Open Enrollment including Health Insurance Buy-out (Is now closed)

Evergreen Open Enrollment Notice - What is open enrollment?

Make sure you are using CURRENT forms.  They have a revision date of 10/15/2020 on them.

Election of these benefits is only available at the time of hire or during                                 Open Enrollment unless you have a HIPAA qualifying event.

What is a Section 125 Cafeteria Plan - A Cafeteria Plan is a reimbursement plan governed by IRS Section 125 which allows employees to contribute a certain amount of their gross income to a designated account or accounts before taxes are calculated. These accounts can be for insurance premiums and medical or dependent care expenses not covered by insurance, from which employees can be reimbursed throughout the plan year or claim period as they incur the expenses. A Cafeteria Plan allows the employer to reduce employees’ gross income, thereby reducing the amount the company pays in Federal Insurance Contributions Act (FICA or Social Security), Federal Unemployment Tax Act (FUTA), Workers’ Compensation, and some State taxes.

Our cafeteria plan includes these options:  (click here to review the plan document)

You must enroll during every open enrollment.  No late submissions will be accepted if you miss the deadline.

Health Flexible Spending Account (FSA)

• Required forms

Dependent Care Assistance (DCAP)

• Required forms

Health Savings Account (HSA) Silver CDHP Plan ONLY  Link to DataPath's HSA information

• Required forms

Health Insurance Buy-out (Cash in Lieu)

• Required forms

Waiver of Premium Conversion (electing this option allows you to pay taxes on your insurance premiums instead of a pre-tax deduction)

• Required form

Medical and Dental Plan information (click here)

**NEW** VEHI Decision tool.  Helps you compare plans and costs.

Open enrollment is the time to add or delete spouse/dependents/Domestic Partners, change your plan election or cancel your coverage.  IF YOU ARE NOT MAKING CHANGES TO YOUR COVERAGE OR WHO IS COVERED BY THE PLAN YOU DO NOT NEED TO COMPLETE ANY FORMS.

• Health Insurance Enrollment/Change form
  • Statement of Domestic Partnership
    • Domestic Partnership FAQs
  • HRA Enrollment form
  • HSA Enrollment form (Silver CDHP plan only)
• Dental Insurance Enrollment/Change form
  • Statement of Domestic Partnership

Claim forms

• Health Flex Spending Account (FSA), and Dependent Care Assistance Program (DCAP) Booklet
  • includes claim forms, worksheets and myRSC instructions

  • You have 45 days to file claims that occured prior to the end of the calendar year OR your date of separation.

• Revocation of Benefit Election Form.

Quick Links

• Open Enrollment
• Health & Dental Benefits
• Employee Assistance
• Retirement Plans
• Life Insurance and Long Term Disability
• Forms