If selecting a Moda Medical Synergy/Summit Plan, prior to the coverage start date you must contact Moda Health to select a Medical Home Provider for each covered member. A list of Medical Home Providers can be found at: not If you are choosing to enroll in an OEBB medical plan, select one of the following options: You will receive a financial incentive from your employing entity to not enroll in medical coverage. OPT-OUT By selecting this option, I confirm all eligible dependents have group coverage. You MUST have other employer-sponsored group medical coverage. Participation or enrollment in the Oregon Health Plan, Medicaid, Veterans’ Administration Benefit Programs, Medicare, or Student Health Insurance does NOT qualify for OEBB opt-out. You must provide proof of other group coverage to your employing entity within five business days or your opt-out will not be effective: Carrier Policy Number Group Number Primary Policy Holder Employer Effective Date (mm/dd/yyyy) WAIVE You will not receive a financial incentive from your employing entity regardless of whether or not you have other medical coverage. Note: Many employing entities do not offer a financial incentive, in those cases you should select “Waive.” DENTAL Decline Dental Dental Plan Selection: Write in plan selection. VISION Vision Plan Selection: Decline Vision Write in plan selection. Must be enrolled in Kaiser Medical to enroll in Kaiser Vision LATE ENROLLMENT PENALTY I understand if I decline Dental and/or Vision coverage when initially eligible or allow coverage to lapse, then choose to enroll in one or both of these plans at a future Open Enrollment period, I and any dependents enrolled will be subject to a 12-month waiting period on these plans for services other than basic services (cleanings, x-rays, and exams only for dental; exam only for vision). Member Signature Date 6. Optional Plans (Member paid voluntary payroll deduction plans.) Plan offering and availability is determined by your employing entity. Contact your employing entity for coverage information and to find out optional plans are available to you. A. Optional Life Insurance As a newly eligible member for your first time enrollment the Optional Member Life has a guarantee issue enrollment amount of up to $100,000 and Optional Spouse/Domestic Partner Life has a guarantee issue enrollment amount of up to $30,000 without needing to submit a medical history to The Standard Insurance Company underwriting for approval.
If selecting a Moda Medical Synergy/Summit Plan, prior to the coverage start date you must contact Moda Health to select a Medical Home Provider for each covered member. A list of Medical Home Providers can be found at: If you are choosing to not enroll in an OEBB medical plan, select one of the following options: OPT-OUT You will receive a financial incentive from your employing entity to not enroll in medical coverage. By selecting this option, I confirm all eligible dependents have group coverage. You MUST have other employer-sponsored group medical coverage. Participation or enrollment in the Oregon Health Plan, Medicaid, Veterans’ Administration Benefit Programs, Medicare, or Student Health Insurance does NOT qualify for OEBB opt-out. You must provide proof of other group coverage to your employing entity within five business days or your opt-out will not be effective: Carrier Policy Number Group Number Primary Policy Holder Employer Effective Date (mm/dd/yyyy) WAIVE You will not receive a financial incentive from your employing entity regardless of whether or not you have other medical coverage. Note: Many employing entities do not offer a financial incentive, in those cases you should select “Waive.” DENTAL Dental Plan Selection: Decline Dental Write in plan selection. VISION Vision Plan Selection: Decline Vision Write in plan selection. Must be enrolled in Kaiser Medical to enroll in Kaiser Vision LATE ENROLLMENT PENALTY I understand if I decline Dental and/or Vision coverage when initially eligible or allow coverage to lapse, then choose to enroll in one or both of these plans at a future Open Enrollment period, I and any dependents enrolled will be subject to a 12-month waiting period on these plans for services other than basic services (cleanings, x-rays, and exams only for dental; exam only for vision). Member Signature Date 6. Optional Plans (Member paid voluntary payroll deduction plans.) Plan offering and availability is determined by your employing entity. Contact your employing entity for coverage information and to find out optional plans are available to you. A. Optional Life Insurance As a newly eligible member for your first time enrollment the Optional Member Life has a guarantee issue enrollment amount of up to $100,000 and Optional Spouse/Domestic Partner Life has a guarantee issue enrollment amount of up to $30,000 without needing to submit a medical history to The Standard Insurance Company underwriting for approval.
Open-Enrollment-Form.docx