8/2024
2024 BENEFITS PROGRAM QUALIFYING EVENT CHANGE FORM
Please fill out this form electronically and email the completed form to [email protected].
Forms must be received by the Office of Total Rewards within 60 days of the qualifying event.
You may
need to provide supporting documentation with this form in order for changes to be processed.
Name: ____________________________ _____________________________ _________
FIRST M.I.
LAST
Employee ID Number (required): ____________
Date of Birth: ____________
Email Address: ____________________________________________________________________
Daytime Phone Number: (____) ____ - _____ Gender (M/F): ______________________
Single
Marital Status:
Married
Widowed
Divorced
Monthly
Pay Cycle:
Semi-Monthly
Bi-Weekly
QUALIFYING EVENTS
Please select the appropriate qualifying event:
Check only one box
Please click within the box to scroll.
1
A Certification of Domestic Partners Status Form is REQUIRED for eligible domestic partners. Also, if your domestic partner and/or his/her
dependent children qualify as your tax dependent under Federal law, an Affidavit of Domestic Partner’s (Opposite-Sex and Same-Sex) Federal
Tax Dependent Status for University Health Benefit Plans Form is required. Forms are available online at www.rochester.edu/totalrewards.
Loss of Coverage
(Date of Qualifying Event requested
below is the 1st date in which you no longer have your
existing coverage)
Spouse/Domestic Partner Open Enrollment
Parent/Dependent Child
Spouse/Dependent Passes Away
Dependent Gains Eligibility Through Their Own
Employer or Parent's Coverage
Change in Cost of Care for Dependent Care FSA
Significant increase in the employee's share of
health care premiums
Significant decrease in the employee's share of
health care premiums
Legal Marriage/Domestic Partnership
1
Legal Separation or Divorce
Termination of Domestic Partnership
Birth of a Child/Adoption of a Child
Gain Eligibility of Medicaid/Medicare
Loss Eligibility of Medicaid/Medicare
Approved Leave (i.e.FMLA, Military Leave)
Return from Leave (i.e.FMLA, Military Leave)
Retirement
Other:________________________________
NOTE: This section must be completed for any request to change University Health, Dental, or Flexible Spending
Account elections outside of the annual open enrollment period due to a qualifying event. Changes due to a
qualifying event must be received within 60 days of the qualifying event. Coverage changes will generally be
effective on the date of the qualifying event. Where a coverage change is effective mid-way through a payroll
period, your employee contribution for that payroll period will be determined based on your coverage election in
effect as of the last day of the payroll period. Please refer to the Appendix A in the Health Program Guide for a list
of benefit changes allowed outside of Open Enrollment.
Please email completed forms and required documentation to the Office of Total Rewards at [email protected].
Page
2 of 6
Are you or any of your dependents currently covered under another University Health or Dental
Plan through a relative employed by the University, please provide the name of the relative below:
No
Yes
If yes, please provide the name of the relative: _______________________________________
DESIRED ACTION
Please check your desired action(s) and include the date of your qualifying event. If you need to provide
supporting documentation, the date of the qualifying event must coincide with your supporting
documentation. For loss of coverage events, the Date of Qualifying Event requested below is the 1st
date in which you no longer have your existing coverage.
I am requesting a change to my Health Care Plan and/or Dental Plan elections due to a Qualifying Event
2
.
Date of Qualifying Event:
I am requesting a change to my Flexible Spending Account (FSA) elections due to a Qualifying Event
2
.
Health Care FSA
Dependent Care FSA
Date of Qualifying Event:
I would like to add or remove a dependent(s) to/from my Health Care Plan and/or Dental Plan elections
due to a Qualifying Event
2
.
Date of Qualifying Event:
Changes to VSP Vision Care due to a qualifying event should be completed on YOURBenefitsExtras.com.
If you would like to make changes to your Health Savings Account, you may do so at any point throughout the
year by filling out the HSA Contribution Form.
2
Completed forms must be received by the Office of Total Rewards within 60 days of the qualifying event. Incomplete forms cannot be processed.
2024 Benefits Program Qualifying Event Change Form
Based on your qualifying event, you are eligible to make the following changes:
Please click within the box to scroll.
8/2023
2024 Benefits Program Qualifying Event Change Form
Page
3 of 6
DEPENDENT INFORMATION
I am not adding or removing a dependent.
Skip to the next page.
I am adding or removing a dependent.
Please complete the below chart, including information for ALL dependents that you would like to
include on your plan(s) moving forward.
Name
(Last, First)
Date of Birth
(MM/DD/YY)
Gender
(M/F)
Social
Security
Number
3
Should be
enrolled in
healthcare (Y/N)
Should be
enrolled in
dental (Y/N)
Spouse
Domestic
Partner
4
Family
Member
Child to age 26
Domestic Partner’s Child
Handicapped
5
Family
Member
Family
Member
Family
Member
I have additional dependents and my Additional Dependents Form will be submitted along with this form.
3
Required field for all dependents.
4
If an employee adds a Domestic Partner, they will need to submit the Certification of Domestic Partner Status form. If applicable, they should
complete the Domestic Partner Tax Affidavit. Both forms are available on the Total Rewards website.
5
A Handicapped Dependent form is REQUIRED for these eligible dependents. Forms are available online at rochester.edu/totalrewards and
from the Office of Total Rewards. Please return completed forms to the address listed on the form.
Beginning with the 2015 Plan Year, the Affordable Care Act Regulations requires all insures and self-insured employer groups (UR) to report to the IRS
the social security numbers (SSN) for each individual (employees and dependents) to whom the group provides minimum essential health care
coverage (MEC) intended primarily to support the IRS' enforcement of the individual mandate. In addition to your own, please provide the SSN for
each dependent to be enrolled under your University Health Care Plan. Under Medicare, Medicaid and SCHIP Extension Act of 2007 (MMSEA), third-
party administrators of self-funded plans like the University of Rochester’s Health Care Plans are required to meet new reporting requirements.
Reportable information includes Social Security Numbers of individuals whose health care plan coverage begins on or after 1/01/09, who are 45 or
older, are covered by Medicare, or have end-stage renal disease.
Child to age 26
Domestic Partner’s Child
Handicapped
5
Child to age 26
Domestic Partner’s Child
Handicapped
5
Child to age 26
Domestic Partner’s Child
Handicapped
5
8/2023
Please email completed forms and required documentation to the Office of Total Rewards at [email protected].
2024 Benefits Program Qualifying Event Change Form
Page 4 of 6
UNIVERSITY HEALTH CARE PLANS
I am not making any changes to my health care plan
Skip to the next section.
I am making one or more changes to my health care plan.
Please use the drop downs to select a plan, TPA, and coverage level below.
SELECT A PLAN
SELECT YOUR DEPENDENT
COVERAGE LEVEL
UNIVERSITY DENTAL PLANS
I am not making any changes to my dental plan
Skip to the next section.
I am making one or more changes to my dental plan.
Please use the drop downs to select a plan and coverage level below.
SELECT A PLAN
6
SELECT YOUR DEPENDENT
COVERAGE LEVEL
7
6
Excellus BlueCross BlueShield is the TPA for Dental Plans.
7
Employee Only coverage is considered single coverage. Family Coverage is coverage for the employee plus one or more dependents.
8/2023
Please email completed forms and required documentation to the Office of Total Rewards at [email protected].
2024 Benefits Program Qualifying Event Change Form
Page 5 of 6
FLEXIBLE SPENDING ACCOUNTS (FSA)
Please be sure to read the FSA Election of Reimbursement & Compensation Reduction Agreement prior to electing
an FSA. This can be found on the Total Rewards website under Flexible Spending Accounts.
I am not making any changes to my FSA.
Skip to the next section.
I am making one or more changes to my FSA.
Please specify your changes in the section below.
Maximum FSA Contribution Amounts for 2024:
Health Care FSA and Limited Purpose FSA - $100 minimum and $3,050 maximum annual contribution.
Dependent Care FSA - $100 minimum and $5,000 maximum or $2,500 if married and filing separate tax
returns annual contribution.
8
Dependent Care FSAs are used for child/daycare services for dependent children up to age 13 or a qualified handicapped spouse or dependent
child/tax dependent.
9
Limited Purpose FSAs are for employees that are enrolled in the HSA-Eligible Plan and are contributing to an HSA.
Please note: Federal non-discrimination guidelines require the University of Rochester to test Dependent Care FSA annually to ensure highly
compensated employees, as defined under IRS guidelines, do not disproportionally contribute to the Dependent Care FSA. Highly compensated
employees, who earned over $150,000 in the 2023 Plan Year, may have their FSA maximum contribution amount reduced if the test results do
not meet federal guidelines. If applicable, you might consider dividing your desired annual maximum contribution between you and your
spouse/partner.
8/2023
Please email completed forms and required documentation to the Office of Total Rewards at [email protected].
I would like to begin contributing to an FSA.
Annual Health Care FSA Contribution: $__________________
Annual Dependent Care FSA
8
Contribution: $__________________
Annual Limited Purpose FSA
9
Contribution: $__________________
I am currently contributing to an FSA at the University and would like to change my
contribution amount.
Annual Health Care FSA Contribution: $__________________
Annual Dependent Care FSA
8
Contribution: $__________________
Annual Limited Purpose FSA
9
Contribution: $__________________
Please note: Your FSA annual election cannot be reduced below the amount of payroll contributions already
deducted or claims submitted for the calendar year if it would result in a negative balance, and the change must be
consistent with the qualifying event. If you do not use your FSA contribution at the end of the plan year, then you will
forfeit the funds (rollover rules may apply). You will not be refunded for any unused FSA contributions. Additionally,
benefit changes may take up to 1-2 pay periods to process.
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Page 6 of 6
I understand that if I have knowingly included any false information or enrolled ineligible dependents,
that coverage may be canceled, upon one month's written notice and any benefit claims may be denied,
and that I may be subject to disciplinary action including termination of employment to the extent
permitted by law. I have read and understand the information defining dependent eligibility under the
University of Rochester Health and Dental Plans. I certified that each of my dependents covered under
my health care and/or dental plan(s) meet the University's current dependent eligibility requirements,
and that I agree to notify the Office of Total Rewards if their status changes during the plan year.
FIRST & LAST NAME: _______________________________________________
DATE: ________________________
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Please email completed forms and required documentation to the Office of Total Rewards at
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Please click within the box to scroll.
8/2023
I agree to the above terms and conditions.
I have reviewed the Qualifying Event Matrix to determine if supporting documentation is needed.
If applicable, supporting documentation will be emailed to [email protected] along
with this form.
I acknowledge that providing my electronic approval is equivalent to signing the document and I
understand that my electronic signature is binding. I understand that it may take up to one full
pay period to process this change.
Signature
Acknowledgment
I acknowledge and agree that by signing this enrollment form and subsequently accepting services, I and each of my
family members who are covered under the Plans are bound by the terms and conditions of the plan documents and
associated administrative documents as from time to time are in effect and that these documents have been available
(and will continue to be available) to me online at www.rochester.edu/totalrewards or in hard copy at the University
of Rochester Office of Total Rewards. This includes, without limitation, the terms and conditions regarding the
receipt and release of medical records and information to the Plan’s Third-Party Administrators and insurance
carriers. I make this acknowledgment and agreement on behalf of myself and each person who now or in the future
accepts coverage under the terms of the Plan applicable to my coverage (who may include, for example, my spouse,
and my eligible family dependents).
I authorize the University to deduct from my wages or salary the amount(s) indicated on the University of Rochester
2024 Health Care and Dental Plans Premium Rate Sheet to pay my share of the cost of being covered by University
benefit plans I have elected. I understand that such pay deductions will generally be taken on an after-tax basis,
with the exception of premium contributions toward the cost of Health Care Plan coverage for tax-qualified
dependents, flexible spending accounts (FSA) contributions, or Health Savings Account (HSA) contributions, which
will be taken on a before-tax basis. I understand that if I am enrolled in coverage through the University and not
receiving paychecks from the University, I must continue to pay my share of the premium for the Health Care and
Dental Plan coverage to continue coverage through the University. If the University does not receive payment for
the coverage, the coverage will be terminated on the last day of the month in which the premium has been paid in
full and notification of the coverage cancellation will be sent to the home address from the University. Employees
whose coverage has been canceled due to non-payment will not be eligible to re-enroll in Health Care or Dental
Plan coverage until the next Open Enrollment period and until the premiums past due are paid to the University.
Employees returning to work with an outstanding balance will be subject to arrears billing.
By electing an FSA or HSA, I and the University of Rochester, hereby agree that my cash compensation will be
reduced by the annual amount set forth in the FSA or HSA section of this form, pro-rated by the number of pay
periods in 2024 (or by the number of pay periods remaining after the date of this agreement) and deducted from my
pay in equal installments. I have read and understand the information contained in the Flexible Spending Account
Election of Reimbursement & Compensation Reduction Agreement.
