In accordance with the terms of the City of New Carlisle Cash Out Plan you may waive coverage under the City of New Carlisle group health plan in exchange for additional taxable cash compensation. The following rules apply for you to waive coverage under the City's optic health plan in exchange for additional taxable cash compensation.
To be eligible to receive the additional taxable compensation under the City of New Carlisle Cash Out Plan you must be eligible to participate in the City's group health plan and you must waive coverage under the City's group health plan. In addition, you must submit this City of New Carlisle Waiver of Health Insurance Form with proof of other health coverage to the Finance Director to receive the additional taxable compensation.
This City of New Carlisle Waiver of Health Insurance Form must be completed and submitted with proof of other health coverage to the Finance Director within thirty days of (1) when you first become eligible to participate in the City's group health plan or (2) the first day (January 1st) of any Plan Year or (3) when you first become covered under another health plan and you want to waive coverage under the City's group health plan.
Once you have submitted this City of New Carlisle Waiver of Health insurance Form with proof of other health coverage to the Finance Director, you will deemed to have continued to waive coverage under the City's group health plan for subsequent Plan Years, (January 1st through December 31st) until you actually enroll in the City's group health plan. In other words, once you waive coverage under the City's group health plan, you will deemed to have continue waiving coverage under the City's group health plan until you actually enroll in the City's group health plan in accordance with the terms of the City's group health plan.
If you elect to waive coverage under the City's group health plan for you and your family for the entire Plan Year (January 1st through December 31st), you will receive $6,000 additional taxable compensation. This amount will be paid in four equal installments of $1,500 each (less all applicable taxes) as soon as administratively possible after each calendar quarter. No payment will be made for any calendar quarter in which you or any member of your family participated in the City's group health plan.
If you elect to participate in the City's group health benefit plan, you may not drop coverage for you (and/or your spouse and dependents) during the Plan- Year (January lst through December 31st) unless there is an Election Change Event as defined under the City of New Carlisle Cash Out Plan. This means once you start to participate in the City's group health plan you must continue to participate in that plan and may not receive additional cash compensation under the City of New
Carlisle Cash Out Plan until the next January 1st unless there is an Election Change Event as defined under the City of New Carlisle Cash Out Plan.
You must contact the Finance Director and submit this City of New Carlisle Waiver of Health Insurance Form within thirty days of experiencing an Election Change Event if you want to drop coverage; order the City's group health benefit and receive additional taxable compensation.
An Election Change Event is (1) a change in your legal marital status including marriage, death of a spouse, divorce, legal separation and annulment (2) a change in the number of your dependents including the birth, death, adoption and placement of adoption of a child (3) a change in your employment status including the termination or commencement of employment, a strike, lockout, the commencement or termination of an unpaid leave of absence and change in worksite (4) a charge in you or your spouse's or dependent child's employment status that effects that individual's eligibility under a cafeteria plan or any benefit plan (including the City's health plan) (5) your dependent child or spouse satisfied or ceases to satisfy the eligibility requirements because of age, student status or similar circumstances (6) the commencement or termination of adoption proceedings (7) a change in you or your spouse's or dependent child's residence that impacts their eligibility under the group health plan (8) a judgment, decree or court order resulting from a divorce, legal separation, annulment or change in legal custody (including a qualified medical child support order) that requires coverage in a group health plan for your child or foster child (9) entitlement or loss of Medicare or Medicaid by you or your spouse or dependent child (10) the commencement or return from a period of absence under the Family and Medical Leave Act (11) eligibility for COBRA coverage (or similar coverage under state law) offered by the City (12) any change resulting from a change made under a plan of your spouse's, former spouse's or dependent child's employer that is listed on this form.
If you drop coverage under the City's group health plan during the Plan Year (January 1st through December 31st) and you complete this City of New Carlisle Waiver of Health Insurance Form within thirty days of the Election Change Event, you will receive a pro-rated portion of the additional compensation based on the number of calendar quarters you waived coverage under the City's group health plan.
The City of New Carlisle Cash Out Plan does not impact the eligibility rules and requirements of the City's group health plan. Therefore, you must review the City's group health plan to determine if you are eligible to participate in that plan. In other words, the City's group health plan has its own rules governing when you can participate and drop coverage.
I have read and understand the information explaining my rights to participate in the City of New Carlisle's group health plan and I have elected to waiver coverage under the City's group health plan in exchange for additional taxable cash compensation.
Employee's Printed Name Social Security Number
Employee Signature Date
I am attaching the following documents to prove that I have other health coverage:
Name of Policy Holder Policy Holder SS Number
Your Relationship to Policy Holder Insurance Plan
By signing this waiver, I understand that I am waiving coverage under the City's group health plan and that I may not be able to enter the City's group health plan unless I comply with the rules of that plan.
(Ord. 07-17. Passed 5-21-07; Ord. 2021-47. Passed 12-6-21.)