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Teaneck Board of Education
HA-0890-0920
OPEN ENROLLMENT 2020-2021

School Employees’ Health Benefits Program (SEHBP) EDUCATION ACTIVE EMPLOYEE GROUP
HEALTH BENEFITS ENROLLMENT AND/OR CHANGE FORM

1. MEMBER INFORMATION — Last Name	First	MI

__________________________________________________________________________________ Gender	Birth Date	Social Security Number	Marital Status*

__________________________________________________________________________________ Phone Number	Email Address

__________________________________________________________________________________

__________________________________________________________________________________ Street Address	City	State	Zip
	DIVISION USE ONLY
	
	Effective Dates	Event Reason:
H     _____/_____/_____ Rx _____/_____/_____

_
	
	EMPLOYER CERTIFICATION (See Instructions on reverse)
Employer
Name _________________________
Location # (State Monthly)

10/12 - month employee (Enter 10 or 12)

MEMBER ACTION
o New Enrollment     o Transfer

Date Employment Began

______/______/______

o Return from Leave of Absence
______/______/______
		
2. EMPLOYMENT STATUS	o Full Time	o Part Time	o National Guard
			
3. REASON FOR APPLICATION (Check one)

o New Enrollment	o Transfer
o Open Enrollment	o Loss of Coverage
o Adding Dependents o Deleting Dependents o Other
Reason_________________________________

Date of Event _______/_______/_______
	4. LEVEL OF COVERAGE
o Single oParent/Child
oMember/Spouse/Civil Union

oMember/Domestic Partner

oFamily
			
		Signature of Certifying Officer
		
		Phone Number	Date Mailed

5. HEALTH PLAN — Check one box only.

oNew Jersey Educators Health Plan	oNJ DIRECT10*	oNJ DIRECT15*

*NJ DIRECT10 AND NJ DIRECT15 are only available to employees hired prior to July 1, 2020.

6. DEPENDENT INFORMATION — List all eligible dependents and attach required proof of dependency documents* oAdditional sheets attached. Any dependents not listed will be removed.
	
Eligible Dependents Last Name, First Name
	Social Security No.
	Circle Relationship
	Birth Date
	Gender
	
	—	—
	
Spouse / Civil Union / Domestic Partner
	
/	/

—	—
	Child
(Natural, Adopted, Foster, Step, Legal Ward)
	
/	/
		
	—	—
	Child
(Natural, Adopted, Foster, Step, Legal Ward)
	
/	/
		
*See Instructions page for detailed information and mailing address

MEMBER CERTIFICATION — I certify that all the information supplied on this form is true to the best of my knowledge and that it is verifiable. I un-derstand that if I waive my right to coverage at this time, enrollment is not permissible until the next scheduled open enrollment or if other coverage is lost and proof of loss is provided (HIPAA). I also understand that there is no guarantee of continuous participation by medical providers, either doctors or facilities, in the plans. If either my physician or medical center terminates participation in my selected plan, I must select another doctor or medical center participating in that plan to receive the in-network benefit. I authorize any hospital, physician, or health care provider to furnish my medical plan or its assignee with such medical information about myself or my covered dependents as the assignee may require. Misrepresentation: Any person that knowingly provides false or misleading information is subject to criminal and civil penalties pursuant to N.J.S.A.17:33A-6c.

7. Member Signature ______________________________________________________________ Date ______/______/______

INSTRUCTIONS FOR THE SEHBP EDUCATION ACTIVE EMPLOYEE GROUP HEALTH BENEFITS ENROLLMENT AND/OR CHANGE FORM

SECTION 1 – MEMBER INFORMATION – Complete entire section. Indicate Marital Status as follows: S (Single), M (Married), CU (Civil Union), DP (Domestic Partner), D (Divorced), W (Widowed)

SECTION 2 – EMPLOYMENT STATUS – Check one box only

SECTION 3 – REASON FOR APPLICATION – Check one box only

•	New Enrollment – New hire or HIPAA event

•	Transfer – Active health benefits coverage transferring from another SHBP/SEHBP location •	Open Enrollment – Annually in October
•	Adding Dependents – Must be done within 60 days of event (i.e. birth, marriage, adoption – indicate reason and date) •	Deleting Dependents – Removal of covered dependents (indicate reason and date)
•	Loss of Coverage – Enrolling because of loss of other coverage (application and HIPAA certificate submitted within 60 days of the loss of other coverage)
•	Other (indicate reason and date) •	Reason – indicate reason
•	Date of Event – indicate date

To waive (decline) coverage: If you wish to waive Health and Prescription Drug coverage under the provisions of N.J.S.A. 52:14-17.31a, you must complete an Employee Coverage Waiver/Reinstatement Form. If you are waiving coverage for yourself or any or all of your eligible depen-dents because of other group health coverage, you may enroll in the future.You must provide proof of the loss of other coverage and submit it with your application and Employee Coverage Waiver/Reinstatement Form within 60 days of the loss of other coverage. Otherwise, you will be required to wait until the annual Open Enrollment.

SECTION 4 – LEVEL OF COVERAGE – Check the appropriate box to enroll in Health and Prescription Drug •	Single – coverage for you only
•	Parent/Child(ren) – coverage for you and any eligible child(ren) under age 26

•	Member/Spouse/Civil Union – coverage for you and your eligible spouse or your Civil Union Partner •	Member/Domestic Partner – coverage for you and your eligible Domestic Partner
•	Family – coverage for you, your eligible Spouse/Civil Union Partner/Domestic Partner, and child(ren) under age 26

Note: Education employers must have elected to provide the Employee Prescription Drug Plan to employees as a separate prescription drug benefit to be eligible for this coverage. If you are eligible for prescription drug coverage through another employer-provided plan or if your employer does not provide a separate drug plan, do not complete this section. If your employer does not provide any separate drug coverage, your SEHBP health plan will include a prescription drug benefit. If you have eligibility questions concerning prescription drug coverage, consult your human resources representative.

SECTION 5 – HEALTH PLAN – Select only one plan. Members who wish to enroll in NJ DIRECT10 or NJ DIRECT15 must have been hired prior to July 1, 2020.The Health Benefits Summary Program Description provides you with all available options.

SECTION 6 – DEPENDENT INFORMATION – List all eligible dependents and attach dependent documentation proof (see attached). If proper documentation has already been provided and approved, do not resubmit. If appropriate dependent documentation proof is not provided, depen-dents may not be enrolled. Ensure your dependents match your level of coverage (Section 4).Your child(ren) may be covered until the end of the calendar year they turn 26. Any dependents not listed will not be covered. Attach extra pages for additional dependents.

Note: Use Section 3 to delete dependents.

SECTION 7 – MEMBER SIGNATURE – Read, sign, date, and attach required dependent documentation. Return the application to your employer’s human resources office for certification.

MISREPRESENTATION: Any person that knowingly provides false or misleading information is subject to criminal and civil penalties pursuant to N.J.S.A. 17:33A-6c.

EMPLOYER CERTIFICATION – Must be completed by the Certifying Officer.The Certifying Officer’s signature confirms that: •	The employee is eligible;
•	The application is legible and completed in its entirety;

•	The employee’s selected plans and coverage levels are appropriate; •	The dependent documentation provided is complete and correct;
•	The Employer Certification section is completed in its entirety; and •	The information presented is true to the best of their knowledge.

MAIL COMPLETED APPLICATION TO:	 New Jersey Division of Pensions & Benefits Health Benefits Bureau
P.O. Box 299

Trenton, NJ 08625-0299

HA-0890-0920

HB-0840-0920
State Health Benefits Program (SHBP) • School Employees’ Health Benefits Program (SEHBP) REQUIRED DOCUMENTATION FOR DEPENDENT ELIGIBILITY AND ENROLLMENT

The State Health Benefits Program (SHBP) and School Employees’ Health Benefits Program (SEHBP) are required to ensure that only employees, retirees, and eligible dependents are receiving health care coverage under the Programs.The New Jersey Division of Pensions & Benefits (NJDPB) must guarantee consistent application of eligibility requirements within the plans. Employees or retirees who enroll dependents for coverage (spouses, civil union partners, domestic partners, children, disabled and/or overage children continuing coverage) must submit the following documentation in addition to the appropriate health benefits enrollment or change of status application. If proper documentation has already been provided and approved, do not resubmit. If appropriate dependent documentation proof is not provided, dependents may not be enrolled. Any dependents not listed on the application will not be covered.
	
DEPENDENTS
	ELIGIBILITY DEFINITION
	DOCUMENTATION REQUIRED

SPOUSE
	A person to whom you are legally married.
	A copy of the marriage certificate and a copy of the front page of the employee/retiree’s federal tax return* (Form 1040) from last year that in-cludes the spouse. If filing separately, submit a copy of both spouses’ tax returns that list the same address. If marriage occurred in the current cal-endar year, a copy of the tax return is not required.

CIVIL UNION PARTNER
	A person of the same sex with whom you have entered into a civil union.
	A copy of the marriage certificate and a copy of the front page of the employee/retiree’s federal tax return* (Form 1040) from last year that in-cludes the partner. If filing separately, submit a copy of both partners’ tax returns that list the same address. If marriage occurred in the current cal-endar year, a copy of the tax return is not required.

DOMESTIC PARTNER
	A person of the same sex with whom you have entered into a do-mestic partnership. Under P.L. 2003, c. 246, the Domestic Part-nership Act, health benefits coverage is available to domestic partners of State employees, State retirees, or employees or re-tirees of a SHBP - or SEHBP - participating local public entity that has adopted a resolution to provide Chapter 246 health benefits.
	A copy of the New Jersey certificate of domestic partnership dated prior to February 19, 2007, or a valid certification from another State or foreign jurisdiction that recognizes same-sex domestic partners and a copy of the front page of both partners’ N.J. tax return* from last year that includes the partner.

CHILDREN
	A subscriber’s child until age 26, regardless of the child’s marital, student, or financial dependency status – even if the young adult no longer lives with his or her parents.
This includes a stepchild, foster child, legally adopted child, or any child in a guardian-ward relationship upon submitting re-quired supporting documentation.
	Natural or Adopted Child – A copy of the child’s birth certificate showing the name of the employee/retiree as a parent.
Step Child – A copy of the child’s birth certificate showing the name of the employee/retiree’s spouse or partner as a parent and a copy of the mar-riage/partnership certificate showing the names of the employee/retiree and spouse/partner.
Legal Ward, Grandchild, or Foster Child – Copies of final court orders with the presiding judge’s signature and seal. Documents must attest to the legal guardianship by the employee.

DEPENDENT CHILDREN WITH DISABILITIES
	If a covered child is not capable of self-support when he or she reaches age 26 due to mental illness or incapacity, or a physical disability, the child may be eligible for a continuance of coverage. Coverage for children with disabilities may continue only while (1) you are covered through the SHBP/SEHBP; (2) the child continues to be disabled; (3) the child is unmarried or does not enter into a civil union or domestic partnership; and (4) the child remains substantially dependent on you for support and mainte-nance.You may be contacted periodically to verify that the child remains eligible for coverage.
	Documentation for the appropriate child type (as noted above) and a copy of the front page of the employee/retiree’s federal tax return* (Form 1040) from last year that includes the child. If Social Security disability has been awarded, or is currently pending, please include this information with the documentation that is submitted. Please note that this information is only verifying the child’s eligibility as a dependent. The disability status of the child is determined through a separate process.

CONTINUED COVERAGE FOR OVERAGE CHILDREN
	Certain children over age 26 may be eligible for continued cov-erage until age 31 under the provisions of P.L. 2005, c. 375.This includes a child by blood or law who: (1) is under the age of 31; (2) is unmarried or not a partner in a civil union or domestic partnership; (3) has no dependent(s) of his or her own; (4) is a resident of New Jersey or is a student at an accredited public or private institution of higher education, with at least 15 credit hours; and (5) is not provided coverage as a subscriber, insured, enrollee, or covered person under a group or individual health benefits plan, church plan, or entitled to benefits under Medicare.
	Documentation for the appropriate child type (as noted above), and a copy of the front page of the child’s federal tax return* (Form 1040) from last year, and if the child resides outside of the State of New Jersey, documen-tation of full time student status must be submitted.
	
*You may black out all financial information and all but the last four digits of any Social Security numbers on tax returns.To obtain copies of the documents listed above, contact the office of the town clerk in the city of the birth, marriage, etc., or visit these websites: www.vitalrec.com or www.studentclearinghouse.org Residents of New Jersey can obtain records from the State Bureau of Vital Statistics and Registration website: www.nj.gov/health/vital/index.shtml