)

Eff

ectiv

e D

ate

of

Cha

nge

AD

D

Dep

ende

nt

YE

S or

NO

DR

OP

Dep

ende

nt

YE

S or

NO

DR

OP

Se

lf

Y

ES

or

NO

AD

D o

r D

RO

P M

edic

al

Cov

erag

e

CH

AN

GE

H

ealth

Pla

n Y

ES

or N

O

CO

BR

A

Eve

nt Y

ES

or N

O

Flex

ible

Sp

endi

ng P

lan

– H

ealth

Car

e

Flex

ible

Sp

endi

ng P

lan

- D

ep. C

are

C-1

Div

orce

, Ann

ulm

ent a

nd L

egal

Sep

arat

ion

(lega

l sep

arat

ion

and

annu

lmen

t are

qu

alifi

ed e

vent

s onl

y if

reco

gniz

ed b

y la

w

of st

ate

of th

e se

para

tion

or a

nnul

men

t)

AD

DA

pplic

atio

n m

ust b

e m

ade

with

in 3

0 da

ys

of c

hang

e in

stat

us

Cop

y of

div

orce

, an

nulm

ent,

or le

gal

sepa

ratio

n or

der

and

elig

ibili

ty d

ata

for

any

new

lyel

igib

lepe

rson

s

Self;

chi

ldre

n

Dat

e of

div

orce

or

der

if A

pplic

atio

n fo

r E

nrol

lmen

t is

timel

y m

ade

YE

SN

/AN

/AA

DD

YE

SN

O

May

enr

oll o

r ca

n in

crea

se

amou

nt if

loss

of

cove

rage

on

spou

se’s

hea

lth

Yes

, if c

hang

e af

fect

s the

am

ount

of t

ime

the

child

nee

ds

to b

e in

de

pend

ent c

are

and

incr

ease

s ex

pens

es O

R

DIV

OR

CE

Off

ice

of G

roup

Ben

efits

Pla

n-R

ecog

nize

d Q

ualif

ied

Life

Eve

nts (

QL

E) 2

017

p)

new

ly-e

ligib

le p

erso

nsy

ppl

anp

lose

cov

erag

e un

der

spou

se’s

D

ep D

ayca

re

Flex

Pla

n

C-2

Div

orce

, Ann

ulm

ent a

nd L

egal

Sep

arat

ion

(whe

re a

nnul

men

t and

lega

l sep

arat

ion

are

reco

gniz

ed b

y la

w o

f the

stat

e of

the

sepa

ratio

n or

ann

ulm

ent)

DR

OP

App

licat

ion

mus

t be

mad

e w

ithin

30

days

of

cha

nge

in st

atus

(O

GB

has

the

disc

retio

n to

re

troa

ctiv

ely

term

inat

e co

vera

ge

to th

e en

d of

the

mon

th o

f the

cha

nge

in st

atus

if c

orre

ct

Cop

y of

off

icia

l div

orce

, an

nulm

ent o

r le

gal

sepa

ratio

n de

cree

Ex-

spou

se a

nd e

x-st

epch

ildre

n

End

of t

he M

onth

of

the

divo

rce,

an

nulm

ent o

r le

gal

sepa

ratio

n if

appl

icat

ion

is ti

mel

y m

ade

N/A

YE

S fo

r E

x-Sp

ouse

and

E

x-St

epch

ildre

n

NO

DR

OP

NO

YE

SM

ay d

ecre

ase

elec

tion

May

dec

reas

e if

divo

rce,

an

nulm

ent o

r le

gal s

epar

atio

n lo

wer

s de

pend

ent

dayc

are

in st

atus

if c

orre

ct

prem

ium

is n

ot

timel

y pa

id a

nd

appl

icat

ion

is no

t tim

ely

mad

e)

mad

eda

ycar

e ex

pens

es

Pag

e 3

QL

E

Cod

ePl

an R

ecog

nize

d Q

ualif

ied

Life

Eve

nt

Enr

olle

e ch

ange

req

uest

to

OG

B p

lan

AD

D o

r D

RO

P

Dea

dlin

e to

subm

it re

ques

t and

pro

vide

pr

oof d

ocum

ent

Proo

f or

docu

men

t re

quir

ed

Enr

olle

e al

low

ed

to c

hang

e (w

ho

mee

ts th

e el

igib

ility

de

finiti

on)

Eff

ectiv

e D

ate

of

Cha

nge

AD

D

Dep

ende

nt

YE

S or

NO

DR

OP

Dep

ende

nt

YE

S or

NO

DR

OP

Se

lf

Y

ES

or

NO

AD

D o

r D

RO

P M

edic

al

Cov

erag

e

CH

AN

GE

H

ealth

Pla

n Y

ES

or N

O

CO

BR

A

Eve

nt Y

ES

or N

O

Flex

ible

Sp

endi

ng P

lan

– H

ealth

Car

e

Flex

ible

Sp

endi

ng P

lan

- D

ep. C

are

Self

and

depe

nden

ts w

ho

gain

edsu

chT

he e

nd o

f the

m

onth

prec

edin

gth

eM

ay d

ecre

ase

or

GA

IN O

F O

TH

ER

CO

VE

RA

GE

Off

ice

of G

roup

Ben

efits

Pla

n-R

ecog

nize

d Q

ualif

ied

Life

Eve

nts (

QL

E) 2

017

D-1

Gai

n M

edic

aid

or st

ate

CH

IP (C

hild

ren’

s H

ealth

Insu

ranc

e Pr

ogra

m) c

over

age

DR

OP

App

licat

ion

mus

t be

mad

e w

ithin

60

days

fr

om d

ate

Med

icai

d be

cam

e ef

fect

ive

Off

icia

l st

ate

docu

men

t in

dica

ting

who

, whe

n M

edic

aid

/SC

HIP

co

vera

ge b

egan

gain

ed su

ch

cove

rage

(d

epen

dent

s ca

nnot

rem

ain

on th

e O

GB

pla

n w

ithou

t the

E

mpl

oyee

bei

ng

cove

red)

mon

th p

rece

ding

the

first

full

mon

th in

w

hich

oth

er

cove

rage

bec

ame

effe

ctiv

e if

appl

icat

ion

is ti

mel

y m

ade

N/A

YE

SY

ES

DR

OP

NO

NO

y deac

tivat

e de

duct

ions

if

gain

of

Med

icai

d; n

o ch

ange

if g

ain

of

SCH

IP

No

chan

ge

D2

Dep

ende

nt g

ains

cov

erag

e un

der

anot

her

DR

OP

App

licat

ion

mus

t be

mad

e w

ithin

30

days

f

dt

thP

ff

thD

epen

dent

who

i

dth

The

end

of t

he

mon

th p

rece

ding

the

first

full

mon

th in

w

hich

oth

er

N/A

YE

SN

OD

RO

PN

ON

ON

hN

hD

-2p

gg

grou

p or

indi

vidu

al h

ealth

pla

nD

RO

Pfr

om d

ate

othe

r co

vera

ge b

ecom

es

effe

ctiv

e

Proo

f of o

ther

cov

erag

ega

ined

oth

er

cove

rage

cove

rage

bec

ame

effe

ctiv

e if

appl

icat

ion

is tim

ely

mad

e

N/A

YE

SN

OD

RO

PN

ON

ON

o ch

ange

No

chan

ge

Pag

e 4

QL

E

Cod

ePl

an R

ecog

nize

d Q

ualif

ied

Life

Eve

nt

Enr

olle

e ch

ange

req

uest

to

OG

B p

lan

AD

D o

r D

RO

P

Dea

dlin

e to

subm

it re

ques

t and

pro

vide

pr

oof d

ocum

ent

Proo

f or

docu

men

t re

quir

ed

Enr

olle

e al

low

ed

to c

hang

e (w

ho

mee

ts th

e el

igib

ility

de

finiti

on)

Eff

ectiv

e D

ate

of

Cha

nge

AD

D

Dep

ende

nt

YE

S or

NO

DR

OP

Dep

ende

nt

YE

S or

NO

DR

OP

Se

lf

Y

ES

or

NO

AD

D o

r D

RO

P M

edic

al

Cov

erag

e

CH

AN

GE

H

ealth

Pla

n Y

ES

or N

O

CO

BR

A

Eve

nt Y

ES

or N

O

Flex

ible

Sp

endi

ng P

lan

– H

ealth

Car

e

Flex

ible

Sp

endi

ng P

lan

- D

ep. C

are

D-3

Gai

n ne

w c

over

age

thro

ugh

Med

icar

e Pa

rt

A o

r Pa

rt B

Con

tinue

with

O

GB

cov

erag

e as

seco

ndar

y (e

mpl

oyee

w

ould

be

App

licat

ion

mus

t be

mad

e w

ithin

30

days

fr

om d

ate

othe

r co

vera

ge b

ecom

es

Off

icia

l doc

umen

tatio

n of

ac

tive

enro

llmen

t on

new

pl

an; m

ust s

how

eff

ectiv

e da

tes o

f eac

h na

med

Self

and

depe

nden

ts w

ho

gain

ed su

ch

cove

rage

(d

epen

dent

s ca

nnot

rem

ain

onth

eO

GB

plan

The

end

of t

he

mon

th p

rece

ding

the

first

full

mon

th in

w

hich

oth

er

cove

rage

beca

me

N/A

Yes

N/A

N/A

YE

SN

ON

/A a

s Ret

iree

no

t elig

ible

for

FSA

N/A

as R

etir

ee

not e

ligib

le fo

r FS

A

Off

ice

of G

roup

Ben

efits

Pla

n-R

ecog

nize

d Q

ualif

ied

Life

Eve

nts (

QL

E) 2

017

wou

ld b

e re

tired

)ef

fect

ive

depe

nden

ton

the

OG

B p

lan

with

out t

he

Em

ploy

ee b

eing

co

vere

d)

cove

rage

bec

ame

effe

ctiv

e

D-4

Gai

n ne

w c

over

age

thro

ugh

Med

icar

e Pa

rt

A o

r Pa

rt B

, Q

ualif

ied

Med

ical

Sup

port

C

ourt

Ord

er w

hen

som

eone

els

e is

ord

ered

to

pro

vide

the

heal

th c

over

age

for

curr

ently

cov

ered

dep

ende

nts,

or c

over

age

unde

rsp

ouse

'sgr

oup

heal

thpl

anor

othe

r

DR

OP

App

licat

ion

mus

t be

mad

e w

ithin

30

days

fr

om d

ate

new

co

vera

ge b

ecam

e ef

fect

ive

Off

icia

l doc

umen

tatio

n of

ac

tive

enro

llmen

t on

new

pl

an; m

ust s

how

eff

ectiv

e da

tes o

f eac

h na

med

de

pend

ent

Self

and

depe

nden

ts w

ho

gain

ed su

ch

cove

rage

(d

epen

dent

s ca

nnot

rem

ain

on th

e O

GB

pla

n

The

end

of t

he

mon

th p

rece

ding

the

first

full

mon

th in

w

hich

oth

er

cove

rage

bec

ame

effe

ctiv

e if

N/A

YE

SY

ES

DR

OP

NO

; but

any

H

ealth

Sa

ving

s A

ccou

nt

cont

ribu

tions

m

ust c

ease

NO

May

dec

reas

e or

de

activ

ate

amou

nt

No

chan

ge

unde

r sp

ouse

s gro

up h

ealth

pla

n or

oth

er

grou

p or

indi

vidu

al h

ealth

pla

nef

fect

ive

depe

nden

tw

ithou

t the

E

mpl

oyee

bei

ng

cove

red)

appl

icat

ion

is tim

ely

mad

eon

ce g

ain

Med

icar

e

Pag

e 5

QL

E

Cod

ePl

an R

ecog

nize

d Q

ualif

ied

Life

Eve

nt

Enr

olle

e ch

ange

req

uest

to

OG

B p

lan

AD

D o

r D

RO

P

Dea

dlin

e to

subm

it re

ques

t and

pro

vide

pr

oof d

ocum

ent

Proo

f or

docu

men

t re

quir

ed

Enr

olle

e al

low

ed

to c

hang

e (w

ho

mee

ts th

e el

igib

ility

de

finiti

on)

Eff

ectiv

e D

ate

of

Cha

nge

AD

D

Dep

ende

nt

YE

S or

NO

DR

OP

Dep

ende

nt

YE

S or

NO

DR

OP

Se

lf

Y

ES

or

NO

AD

D o

r D

RO

P M

edic

al

Cov

erag

e

CH

AN

GE

H

ealth

Pla

n Y

ES

or N

O

CO

BR

A

Eve

nt Y

ES

or N

O

Flex

ible

Sp

endi

ng P

lan

– H

ealth

Car

e

Flex

ible

Sp

endi

ng P

lan

- D

ep. C

are

E-1

Qua

lifie

d M

edic

al C

hild

Sup

port

Ord

er

(QM

CSO

)A

DD

30 d

ays f

rom

dat

e of

th

e Q

MC

SO o

r as

ot

herw

ise

spec

ified

by

law

Cop

y of

QM

CSO

and

el

igib

ility

dat

a fo

r ne

wly

-el

igib

le p

erso

ns

Elig

ible

Chi

ld

depe

nden

t(s)

co

vere

d by

O

rder

(and

el

igib

le e

mpl

oyee

if

notc

urre

ntly

1st o

f mon

th

follo

win

g re

ceip

t of

appl

icat

ion

or a

s ot

herw

ise

spec

ified

in

the

Ord

er

Yes

, onl

y fo

r th

e de

pend

ent(

s) r

equi

red

by O

rder

(a

nd

empl

oyee

if

N/A

NO

only

ch

ange

s co

nsis

tent

w

ith

Ord

er

YE

SN

OM

ay e

nrol

l or

can

incr

ease

am

ount

No

chan

ge

allo

wed

Off

ice

of G

roup

Ben

efits

Pla

n-R

ecog

nize

d Q

ualif

ied

Life

Eve

nts (

QL

E) 2

017

CO

UR

T-O

RD

ER

ED

LE

GA

L G

UA

RD

IAN

SHIP

OR

CO

UR

T-O

RD

ER

ED

CU

STO

DY

; QM

CSO

yif

not c

urre

ntly

en

rolle

d)in

the

Ord

erp

yno

t cu

rren

tly

enro

lled)

Ord

er

E-2

Cou

rt-O

rder

ed L

egal

Gua

rdia

nshi

p or

C

ourt

-Ord

ered

Cus

tody

AD

D

App

licat

ion

mus

t be

mad

e w

ithin

30

days

fr

om th

e da

te o

f the

co

urt-

orde

red

lega

l gu

ardi

ansh

ip o

r co

urt-

orde

red

cust

ody

Cer

tifie

d co

py o

f the

si

gned

cou

rt o

rder

gr

antin

g cu

stod

y o

r gu

ardi

ansh

ip, a

nd

elig

ibili

ty d

ata

for

any

new

ly-e

ligib

le p

erso

ns

New

ly A

cqui

red

Dep

ende

nt(s

)

The

dat

e of

the

cour

t-or

dere

d le

gal

guar

dian

ship

or

cust

ody

or t

he

effe

ctiv

e da

te

spec

ified

in th

e co

urt

orde

r, if

App

licat

ion

for

enro

llmen

tis

YE

S fo

r ne

wly

- ac

quir

ed

depe

nden

t on

ly

NO

NO

AD

DY

ES

NO

May

enr

oll o

r ca

n in

crea

se

amou

nt

May

enr

oll o

r in

crea

se a

mt i

f de

pend

ent c

are

expe

nses

in

crea

sed

cust

ody

for

enro

llmen

t is

timel

y m

ade

Pag

e 6

QL

E

Cod

ePl

an R

ecog

nize

d Q

ualif

ied

Life

Eve

nt

Enr

olle

e ch

ange

req

uest

to

OG

B p

lan

AD

D o

r D

RO

P

Dea

dlin

e to

subm

it re

ques

t and

pro

vide

pr

oof d

ocum

ent

Proo

f or

docu

men

t re

quir

ed

Enr

olle

e al

low

ed

to c

hang

e (w

ho

mee

ts th

e el

igib

ility

de

finiti

on)

Eff

ectiv

e D

ate

of

Cha

nge

AD

D

Dep

ende

nt

YE

S or

NO

DR

OP

Dep

ende

nt

YE

S or

NO

DR

OP

Se

lf

Y

ES

or

NO

AD

D o

r D

RO

P M

edic

al

Cov

erag

e

CH

AN

GE

H

ealth

Pla

n Y

ES

or N

O

CO

BR

A

Eve

nt Y

ES

or N

O

Flex

ible

Sp

endi

ng P

lan

– H

ealth

Car

e

Flex

ible

Sp

endi

ng P

lan

- D

ep. C

are

30 d

ays f

rom

dat

e of

D

epen

dent

chi

ld,

or S

elf a

nd

End

of m

onth

fo

llow

ing

rece

ipto

f

Off

ice

of G

roup

Ben

efits

Pla

n-R

ecog

nize

d Q

ualif

ied

Life

Eve

nts (

QL

E) 2

017

E-3

Qua

lifie

d M

edic

al C

hild

Sup

port

Ord

er

(QM

CSO

)D

RO

P

yth

e Q

MC

SO o

r as

ot

herw

ise

spec

ified

by

law

Cop

y of

QM

CSO

depe

nden

t chi

ld

who

was

add

ed

as a

res

ult o

f the

O

rder

follo

win

g re

ceip

t of

appl

icat

ion,

if

appl

icat

ion

is ti

mel

y m

ade

NO

YE

SY

ES

DR

OP

NO

YE

SM

ay d

ecre

ase

or

dise

nrol

lN

o ch

ange

al

low

ed

E-4

Cou

rt-O

rder

ed L

egal

Gua

rdia

nshi

p or

C

ourt

Ord

ered

Cus

tody

DR

OP

App

licat

ion

mus

t be

mad

e w

ithin

30

days

fr

om d

ate

of th

e O

rder

rem

ovin

gC

opy

of O

rder

Dep

ende

nt c

hild

fo

r w

hom

cu

stod

y or

E

nd o

f mon

th

follo

win

g re

ceip

t of

NO

YE

SN

OD

RO

PN

OY

ES

May

dec

reas

e am

ount

or

May

dec

reas

e am

ount

if

depe

nden

t car

e ex

pens

esC

ourt

-Ord

ered

Cus

tody

Ord

er r

emov

ing

cust

ody

or

guar

dian

ship

pyy

guar

dian

ship

w

as lo

st

gp

timel

y ap

plic

atio

ndi

senr

oll

expe

nses

de

crea

sed,

or

dise

nrol

l

Pag

e 7

QL

E

Cod

ePl

an R

ecog

nize

d Q

ualif

ied

Life

Eve

nt

Enr

olle

e ch

ange

req

uest

to

OG

B p

lan

AD

D o

r D

RO

P

Dea

dlin

e to

subm

it re

ques

t and

pro

vide

pr

oof d

ocum

ent

Proo

f or

docu

men

t re

quir

ed

Enr

olle

e al

low

ed

to c

hang

e (w

ho

mee

ts th

e el

igib

ility

de

finiti

on)

Eff

ectiv

e D

ate

of

Cha

nge

AD

D

Dep

ende

nt

YE

S or

NO

DR

OP

Dep

ende

nt

YE

S or

NO

DR

OP

Se

lf

Y

ES

or

NO

AD

D o

r D

RO

P M

edic

al

Cov

erag

e

CH

AN

GE

H

ealth

Pla

n Y

ES

or N

O

CO

BR

A

Eve

nt Y

ES

or N

O

Flex

ible

Sp

endi

ng P

lan

– H

ealth

Car

e

Flex

ible

Sp

endi

ng P

lan

- D

ep. C

are

F-1

Los

e co

vera

ge o

n sp

ouse

's e

mpl

oyer

-pr

ovid

ed in

sura

nce

for

any

of th

e fo

llow

ing

reas

ons:

1) S

pous

e de

ceas

ed, 2

) E

mpl

oym

ent o

f Spo

use

term

inat

ed, 3

) C

OB

RA

cov

erag

e un

der

Spou

se's

pla

n te

rmin

ated

orex

pire

d4)

Spou

selo

ses

AD

D

App

licat

ion

mus

t be

mad

e w

ithin

30

days

fr

om th

e da

te th

e he

alth

insu

ranc

e

Doc

umen

ts fr

om p

rior

pl

an c

onfir

min

g co

vera

ge

term

inat

ion

and

elig

ibili

tyda

tafo

ran

y

Self

and

othe

r de

pend

ent(

s)

who

lost

Dat

e of

loss

of

prev

ious

cov

erag

e if

App

licat

ion

for

enro

llmen

tist

imel

y

YE

S to

Add

se

lf an

d/or

el

igib

le

N/A

N/A

AD

DY

ES

NO

May

enr

oll o

r ca

n in

crea

se

amou

ntN

o ch

ange

LO

SS O

F O

TH

ER

CO

VE

RA

GE

Off

ice

of G

roup

Ben

efits

Pla

n-R

ecog

nize

d Q

ualif

ied

Life

Eve

nts (

QL

E) 2

017

term

inat

ed o

r ex

pire

d, 4

) Spo

use

lose

s E

mpl

oyer

's In

sura

nce

due

to n

o fa

ult o

f the

sp

ouse

, 5) S

pous

e te

rmin

ates

cov

erag

e on

hi

s/he

r pl

an d

urin

g op

en e

nrol

lmen

t

heal

th in

sura

nce

ende

del

igib

ility

dat

a fo

r an

y ne

wly

-elig

ible

per

sons

cove

rage

en

rollm

ent i

s tim

ely

mad

e

depe

nden

tsam

ount

F-2

Elig

ible

Dep

ende

nt lo

ses c

urre

nt c

over

age

unde

r an

othe

r em

ploy

men

t-ba

sed

grou

p he

alth

pla

n or

indi

vidu

al h

ealth

pla

nA

DD

App

licat

ion

mus

t be

mad

e w

ithin

30

days

fr

om th

e da

te th

e he

alth

insu

ranc

e en

ded

Doc

umen

ts fr

om p

rior

pl

an c

onfir

min

g co

vera

ge

term

inat

ion

and

elig

ibili

ty d

ata

for

any

new

lyel

igib

lepe

rson

s

Self

and

othe

r de

pend

ent(

s)

who

lost

co

vera

ge

Dat

e of

loss

of

prev

ious

cov

erag

e if

App

licat

ion

for

enro

llmen

t is t

imel

y m

ade

YE

S to

Add

se

lf an

d/or

el

igib

le

depe

nden

ts

N/A

N/A

AD

DY

ES

NO

May

enr

oll o

r ca

n in

crea

se

amou

ntN

o ch

ange

ende

dne

wly

-elig

ible

per

sons

gm

ade

p

Pag

e 8

QL

E

Cod

ePl

an R

ecog

nize

d Q

ualif

ied

Life

Eve

nt

Enr

olle

e ch

ange

req

uest

to

OG

B p

lan

AD

D o

r D

RO

P

Dea

dlin

e to

subm

it re

ques

t and

pro

vide

pr

oof d

ocum

ent

Proo

f or

docu

men

t re

quir

ed

Enr

olle

e al

low

ed

to c

hang

e (w

ho

mee

ts th

e el

igib

ility

de

finiti

on)

Eff

ectiv

e D

ate

of

Cha

nge

AD

D

Dep

ende

nt

YE

S or

NO

DR

OP

Dep

ende

nt

YE

S or

NO

DR

OP

Se

lf

Y

ES

or

NO

AD

D o

r D

RO

P M

edic

al

Cov

erag

e

CH

AN

GE

H

ealth

Pla

n Y

ES

or N

O

CO

BR

A

Eve

nt Y

ES

or N

O

Flex

ible

Sp

endi

ng P

lan

– H

ealth

Car

e

Flex

ible

Sp

endi

ng P

lan

- D

ep. C

are

Los

e M

edic

aid

or st

ate

CH

IP (C

hild

ren’

s A

pplic

atio

n m

ust b

e m

ade

with

in 6

0 da

ys

Off

icia

l st

ate

docu

men

t in

dica

ting

for

who

m a

nd

hM

diid

/CH

IPSe

lf an

d d

dt(

)

Dat

e M

edic

aid/

CH

IP

May

enr

oll o

r ca

n in

crea

se

tifl

f

Off

ice

of G

roup

Ben

efits

Pla

n-R

ecog

nize

d Q

ualif

ied

Life

Eve

nts (

QL

E) 2

017

F-3

C(C

Hea

lth In

sura

nce

Prog

ram

) cov

erag

e be

caus

e no

long

er e

ligib

leA

DD

yfr

om th

e da

te th

e he

alth

insu

ranc

e en

ded

whe

n M

edic

aid/

CH

IP

cove

rage

end

ed a

nd

elig

ibili

ty d

ata

for

any

new

ly-e

ligib

le p

erso

ns

depe

nden

t(s)

w

ho lo

st

cove

rage

/Cco

vera

ge e

nds i

f ap

plic

atio

n is

tim

ely

mad

e

YE

SN

/AN

/AA

DD

YE

SN

/Aam

ount

if lo

ss o

f M

edic

aid;

no

chan

ge if

loss

of

CH

IP c

over

age

No

chan

ge

F4

Los

e an

othe

r gr

oup

or in

divi

dual

hea

lth

plan

spon

sore

d by

gov

ernm

ent o

r ed

ucat

iona

lins

titut

ion

incl

udin

gIn

dian

AD

D

App

licat

ion

mus

t be

mad

e w

ithin

30

days

fr

omth

eda

teth

e

Proo

f of l

oss o

f ins

uran

ce

on o

ther

pla

n an

d Se

lf an

d de

pend

ent(

s)

Dat

e of

loss

of

prev

ious

cov

erag

e if

YE

SN

/AN

/AA

DD

YE

SN

/AN

och

ange

No

chan

geF-

4ed

ucat

iona

l ins

titut

ion,

incl

udin

g In

dian

T

riba

l gov

ernm

ent a

nd fo

reig

n go

vern

men

t, or

oth

er in

divi

dual

cov

erag

e

AD

Dfr

om th

e da

te th

e he

alth

insu

ranc

e en

ded

elig

ibili

ty d

ata

for

any

new

ly-e

ligib

le p

erso

nsw

ho lo

st

cove

rage

App

licat

ion

is tim

ely

mad

e

YE

SN

/AN

/AA

DD

YE

SN

/AN

o ch

ange

No

chan

ge

Pag

e 9

QL

E

Cod

ePl

an R

ecog

nize

d Q

ualif

ied

Life

Eve

nt

Enr

olle

e ch

ange

req

uest

to

OG

B p

lan

AD

D o

r D

RO

P

Dea

dlin

e to

subm

it re

ques

t and

pro

vide

pr

oof d

ocum

ent

Proo

f or

docu

men

t re

quir

ed

Enr

olle

e al

low

ed

to c

hang

e (w

ho

mee

ts th

e el

igib

ility

de

finiti

on)

Eff

ectiv

e D

ate

of

Cha

nge

AD

D

Dep

ende

nt

YE

S or

NO

DR

OP

Dep

ende

nt

YE

S or

NO

DR

OP

Se

lf

Y

ES

or

NO

AD

D o

r D

RO

P M

edic

al

Cov

erag

e

CH

AN

GE

H

ealth

Pla

n Y

ES

or N

O

CO

BR

A

Eve

nt Y

ES

or N

O

Flex

ible

Sp

endi

ng P

lan

– H

ealth

Car

e

Flex

ible

Sp

endi

ng P

lan

- D

ep. C

are

F-5

Mag

nolia

Loc

al P

lan

mem

ber

mov

es o

ut o

f M

agno

lia L

ocal

Pla

n ne

twor

k ar

ea

Tra

nsfe

r to

M

agno

lia L

ocal

Pl

us P

lan

App

licat

ion

mus

t be

mad

e w

ithin

30

days

of

cha

nge

in

resi

denc

e

Doc

umen

tatio

n pr

ovin

g da

te o

f cha

nge

in

resi

denc

e fr

om M

agno

lia

Loc

al n

etw

ork

area

(e

xam

ples

incl

ude

vote

r re

gist

ratio

n ca

rd,

hom

este

ad e

xem

ptio

n,

copy

of w

ater

or

elec

tric

bi

lli

di

Self;

self

and

curr

ent c

over

ed

depe

nden

ts w

ho

lost

cov

erag

e

Dat

e of

loss

of

prev

ious

cov

erag

e if

App

licat

ion

is tim

ely

mad

e

N/A

(can

on

ly a

dd

pers

ons w

ho

wer

e co

vere

d be

fore

and

lo

st

)

NO

NO

AD

D

YE

S, o

nly

to

the

Mag

nolia

L

ocal

Plu

s Pl

an

NO

No

chan

geN

o ch

ange

Off

ice

of G

roup

Ben

efits

Pla

n-R

ecog

nize

d Q

ualif

ied

Life

Eve

nts (

QL

E) 2

017

bill,

not

ariz

ed a

ttes

tatio

n,

etc.

)co

vera

ge)

G-1

Mar

riag

e A

DD

App

licat

ion

mus

t be

mad

e w

ithin

30

days

of

cha

nge

in st

atus

Cop

y of

cer

tifie

d m

arri

age

cert

ifica

te a

nd

elig

ibili

ty d

ata

for

any

new

ly-e

ligib

le p

erso

ns

Self

and

new

sp

ouse

and

/or

ne

w

step

child

ren;

em

ploy

ee m

ay

add

child

onl

y if

child

was

im

med

iate

ly

Dat

e of

the

mar

riag

e if

appl

icat

ion

is

timel

y m

ade

YE

S (N

ew

Spou

se

and/

or N

ew

Step

-C

hild

ren)

N/A

NO

AD

DY

ES

NO

May

enr

oll o

r in

crea

se a

mou

ntM

ay e

nrol

l or

incr

ease

am

ount

MA

RR

IAG

E

prev

ious

ly

cove

red

unde

r ne

w sp

ouse

's

insu

ranc

e.

Chi

ldre

n)

Pag

e 10

QL

E

Cod

ePl

an R

ecog

nize

d Q

ualif

ied

Life

Eve

nt

Enr

olle

e ch

ange

req

uest

to

OG

B p

lan

AD

D o

r D

RO

P

Dea

dlin

e to

subm

it re

ques

t and

pro

vide

pr

oof d

ocum

ent

Proo

f or

docu

men

t re

quir

ed

Enr

olle

e al

low

ed

to c

hang

e (w

ho

mee

ts th

e el

igib

ility

de

finiti

on)

Eff

ectiv

e D

ate

of

Cha

nge

AD

D

Dep

ende

nt

YE

S or

NO

DR

OP

Dep

ende

nt

YE

S or

NO

DR

OP

Se

lf

Y

ES

or

NO

AD

D o

r D

RO

P M

edic

al

Cov

erag

e

CH

AN

GE

H

ealth

Pla

n Y

ES

or N

O

CO

BR

A

Eve

nt Y

ES

or N

O

Flex

ible

Sp

endi

ng P

lan

– H

ealth

Car

e

Flex

ible

Sp

endi

ng P

lan

- D

ep. C

are

G-2

Mar

riag

e- G

ain

of c

over

age

on n

ew

spou

se’s

pla

nD

RO

P

App

licat

ion

mus

t be

mad

e w

ithin

30

days

fr

om e

ffec

tive

date

of

new

cov

erag

e on

sp

ouse

’s p

lan

due

to

mar

riag

e ev

ent

Cop

y of

cer

tifie

d m

arri

age

cert

ifica

te a

nd

proo

f of a

ctiv

e en

rollm

ent o

n sp

ouse

’s

plan

on

com

pany

le

tter

head

; mus

t sho

w

cove

rage

eff

ectiv

e da

tes

of e

ach

nam

ed d

epen

dent

Self;

cur

rent

co

vere

d de

pend

ents

Cov

erag

e w

ill b

e ca

ncel

led

at th

e en

d of

the

mon

th fo

r w

hich

tim

ely

App

licat

ion

for

dise

nrol

lmen

t is

mad

e

N/A

YE

SY

ES

DR

OP

N/A

NO

May

dec

reas

e if

fam

ily m

embe

rs

beco

me

cove

red

unde

r sp

ouse

’s

heal

th p

lan

May

dec

reas

e if

spou

se h

as

Dep

ende

nt F

SA

thro

ugh

his/

her

empl

oyer

Off

ice

of G

roup

Ben

efits

Pla

n-R

ecog

nize

d Q

ualif

ied

Life

Eve

nts (

QL

E) 2

017

H-1

Em

ploy

ee w

ho d

ropp

ed c

over

age

whi

le o

n un

paid

leav

e re

turn

ing

to w

ork

with

pay

fr

om u

npai

d le

ave

in sa

me

capa

city

Rei

nsta

te

cove

rage

App

licat

ion

mus

t be

mad

e w

ithin

30

days

of

ret

urn

to w

ork

with

pay

Sign

ed G

B-0

1 fr

om

Em

ploy

er

Can

rei

nsta

te

cove

rage

for

self

and

depe

nden

ts

who

wer

e co

vere

d pr

ior

to

taki

ng u

npai

d le

ave

Dat

e re

turn

s to

wor

k w

ith p

aid

stat

us if

app

licat

ion

is ti

mel

y m

ade

AD

D (m

ay

add

new

ly-

acqu

ired

de

pend

ents

on

ly)

NO

unl

ess

depe

nden

t is

no lo

nger

el

igib

le

N/A

Rei

nsta

te

prio

r co

vera

ge

N

O

N

O

May

re-

enro

ll ei

ther

a) a

t sam

e le

vel o

f ben

efits

as

bef

ore

leav

e,

whi

ch r

equi

res

incr

ease

d de

duct

ion

amou

nt fo

r ca

tch-

up, o

r b)

co

ntin

ue sa

me

dedu

ctio

nas

May

re-

enro

ll ei

ther

a) a

t sam

e le

vel o

f ben

efits

as

bef

ore

leav

e,

whi

ch r

equi

res

incr

ease

d de

duct

ion

amou

nt fo

r ca

tch-

up, o

r b)

co

ntin

ue sa

me

dedu

ctio

nas

MIL

ITA

RY

LE

AV

E A

ND

UN

PAID

LE

AV

E

dedu

ctio

n as

be

fore

unp

aid

leav

e w

ith n

o ca

tch-

up.

dedu

ctio

n as

be

fore

unp

aid

leav

e w

ith n

o ca

tch-

up.

Pag

e 11

QL

E

Cod

ePl

an R

ecog

nize

d Q

ualif

ied

Life

Eve

nt

Enr

olle

e ch

ange

req

uest

to

OG

B p

lan

AD

D o

r D

RO

P

Dea

dlin

e to

subm

it re

ques

t and

pro

vide

pr

oof d

ocum

ent

Proo

f or

docu

men

t re

quir

ed

Enr

olle

e al

low

ed

to c

hang

e (w

ho

mee

ts th

e el

igib

ility

de

finiti

on)

Eff

ectiv

e D

ate

of

Cha

nge

AD

D

Dep

ende

nt

YE

S or

NO

DR

OP

Dep

ende

nt

YE

S or

NO

DR

OP

Se

lf

Y

ES

or

NO

AD

D o

r D

RO

P M

edic

al

Cov

erag

e

CH

AN

GE

H

ealth

Pla

n Y

ES

or N

O

CO

BR

A

Eve

nt Y

ES

or N

O

Flex

ible

Sp

endi

ng P

lan

– H

ealth

Car

e

Flex

ible

Sp

endi

ng P

lan

- D

ep. C

are

H-2

Em

ploy

ee o

n un

paid

leav

eD

RO

P

App

licat

ion

mus

t be

mad

e w

ithin

30

days

of

taki

ng u

npai

d le

ave

Sign

ed G

B-0

1 fr

om

Em

ploy

er

Self;

self

and/

or

curr

ent c

over

ed

depe

nden

ts

End

of m

onth

un

paid

leav

e be

gins

if

appl

icat

ion

is tim

ely

mad

e

N/A

YE

SY

ES

DR

OP

N/A

NO

May

pre

-pay

, de

crea

se o

r de

activ

ate

dedu

ctio

ns

May

pre

-pay

, de

crea

se o

r de

activ

ate

dedu

ctio

ns

App

licat

ion

mus

tbe

End

ofm

onth

that

May

pre-

pay,

May

pre-

pay,

Off

ice

of G

roup

Ben

efits

Pla

n-R

ecog

nize

d Q

ualif

ied

Life

Eve

nts (

QL

E) 2

017

H-3

Mili

tary

Em

ploy

ee g

oes o

n U

SER

RA

leav

eD

RO

P

App

licat

ion

mus

tbe

mad

e w

ithin

30

days

of

taki

ng U

SER

RA

le

ave

Sign

ed G

B-0

1 fr

om

Em

ploy

er a

nd a

ny

mili

tary

ord

ers

Self;

self

and/

or

curr

ent c

over

ed

depe

nden

ts

End

of m

onth

that

U

SER

RA

leav

e be

gins

if a

pplic

atio

n is

tim

ely

mad

e

N/A

YE

SY

ES

DR

OP

N/A

NO

May

pre

-pay

, de

crea

se o

r de

activ

ate

dedu

ctio

ns

May

pre

-pay

, de

crea

se o

r de

activ

ate

dedu

ctio

ns

H-4

Mili

tary

Em

ploy

ee r

etur

ns fr

om U

SER

RA

le

ave

to fu

ll-tim

e st

atus

. R

eins

tate

co

vera

ge

App

licat

ion

mus

t be

mad

e w

ithin

30

days

fr

om r

e-em

ploy

men

t or

from

dat

e th

at

Em

ploy

ee’s

act

ive

duty

mili

tary

hea

lth

bene

fits e

nd,

HR

mus

t pro

vide

do

cum

enta

tion

of

mili

tary

ord

ers a

nd o

f m

ilita

ry h

ealth

cov

erag

e en

d da

te

Can

rei

nsta

te

cove

rage

for

self

and

depe

nden

ts

who

wer

e co

vere

d pr

ior

to

taki

ng U

SER

RA

le

ave

Dat

e re

turn

s to

full-

time

activ

e st

atus

fr

om U

SER

RA

leav

e or

the

date

that

E

mpl

oyee

’s a

ctiv

e du

ty m

ilita

ry h

ealth

co

vera

ge e

nds,

whi

chev

er is

late

r, if

AD

D (m

ay

only

add

ne

wly

ac

quir

ed

depe

nden

ts)

NO

unl

ess

depe

nden

t is

no lo

nger

el

igib

le

N/A

Rei

nsta

te

prio

r co

vera

ge;

may

als

o al

low

for

a ch

ange

in

hea

lth

YE

SN

O

May

re-

enro

ll ei

ther

a) a

t sam

e le

vel o

f ben

efits

as

bef

ore

leav

e,

whi

ch r

equi

res

incr

ease

d de

duct

ion

amou

nt fo

r ca

tch-

up, o

r b)

co

ntin

ue sa

me

May

re-

enro

ll ei

ther

a) a

t sam

e le

vel o

f ben

efits

as

bef

ore

leav

e,

whi

ch r

equi

res

incr

ease

d de

duct

ion

amou

nt fo

r ca

tch-

up, o

r b)

co

ntin

ue sa

me

whi

chev

er is

late

rle

ave

appl

icat

ion

is tim

ely

mad

epl

ande

duct

ion

as

befo

re m

ilita

ry

leav

e w

ith n

o ca

tch-

up.

dedu

ctio

n as

be

fore

mili

tary

le

ave

with

no

catc

h-up

.

Pag

e 12

QL

E

Cod

ePl

an R

ecog

nize

d Q

ualif

ied

Life

Eve

nt

Enr

olle

e ch

ange

req

uest

to

OG

B p

lan

AD

D o

r D

RO

P

Dea

dlin

e to

subm

it re

ques

t and

pro

vide

pr

oof d

ocum

ent

Proo

f or

docu

men

t re

quir

ed

Enr

olle

e al

low

ed

to c

hang

e (w

ho

mee

ts th

e el

igib

ility

de

finiti

on)

Eff

ectiv

e D

ate

of

Cha

nge

AD

D

Dep

ende

nt

YE

S or

NO

DR

OP

Dep

ende

nt

YE

S or

NO

DR

OP

Se

lf

Y

ES

or

NO

AD

D o

r D

RO

P M

edic

al

Cov

erag

e

CH

AN

GE

H

ealth

Pla

n Y

ES

or N

O

CO

BR

A

Eve

nt Y

ES

or N

O

Flex

ible

Sp

endi

ng P

lan

– H

ealth

Car

e

Flex

ible

Sp

endi

ng P

lan

- D

ep. C

are

I-1

New

Ful

l-Tim

e E

mpl

oyee

AD

D

App

licat

ion

mus

t be

mad

e w

ithin

30

days

fr

omda

teof

full-

Sign

ed G

B-0

1 fr

om

Em

ploy

er a

nd e

ligib

ility

da

tafo

ran

yne

wly

-

Em

ploy

ee;

empl

oyee

and

el

igib

le

Bas

ed u

pon

date

of

empl

oym

ent (

Hir

e D

ate

- 1st

Day

of t

he

Mon

th -

Cov

erag

e ef

fect

ive

on F

irst

day

of

the

follo

win

g m

onth

; Hir

e D

ate

- 2n

d da

y of

the

mon

thor

afte

r-

YE

S N

/AN

/AA

DD

YE

S N

OM

ay E

nrol

lM

ay E

nrol

l

NE

W H

IRE

S A

ND

TE

RM

INA

TIO

NS,

AC

A R

EQ

UIR

EM

EN

TS,

AN

D C

HA

NG

E IN

CL

ASS

IFIC

AT

ION

Off

ice

of G

roup

Ben

efits

Pla

n-R

ecog

nize

d Q

ualif

ied

Life

Eve

nts (

QL

E) 2

017

from

dat

e of

full-

time

empl

oym

ent

data

for

any

new

ly-

elig

ible

per

sons

elig

ible

de

pend

ent(

s)m

onth

or

afte

r -

Cov

erag

e ef

fect

ive

on th

e fir

st d

ay o

f th

e se

cond

mon

th

follo

win

g em

ploy

men

t) if

ap

plic

atio

n is

tim

ely

mad

e

I-2

Non

-Ful

l-Tim

e (v

aria

ble,

seas

onal

, par

t-tim

e) E

mpl

oyee

who

is d

eter

min

ed to

be

Full-

Tim

e at

end

of t

he In

itial

M

easu

rem

ent P

erio

d

AD

DA

pplic

atio

n m

ust b

e m

ade

with

in 3

0 da

ys

of d

ate

of e

ligib

ility

Sign

ed G

B-0

1 fr

om

Em

ploy

er a

nd e

ligib

ility

da

ta fo

r an

y ne

wly

-el

igib

le p

erso

ns

Em

ploy

ee;

empl

oyee

and

el

igib

le

depe

nden

t(s)

Firs

t of t

he m

onth

fo

llow

ing

the

end

of

the

30-d

ay

enro

llmen

t per

iod

if ap

plic

atio

n is

tim

ely

YE

SN

/AN

/AA

DD

N/A

NO

May

Enr

oll

May

Enr

oll

Mea

sure

men

t Per

iod

elig

ible

per

sons

depe

nden

t(s)

appl

icat

ion

is ti

mel

y m

ade

Pag

e 13

QL

E

Cod

ePl

an R

ecog

nize

d Q

ualif

ied

Life

Eve

nt

Enr

olle

e ch

ange

req

uest

to

OG

B p

lan

AD

D o

r D

RO

P

Dea

dlin

e to

subm

it re

ques

t and

pro

vide

pr

oof d

ocum

ent

Proo

f or

docu

men

t re

quir

ed

Enr

olle

e al

low

ed

to c

hang

e (w

ho

mee

ts th

e el

igib

ility

de

finiti

on)

Eff

ectiv

e D

ate

of

Cha

nge

AD

D

Dep

ende

nt

YE

S or

NO

DR

OP

Dep

ende

nt

YE

S or

NO

DR

OP

Se

lf

Y

ES

or

NO

AD

D o

r D

RO

P M

edic

al

Cov

erag

e

CH

AN

GE

H

ealth

Pla

n Y

ES

or N

O

CO

BR

A

Eve

nt Y

ES

or N

O

Flex

ible

Sp

endi

ng P

lan

– H

ealth

Car

e

Flex

ible

Sp

endi

ng P

lan

- D

ep. C

are

I-3

Non

-Ful

l-Tim

e (v

aria

ble,

seas

onal

, par

t-tim

e) E

mpl

oyee

who

is d

eter

min

ed to

be

Full-

Tim

e at

end

of t

he S

tand

ard

Mea

sure

men

t Per

iod

AD

DA

pplic

atio

n m

ust b

e m

ade

with

in 3

0 da

ys

of d

ate

of e

ligib

ility

Sign

ed G

B-0

1 fr

om

Em

ploy

er a

nd e

ligib

ility

da

ta fo

r an

y ne

wly

-el

igib

le p

erso

ns

Em

ploy

ee;

empl

oyee

and

el

igib

le

depe

nden

t(s)

Janu

ary

1 of

fo

llow

ing

plan

yea

r if

appl

icat

ion

is tim

ely

mad

e

YE

SN

/AN

/AA

DD

N/A

NO

May

Enr

oll

May

Enr

oll

Off

ice

of G

roup

Ben

efits

Pla

n-R

ecog

nize

d Q

ualif

ied

Life

Eve

nts (

QL

E) 2

017

I-4

Non

-Ful

l-Tim

e (v

aria

ble,

seas

onal

, par

t-tim

e) E

mpl

oyee

who

exp

erie

nces

a C

hang

e in

Cla

ssifi

catio

n to

per

man

ent F

ull-T

ime

in

any

mea

sure

men

t or

stab

ility

per

iod

(thi

s re

quir

es a

del

iber

ate

docu

men

ted

empl

oyer

de

cisi

on to

mak

e th

e em

ploy

ee a

full-

time

empl

oyee

)

AD

D

App

licat

ion

mus

t be

mad

e w

ithin

30

days

of

dat

e of

cha

nge

in

clas

sific

atio

n

Sign

ed G

B-0

1 fr

om

Em

ploy

er a

nd e

ligib

ility

da

ta fo

r an

y ne

wly

-el

igib

le p

erso

ns

Em

ploy

ee;

empl

oyee

and

el

igib

le

depe

nden

t(s)

Firs

t of t

he m

onth

fo

llow

ing

the

end

of

the

30-d

ay

enro

llmen

t per

iod

if ap

plic

atio

n is

tim

ely

mad

e

YE

SN

/AN

/AA

DD

N/A

NO

May

Enr

oll

May

Enr

oll

Pag

e 14

QL

E

Cod

ePl

an R

ecog

nize

d Q

ualif

ied

Life

Eve

nt

Enr

olle

e ch

ange

req

uest

to

OG

B p

lan

AD

D o

r D

RO

P

Dea

dlin

e to

subm

it re

ques

t and

pro

vide

pr

oof d

ocum

ent

Proo

f or

docu

men

t re

quir

ed

Enr

olle

e al

low

ed

to c

hang

e (w

ho

mee

ts th

e el

igib

ility

de

finiti

on)

Eff

ectiv

e D

ate

of

Cha

nge

AD

D

Dep

ende

nt

YE

S or

NO

DR

OP

Dep

ende

nt

YE

S or

NO

DR

OP

Se

lf

Y

ES

or

NO

AD

D o

r D

RO

P M

edic

al

Cov

erag

e

CH

AN

GE

H

ealth

Pla

n Y

ES

or N

O

CO

BR

A

Eve

nt Y

ES

or N

O

Flex

ible

Sp

endi

ng P

lan

– H

ealth

Car

e

Flex

ible

Sp

endi

ng P

lan

- D

ep. C

are

Full-

Tim

e E

mpl

oyee

ret

urni

ng fu

ll-tim

e or

t

tiith

lth

13k

(l

App

licat

ion

mus

tbe

Sign

ed G

B-0

1 fr

om

Em

ploy

ee;

Firs

t of t

he m

onth

f

lli

thR

t

Off

ice

of G

roup

Ben

efits

Pla

n-R

ecog

nize

d Q

ualif

ied

Life

Eve

nts (

QL

E) 2

017

I-5

part

-tim

e w

ith le

ss th

an 1

3 w

eeks

(or

less

th

an 2

6 w

eeks

for

educ

atio

nal i

nstit

utio

ns)

sinc

e Se

para

tion

(thi

s wou

ld in

clud

e re

tiree

s who

are

reh

ired

as W

AE

s)

AD

D

ppm

ade

with

in 3

0 da

ys

follo

win

g th

e re

turn

to

wor

k

gE

mpl

oyer

and

elig

ibili

ty

data

for

any

new

ly-

elig

ible

per

sons

py

;em

ploy

ee a

nd

elig

ible

de

pend

ent(

s)

follo

win

g th

e R

etur

n to

Wor

k if

appl

icat

ion

is ti

mel

y m

ade

YE

SN

/AN

/AA

DD

YE

SN

OM

ay E

nrol

lM

ay E

nrol

l

I-6

Em

ploy

ee c

hang

es fr

om F

ull-T

ime

stat

us to

no

n-Fu

ll-T

ime

(req

uire

s del

iber

ate

docu

men

ted

deci

sion

to r

educ

e ho

urs b

elow

fu

lltim

e)(n

otin

stab

ility

peri

od)

Em

ploy

ee m

ust

cont

inue

co

vera

ge

App

licat

ion

mus

t be

mad

e w

ithin

30

days

of

cha

nge

in st

atus

co

nfir

min

g ch

ange

in

hour

s fro

m F

ull-

Sign

ed G

B-0

1 fr

om

Em

ploy

er

Em

ploy

ee;

empl

oyee

and

el

igib

le

depe

nden

t(s)

w

ould

be

drop

ped

atth

e

Cov

erag

e te

rmin

ates

at

the

end

of th

e pl

an y

ear

N/A

N/A

N/A

N/A

NO

YE

S at

the

end

of th

e pl

an y

ear

Aut

o dr

op a

t the

en

d of

the

plan

ye

ar

Aut

o dr

op a

t the

en

d of

the

plan

ye

arfu

ll tim

e) (n

ot in

stab

ility

per

iod)

Tim

e to

non

-Ful

l-T

ime

drop

ped

at th

e en

d of

the

plan

ye

ar

Pag

e 15

QL

E

Cod

ePl

an R

ecog

nize

d Q

ualif

ied

Life

Eve

nt

Enr

olle

e ch

ange

req

uest

to

OG

B p

lan

AD

D o

r D

RO

P

Dea

dlin

e to

subm

it re

ques

t and

pro

vide

pr

oof d

ocum

ent

Proo

f or

docu

men

t re

quir

ed

Enr

olle

e al

low

ed

to c

hang

e (w

ho

mee

ts th

e el

igib

ility

de

finiti

on)

Eff

ectiv

e D

ate

of

Cha

nge

AD

D

Dep

ende

nt

YE

S or

NO

DR

OP

Dep

ende

nt

YE

S or

NO

DR

OP

Se

lf

Y

ES

or

NO

AD

D o

r D

RO

P M

edic

al

Cov

erag

e

CH

AN

GE

H

ealth

Pla

n Y

ES

or N

O

CO

BR

A

Eve

nt Y

ES

or N

O

Flex

ible

Sp

endi

ng P

lan

– H

ealth

Car

e

Flex

ible

Sp

endi

ng P

lan

- D

ep. C

are

I-7

Em

ploy

ee d

eter

min

ed to

be

Full-

Tim

e du

ring

pre

viou

s Mea

sure

men

t Per

iod

chan

ges t

o N

on-F

ull-T

ime

unde

r co

rres

pond

ing

Stab

ility

Per

iod

Em

ploy

ee m

ust

cont

inue

co

vera

ge

App

licat

ion

mus

t be

mad

e w

ithin

30

days

of

cha

nge

in st

atus

Sign

ed G

B-0

1 fr

om

Em

ploy

er

Em

ploy

ee;

empl

oyee

and

el

igib

le

depe

nden

t(s)

w

ould

be

drop

ped

at th

e en

d of

the

tbi

liti

d

Cov

erag

e te

rmin

ates

at

the

end

of th

e st

abili

ty p

erio

d on

th

e la

st d

ay o

f tha

t m

onth

N/A

N/A

N/A

N/A

NO

Upo

n te

rmin

atio

n of

co

vera

ge

Aut

o dr

op a

t the

en

d of

the

plan

ye

ar h

ealth

co

vera

ge e

nds

Aut

o dr

op a

t the

en

d of

the

plan

ye

ar h

ealth

co

vera

ge e

nds

Off

ice

of G

roup

Ben

efits

Pla

n-R

ecog

nize

d Q

ualif

ied

Life

Eve

nts (

QL

E) 2

017

stab

ility

per

iod

on th

e la

st d

ay o

f th

at m

onth

mon

th

I-8

Full-

Tim

e to

Ful

l-Tim

e T

rans

ferr

ing

Em

ploy

ee

Mov

ing

Cov

erag

e fr

om

one

OG

B

Part

icip

ant

Em

ploy

er to

an

othe

r O

GB

Pa

rtic

ipan

t E

mpl

oyer

(E

mpl

oyee

may

tA

ddD

Tra

nsfe

rrin

g Pa

rtic

ipan

t E

mpl

oyer

- A

pplic

atio

n to

R

emov

e sh

ould

be

rece

ived

with

in 3

0 da

ys o

f tra

nsfe

r;

New

Par

ticip

ant

Em

ploy

er -

Sign

ed G

B-0

1 fr

om th

e hi

ring

Par

ticip

ant

Em

ploy

er

Em

ploy

ee;

empl

oyee

and

el

igib

le

depe

nden

ts

Con

tinuo

us c

over

age,

no

gap

. H

irin

g Pa

rtic

ipan

t Em

ploy

er

will

ass

ume

cove

rage

ba

sed

upon

dat

e of

hi

re.

If h

ired

the

1st

day

of th

e m

onth

, hi

ring

Par

ticip

ant

Em

ploy

er w

ill a

ssum

e re

spon

sibi

lity

for

plan

m

embe

r im

med

iate

ly.

If h

ired

on

the

2nd

day

NO

NO

NO

N/A

YE

SN

O

May

Enr

oll i

f tr

ansf

erri

ng fr

om

a N

on-F

lex

Part

icip

ant

Em

ploy

er; m

ay

deac

tivat

e or

de

crea

se a

mou

nts

if em

ploy

ee

choo

ses n

ew p

lan

av

aila

ble

with

the

tf

tht

May

Enr

oll i

f tr

ansf

erri

ng

from

a N

on-F

lex

Part

icip

ant

Em

ploy

er

not A

dd o

r D

rop

cove

rage

but

m

ay c

hang

e he

alth

pla

ns)

App

licat

ion

to A

dd

mus

t be

rece

ived

w

ithin

30

days

of

hire

If h

ired

on

the

2nd

day

of th

e m

onth

or

afte

r,

the

hiri

ng P

artic

ipan

t E

mpl

oyer

will

ass

ume

resp

onsi

bilit

y on

the

first

of t

he se

cond

m

onth

follo

win

g hi

re.

tran

sfer

that

was

no

t ava

ilabl

e be

fore

the

tran

sfer

, with

a

low

er d

educ

tible

Pag

e 16

QL

E

Cod

ePl

an R

ecog

nize

d Q

ualif

ied

Life

Eve

nt

Enr

olle

e ch

ange

req

uest

to

OG

B p

lan

AD

D o

r D

RO

P

Dea

dlin

e to

subm

it re

ques

t and

pro

vide

pr

oof d

ocum

ent

Proo

f or

docu

men

t re

quir

ed

Enr

olle

e al

low

ed

to c

hang

e (w

ho

mee

ts th

e el

igib

ility

de

finiti

on)

Eff

ectiv

e D

ate

of

Cha

nge

AD

D

Dep

ende

nt

YE

S or

NO

DR

OP

Dep

ende

nt

YE

S or

NO

DR

OP

Se

lf

Y

ES

or

NO

AD

D o

r D

RO

P M

edic

al

Cov

erag

e

CH

AN

GE

H

ealth

Pla

n Y

ES

or N

O

CO

BR

A

Eve

nt Y

ES

or N

O

Flex

ible

Sp

endi

ng P

lan

– H

ealth

Car

e

Flex

ible

Sp

endi

ng P

lan

- D

ep. C

are

I-9

Em

ploy

ee T

erm

inat

ed/s

epar

atio

n of

serv

ice

(oth

er th

an r

etir

emen

t)D

RO

P

30 d

ays f

rom

the

date

of t

erm

inat

ion

(OG

B h

as th

e di

scre

tion

to

retr

oact

ivel

y dr

op if

co

rrec

t pre

miu

m is

no

t tim

ely

paid

and

A

liti

f

GB

-01

sign

ed b

y pa

rtic

ipan

t em

ploy

er

Em

ploy

ee a

nd a

ll co

vere

d de

pend

ents

The

end

of t

he

mon

th in

whi

ch

Em

ploy

ee's

te

rmin

atio

n is

effe

ctiv

e

N/A

YE

SY

ES

DR

OP

NO

YE

S

Aut

omat

ic

Can

cel o

n da

te

of te

rmin

atio

n of

em

ploy

men

t

Aut

omat

ic

Can

cel o

n da

te

of te

rmin

atio

n of

em

ploy

men

t+A

81

Off

ice

of G

roup

Ben

efits

Pla

n-R

ecog

nize

d Q

ualif

ied

Life

Eve

nts (

QL

E) 2

017

App

licat

ion

for

dise

nrol

lmen

t is n

ot

timel

y m

ade)

effe

ctiv

e1

I-10

Ann

ual E

nrol

lmen

tA

DD

OR

D

RO

P

Ann

ual E

nrol

lmen

t pe

riod

des

igna

ted

by

OG

B

Em

ploy

ee;

empl

oyee

and

el

igib

le

depe

nden

ts

Janu

ary

1 of

fo

llow

ing

plan

yea

r if

appl

icat

ion

is

timel

y m

ade

YE

SY

ES

YE

SA

DD

or

DR

OP

YE

SN

/AC

hang

es

allo

wed

Cha

nges

al

low

ed

Nat

ural

,Ado

pted

orSt

epch

ildde

pend

ent

Exe

cute

d ph

ysic

ian

atte

stat

ion

on O

GB

Fo

rm "

Req

uest

for

Con

tinua

tion

of

Cov

erag

efo

rO

GB

For

m "

Req

uest

for

Onl

y ch

ild

depe

nden

t cu

rren

tly

enro

lled

inth

eFi

rst o

f the

mon

th

follo

win

gth

ech

ild's

OV

ER

-AG

E D

EPE

ND

EN

T

J-1

Nat

ural

, Ado

pted

or

Step

child

dep

ende

nt

reac

hes a

ttai

nmen

t age

for

that

dep

ende

nt

and

is n

ot c

apab

le o

f sel

f-su

stai

ning

em

ploy

men

t

Con

tinua

tion

of

Cov

erag

e

Cov

erag

e fo

r In

capa

cita

ted

Dep

ende

nt C

hild

" m

ust b

e su

bmitt

ed

prio

r to

the

depe

nden

tchi

ld

reac

hing

the

age

of

26

Con

tinua

tion

of

Cov

erag

e fo

r In

capa

cita

ted

Dep

ende

nt

Chi

ld"

enro

lled

in th

e pl

an w

ho is

at

tain

ing

the

age

of 2

6 an

d is

in

capa

ble

of se

lf-su

stai

ning

em

ploy

men

t

follo

win

g th

e ch

ilds

atta

inm

ent o

f the

ag

e of

26

if ap

plic

atio

n is

tim

ely

mad

e an

d ac

cept

ed

N/A

N/A

N/A

N/A

NO

N/A

No

chan

geN

o ch

ange

Pag

e 17

QL

E

Cod

ePl

an R

ecog

nize

d Q

ualif

ied

Life

Eve

nt

Enr

olle

e ch

ange

req

uest

to

OG

B p

lan

AD

D o

r D

RO

P

Dea

dlin

e to

subm

it re

ques

t and

pro

vide

pr

oof d

ocum

ent

Proo

f or

docu

men

t re

quir

ed

Enr

olle

e al

low

ed

to c

hang

e (w

ho

mee

ts th

e el

igib

ility

de

finiti

on)

Eff

ectiv

e D

ate

of

Cha

nge

AD

D

Dep

ende

nt

YE

S or

NO

DR

OP

Dep

ende

nt

YE

S or

NO

DR

OP

Se

lf

Y

ES

or

NO

AD

D o

r D

RO

P M

edic

al

Cov

erag

e

CH

AN

GE

H

ealth

Pla

n Y

ES

or N

O

CO

BR

A

Eve

nt Y

ES

or N

O

Flex

ible

Sp

endi

ng P

lan

– H

ealth

Car

e

Flex

ible

Sp

endi

ng P

lan

- D

ep. C

are

K-1

Obt

ain

subs

idy

unde

r st

ate’

s pre

miu

m

assi

stan

cepr

ogra

mA

DD

App

licat

ion

mus

t be

mad

e w

ithin

60

days

fr

om d

ate

subs

idy

Off

icia

l st

ate

docu

men

t in

dica

ting

eff

ectiv

e da

te

whe

n st

ate

subs

idy

was

aw

arde

d an

d to

who

m

Self

and

depe

nden

t(s)

Dat

e of

aw

ard

of

subs

idy

(or

effe

ctiv

e da

te o

f sub

sidy

if

othe

r th

an d

ate

of

awar

d)if

YE

SN

/AN

/AA

DD

YE

SN

/AM

ay e

nrol

l or

can

incr

ease

N

o ch

ange

STA

TE

PR

EM

IUM

SU

BSI

DY

Off

ice

of G

roup

Ben

efits

Pla

n-R

ecog

nize

d Q

ualif

ied

Life

Eve

nts (

QL

E) 2

017

assi

stan

ce p

rogr

amw

as a

war

ded

by

stat

ean

d el

igib

ility

dat

a fo

r an

y ne

wly

-elig

ible

pe

rson

s

depe

nden

t(s)

awar

d) if

A

pplic

atio

n fo

r en

rollm

ent i

s tim

ely

mad

e

amou

nt

Not

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6

Pag

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For more information on your Flexible Benefits Plan 

 

OGB Flexible Benefits Administration 

Office of Group Benefits 

ATTN: Flexible Benefits Plan Administration 

P.O. Box 44036 

Baton Rouge, LA 70804 

 

Email address: FlexibleSpendingAccounts@la.gov   

Fax: 225‐342‐9919 or 225‐342‐9980 

Website: www.groupbenefits.org