Missouri State Employees' Cafeteria Plan Change Form
Name Social Security Number / Street Address Agency/Org / City, State, Zip Date of status change event/Daytime Phone
Change of Status Events: Circle all status change events that have occurred in the last 60 days in the list below 1. Death of spouse/dependent 2. Divorce finalized 3. Marriage 4. Birth/Adoption 5. Residence change 6. New dependent care provider 7. Employment status change of 8. Gain/Loss of dependent due to 9. Gain or lose eligibility and your spouse /dependent age, military status, marriage, coverage under divorce, etc. Medicare/Medicaid 10. Court order (see instructions) 11. Begin FMLA(see instructions) 12. End FMLA (see instructions) 13. COBRA (dependent) 14. Dependent child turns 13 15. Your employment changes
Events 6, 11, and 14 do not allow you to add or increase any insurance premium. Events 6, 12, and 14 do not allow you to drop or decrease any insurance premium. Change on Section A Health Insurance Dental Insurance Vision Insurance Paycheck Dated Current Per Check Premium New Per Check Premium
Events circled above Deducted Total for New per Change on Total for must include one of this year thru balance of check Paycheck Section B year these end of month year amount Dated Start/Increase Flex Medical 1,2,3,4,7,8,9,10,12,15 Stop/Decrease Flex Medical 1,2,11 Start/Increase Dep Care 1,2,3,4,6,7,12,15 Stop/Decrease Dep Care 1,2,3,6,7,11,14,15
Change on Do not write in the shaded areas. The Current Per New Per Paycheck Administrative Fees Check Amt. Check Amt. shaded areas are reserved for Cafeteria (see instructions #6) Dated Plan office use.
Section C - (Required) Please explain the gain or loss of coverage (or the change in dependent care rates) in this section. To start or increase any deduction amounts, you, your spouse or dependent must gain coverage eligibility under that State Plan or lose coverage eligibility under a similar plan of your spouse or dependent’s employer because of the event circled above. To stop or decrease any deduction amounts, you, your spouse or dependent must lose coverage eligibility under that State Plan or gain coverage eligibility under a similar plan of your spouse or dependent’s employer because of the event circled above. You can change the dependent care deduction amount to reflect a rate change to a new care provider. Refer to the Plan Summary & Enrollment Guide or contact the Cafeteria Plan for more information.
FMLA/Termination (Flexible Medical Category) Terminating or Retiring 1. I authorize a lump sum payoff for coverage through December 31 of this year totaling $ on my paycheck dated / / . 2. Please stop my coverage on the date of the last paycheck I will receive. FMLA beginning 1. I authorize to prepay for coverage through / / totaling $ on by paycheck dated / / . 2. I will pay direct to MO Cafeteria Plan before each pay day. (Make checks payable to MO Cafeteria Plan.) Coverage is stopped if payment is not received by pay date. 3. When I return to work, I elect to pay a total of $ for coverage through / / on the paycheck I receive on / / . Coverage is stopped if payment is not received by this pay date. 4. Please stop my coverage while I’m on unpaid FMLA leave. I understand that, if I want to, I can start my coverage within 60 days of returning to work (only at the same amount per check). I certify that all the above statements are true.
Employee's Signature Day time phone Date
Payroll/Personnel Officer Signature Date form received from employee CP-ECHG (01/02) Missouri State Employees’ Cafeteria Plan Change Form Instructions
Before you fill in this form: One of the 15 Change of Status Events (see the change form) has to have happened already, and The event must have happened within the last 60 days. (If it has been more than 60 days, you cannot change your deduction because of that event. You must have another qualifying event to make a change.)
Required Information – Please complete all of the following: 1. Print your name, address, social security number and agency/org number. Agency/Org is listed on your paycheck stub as a 3 digit/4 alpha-numeric number (Universities use acronym)
2. Enter the date of the status change event
3. Circle the event or events that best describe your reason for changing your election
4. Complete Section A if your event has affected the insurance premiums you will pay under the cafeteria plan. Complete Section B if your event has affected your flexible medical or dependent care deductions under the cafeteria plan. (“Deducted this year thru end of month” is the total including this month. “Total for balance of year” is the amount you want deducted after this month thru the end of the year. “Total for year” is total of the previous two columns.)
5. If starting a deduction in Section B for this year, also complete the MO Cafeteria Plan Reimbursement and E-Mail Authorization form (CP-RMC 11/01).
6. Complete Section C - you must tell us why you wish to make the election change. This statement must include an explanation of the coverage that was gained or lost due to the status change event.
7. Complete FMLA/Termination Section only if you have coverage under the Flexible Medical Account (See FMLA below).
8. Sign the change form.
9. Mail to: Missouri State Employees' Cafeteria Plan P O Box 858 Columbia, MO 65205-0858
10. If approved, the cafeteria plan will send an approved copy to your payroll/personnel office for deduction processing.
Definitions: Court Order (event #10): If you are served with a court order that requires you to provide health coverage for a child, then you may increase or add the appropriate insurance premium and add or increase Flexible Medical Benefits. If you are served with a court order that requires your ex-spouse to provide health coverage, then you may decrease or drop the appropriate insurance premium if your ex-spouse picks up that coverage.
Effective Date for Coverage Changes: Coverage changes are not in effect until after the event and after this form is received/approved by the MO Cafeteria Plan office. Please refer to your Plan Summary (available from payroll/personnel or on the web site) for specifics on effective dates of changes.
FMLA: If you are going on FMLA leave, you may maintain coverage under the Flexible Medical Benefits plan while you are on leave or you may stop coverage during your leave. If you maintain coverage, you will be able to file claims for medical services provided during your leave. If you elect to maintain coverage you must chose how you want to make your contributions due during your leave. You may pay them before you go, pay them while you are leave, or pay them when you come back from leave. If you do not maintain coverage, you will not be able to file claims for medical services provided during your leave. Please complete the FMLA section if this applies to you.
Insurance Coverage Changes: Forms to add, delete or change insurance coverage should not be sent to the insurance administrator (MCHCP, Highway Insurance Fund, etc.) until after an approved change of election form has been received from the Cafeteria Plan office.
For Assistance: Contact Missouri State Employees’ Cafeteria Plan www.mocafe.com 1-800-659-3035 [email protected]