7 According to the Internal Revenue Service (IRS) regulations that govern flexible benefit plans, the optional Benefits you elect during enrollment must remain in effect throughout the calendar year, unless you experience a qualified change of life event. If you decide to change your elections as the result of one of the events listed below, you must do so within 30 days after the qualifying event. If you do NOT notify the Human Resources Office within 30 days after the event, you cannot change your elections until the next annual open enrollment. You must provide the Human Resources Office with verification of all change of life events. Change of Life Events Event Qualified Status Change How to begin If you experience a life change – such as marriage, legal separation, divorce, birth or adoption of a child, or death. If you, your spouse or dependent child become covered by another plan or lose coverage in another plan. If you experience a loss of coverage due to relocation out of the Plan’s coverage area. If your physician or facility discontinues participation in plan. Yes – you have 30 days to notify Human Resources. Yes – you have 30 days to notify Human Resources. Yes – you have 30 days to notify Human Resources. No – you must wait until the next open enrollment to change plans. • Contact the Benefits Team in Human Resources and make a request to add or drop dependents. • Provide HR with certified docu- mentation such as a marriage license, birth certificate, divorce decree or other legal document. • Contact the Benefits Team in Human Resources and make a request to enroll (or disenroll) in our benefits or to add (or remove) dependents to your existing plan. • Provide HR with proof of previous (or new) coverage from the family members insurance carrier and/or former employer. • Contact the Benefits Team in Human Resources and make a request to enroll in another health and/or dental plan. • Provide HR with proof of your new residence. • You must wait until the next open enrollment to change plans. NOTE: This chart applies only if you currently have coverage. Summary of Services Disclaimer The purpose of this Open Enrollment Guide is to give you basic information about your benefit options and how to enroll for coverage or make changes to existing coverage. This guide is only a summary of your choices and does not fully describe each benefit option. For a more detailed description of benefits, please refer to the plan’s benefit booklet, brochure, summary plan description (SPD), summary of benefits and coverage (SBC) or evidence of coverage (EOC). You may also call the plan using the customer service phone number on the last page of this booklet. Please note that plans will not cover a service if it is not considered medically necessary. Additionally, if your physician or facility discontinues participation in a plan, you will not be allowed to change plans outside the window of Open Enrollment as this is NOT considered a qualifying life event for you or your dependents. Every effort has been made to make the information contained in this booklet accurate; however, if there are discrepancies between this document and the contract with the carrier, the contract will govern.