Benefits - Benefits Administration Manual

	Department of Personnel Administration
	Benefits Administration Manual
	Section 500 501. General Information 502. Current State-Sponsored Dental Plans 503. Responsibilities 504. Dental Plan Deduction Codes/Premiums 505. Employee Eligibility 506. Intentionally Unused 507. 24 Month Plan Restriction 508. Dependent Eligibility 509. Intentionally Unused 510. Enrollment 511. Allowable Changes to Enrollment 512. Effective Dates 513. Re-Enrollment of Employees 514. Annual Open Enrollment Period 515. Continuation of Coverage While Off Pay Status 516. 120-Day Survivor Death Benefit for Continuation Of Benefits 517. Retiring Employees 518. Cancellation/ Termination of Dental Enrollment/Coverage 519. Consolidated Omnibus Budget Reconciliation Act (COBRA) 520. Document Completion 521. Dental Carriers/Benefit Information View all Section 500 Attachments Attachment A - Dental Plan Enrollment Authorization (Std. 692) Attachment B - Dental Deduction Codes/Premiums Attachment C - Permitting Events Code Chart Attachment D - Affidavit of Eligibility Attachment E - HDB-34 Attachment F - Dental Plan Direct Payment Authorization (Std. 696) Attachment G - Affidavit of Eligibility - Domestic Partner (DPA 680) Attachment H - Instructions for Completion of Dental Plan Enrollment Authorization (Std. 692) Attachment I - Examples of Completed Std. 692 Attachment J - Delta Form 602A (blank form) Attachment J1 - Delta Form 602A (example) Navigation Table of Contents	Dental Program 518. Cancellation/Termination Of Dental Enrollment/Coverage Cancellation of Dental Enrollment Employees may cancel enrollment at any time by completing a STD. 692 and submitting it to their Personnel Office. These employees may not re-enroll in a plan until the next scheduled open enrollment period. Enrollment for PI employees who do not qualify during a control period must be administratively cancelled. The effective date of cancellation is February 1 for the December 31 control period, and August 1 for the June 30 control period. These employees may continue coverage through COBRA. Employees/dependents who were enrolled but never eligible must be retroactively cancelled back to the effective date of their enrollment. Employees who lose eligibility due to a reduction in time base to less than half-time must be administratively cancelled, with the exception of those employees approved for Partial Service Retirement. Termination of Coverage An employee's coverage ceases at midnight on the last day of the month following the month in which the last premium was paid.