It's Open Enrollment season - the annual opportunity to review your benefits, make changes, or choose a plan that better fits your evolving needs.
You can make changes to your benefits by completing the form on page 21 of this booklet and returning it to the OUC Benefits Team by no later than October 31, 2025. Get updates throughout the year from the OUC Benefits Team online at ouc360.com/retiree
Important Reminders
• OUC Retiree Life Insurance is $10,000 for eligible retirees.
• Keep your address, phone number and email up to date to receive benefits information, retiree news and the Update! newsletter. Contact HR/Benefits to provide updated contact information at benefits@ouc.com
• To update your retiree life insurance beneficiary designation, reach out to HR/Benefits.
• Death notification: When a retiree and/or beneficiary passes, it’s important to inform HR/Benefits as soon as possible. This will help to avoid any issues with pension and health benefits. This guide is provided as a
or without prior notice.
Contacts & Resources
Find more details about the benefits offered to you by contacting your insurance carrier or logging into OUC360 at ouc360.com/retiree
If you have questions or need assistance with enrolling, you may contact the OUC Human Resources/Benefits Team by emailing benefits@ouc.com or calling 407-434-2284 ext. 42284.
The Benefits Team is located at 100 W. Anderson Street, Orlando, FL 32802. Our fax number is 407-434-5003.
To find Insurance Carrier Websites and/or Apps
Search for carrier apps on Google Play or the App Store® to access your benefits information anytime, anywhere from your mobile device or tablet. Valuable information accessible on carrier apps can include:
• Specific plan details
• ID cards
• In-network provider search
• Your claims history
• Other tools and resources
Aetna Medicare Advantage (Medical and Prescription)
and Prescription Home Delivery (Mail-Order)
Eligibility & Enrollment
Eligible Dependents
• Retiree’s legally married spouse.
Your legal spouse
• Common law marriage partners are not recognized by the state of Florida and are not eligible.
• Separated spouses are eligible as there is no defined “legal separation” in the state of Florida.
• Biological or stepchild(ren)
Your child(ren) up to age 26
Your child with a disability
Grandchild(ren)
• Legally adopted child(ren) or child(ren) who have been placed for adoption.
• Other children for whom the employee is the legal guardian or has legal responsibility for providing medical coverage as defined by a court order.
• Age 26 and older, unmarried and unable to attain self-sustaining employment by reason of mental or physical disability which arose while the child was covered as an under-26 dependent under this plan, or while covered as an under-26 dependent under a prior plan with no break in coverage.
• Child(ren) of covered dependent child(ren) can be covered through the end of the month the grandchild(ren) turns 18 months of age if the parent is covered under the plan.
All of the following criteria must be met:
• Biological child, legally adopted child, or stepchild
Overage dependent (Independent Plan)
• Between ages 26 to 30
• Unmarried
• No dependent of their own.
• Does not have insurance coverage under any other individual/group health plan.
• Not entitled to benefits under Medicare or Medicaid.
• Resides in the state of Florida or is a full-time or part-time student.
Qualifying Life Event
Benefit elections and their related payroll deductions can only be changed during the annual Open Enrollment period unless you, your spouse, or your dependent child(ren) experience an IRS-defined qualifying life event. You must make benefit changes within 31 days of a qualifying life event. Examples of a qualifying life event include, but are not limited to:
• Marriage or divorce
• Medicare eligibility at age 65 for yourself and/or your spouse
• Birth or adoption of a child
• Change in child’s dependent status
• Death of a spouse, child or other qualified dependent
• Change in spouse’s benefits or employment status
• Commencement or termination of adoption proceedings
• Loss of coverage under another plan or expiration of COBRA coverage
To report a qualifying life event, contact the Human Resources/Benefits Team at benefits@ouc.com Supporting documentation (birth certificate, marriage license, Social Security card, etc.) must be provided regarding the life event. Coverage begins as soon as administratively possible after all documents are reviewed and approved.
Medical & Prescription Benefits
Medical Benefits
You have three medical plan options to choose from through Aetna: the Core Plan, the Health Reimbursement Arrangement (HRA) Plan and the Medicare Advantage Plan. To explore doctors and providers in your network, visit aetna.com.
If you are enrolled in the HRA medical plan, OUC contributes money into your HRA account for you to use towards healthcare expenses. Retiree contributions in the HRA are not allowed.
See page 13 for more information on HRA accounts that can help you save on healthcare expenses.
Prescription Drugs
When you enroll in a medical plan, you are automatically enrolled in prescription drug coverage. If you regularly take routine medications, you can receive a 90-day supply at any pharmacy, including retail locations Opting for a 90-day supply of your routine medications can also come with a cost savings on associated prescription copays. See page 7 for more details.
Check with your pharmacy to determine if any discounts or rebates are available. Discuss lowercost alternatives with your physician and check the insurance company's website for a complete drug list at aetna.com. The covered drug formulary lists change throughout the year; impacted participants receive notice of the changes two months in advance in the mail.
Preventive Care
All medical plans cover preventive care services at 100%, meaning no copays or deductibles will apply when an in-network provider is chosen. Preventive exams can detect if you are at risk for a chronic diseases that may be preventable. Talk to your healthcare provider to determine which screenings are recommended for you and when you need them.
The preventive services described below are for innetwork providers only. The claim must be submitted to Aetna as preventive care by the provider, otherwise care may be subject to deductible and/or coinsurance.
• Routine adult physical exams/immunizations (age and frequency schedules apply)
• Well child exams/immunizations (age and frequency schedules apply)
• Routine gynecological care exams (includes Pap smear and related lab fees)
• Routine mammograms (one baseline mammogram for females age 35-39; one annual mammogram for females age 40 & over)
• Routine digital rectal exams/prostate specific antigen test
• Colorectal cancer screening (for all members age 45 and over. Frequency schedule applies)
Out-of-network providers may charge for these services. Co-insurance will apply.
Medicare
If you or your dependent become eligible for Medicare, you must enroll in Medicare Part A and Part B. Medicare becomes your primary insurance, and the Core or HRA Medical Plan becomes your secondary coverage. OUC offers the Aetna Medicare Advantage Plan as the preferred complement plan for Medicare benefits. If you or your dependent become Medicare eligible, you should do the following:
1. At least two (2) months before you become Medicare eligible, please contact HR/Benefits at 407-434-2284 or benefits@ouc.com
2. Choose from OUC’s three (3) health plan options (Medicare Advantage/Core/HRA) or waive coverage.
3. Complete and return the retiree enrollment/change form with a copy of your Medicare card.
• If choosing Medicare Advantage, contact HR/Benefits at 407-434-2284 or benefits@ouc.com to receive the Medicare Advantage enrollment form
4. If you choose the Core Plan or HRA Plan as your supplemental coverage, you must:
• Contact Medicare at 800-633-4227 and Aetna at 855-281-8858 to inform them that Medicare is primary and Aetna is secondary coverage. Enroll in the Aetna Medicare Direct Program (Aetna’s electronic filing system with Medicare).
5. Dental coverage ends when you become Medicare eligible. You must enroll on the enrollment form to continue coverage.
Terms to Know
Deductible: The amount you pay out of pocket during the plan year (January December) before the insurance company pays a percentage of the provider charges.
Coinsurance: The amount of payment split between you and the insurance company. Example: The insurance company pays 80%, and you pay 20% of the charges after you meet the annual deductible.
Copayments: Copayments (copays) are fixed dollar amounts paid for healthcare services. They do not count toward the annual deductible. They do count toward the annual out-of-pocket maximum.
Out-of-Pocket Maximum: The maximum amount you are responsible for paying out of pocket in any calendar year before the insurance company pays the entire eligible amount for the remaining calendar year.
Network Providers: Doctors, hospitals, and other healthcare providers with an agreement/contract with
insurance companies agreeing to charge a discounted amount for services rendered.
Pre-Authorization: Certain procedures or hospitalizations may require that the provider receive authorization. The provider is typically the one to go through this process with the insurance company and obtain pre-authorization.
Explanation of Benefits (EOB): The EOB is mailed to you after the insurance company receives and processes a claim. The EOB describes how the claim was processed and outlines what portion of the charges have been applied to the deductible, what amount you are responsible for, and explains if there was a denial or error in processing the claim.
Appeal: If your health insurance company doesn’t pay for a specific healthcare provider or service, you have the right to appeal the decision and have it reviewed by an independent third party through Aetna.
Medical Plan Comparison
MC
Imaging (MRI, CT Scan)
(30
Employee Assistance Program
OUC offers an Employee Assistance Program (EAP) through Aetna’s Resources for Living to support the well-being of our employees and their families. It is a confidential program offered at no cost to you and all the members of your household. Children living away from home are covered up to age 26. The program is available 24 hours a day, 7 days a week to help you deal with a variety of life stages and concerns, including:
• Emotional Well-Being Support: Access up to six counseling sessions per issue each year. In-the-moment emotional well-being support is also available 24 hours a day.
• Daily Life Assistance: Receive personalized guidance for resources to help you manage your and your family’s day-to-day needs. Resources are available for topics such as childcare, elder care, education, college financial aid, pet care, and more.
• Legal Services: Access a free 30-minute consultation with a participating attorney for each new legal topic related to general legal questions, family legal questions, preparation of legal documents, wills, elder law, and estate planning.
• Financial Services: Take advantage of a free 30-minute phone consultation with a financial advisor for each new financial topic related to budgeting, retirement or financial planning, mortgages and financing.
• Other Services: Access additional resources, including chat therapy, mental health self-care, and identity theft assistance.
To access confidential EAP services, call 800-272-7252 (TTY: 711) or visit resourcesforliving.com
Enter Username: OUC | Password: OUC
Know Before You Go
When you aren’t feeling well and need to be seen by a medical professional, a variety of options are available to you through OUC’s Aetna medical plans. Some healthcare facilities have a higher copay cost associated with them, so it may save you money to review your options before you go. Aetna’s website (aetna.com) provides cost of care estimates for in-network providers and facilities. Aetna’s 24-Hour Nurse Line may be helpful too: (800) 556-1555.
Telemedicine (Teladoc)
Convenience Care
Urgent Care
Emergency Room
Mild illnesses and rashes not requiring in-person care such as allergies, cough, fever, headaches and sinus problems. No copay for sick visits
Minor illnesses such as allergies, cough, fever, headaches, sinus problems, injuries, preventive care requiring in-person care and vaccines.
Moderate and non-life threatening illnesses and injuries such as minor cuts, sprains, broken bones, back and joint pain.
$25/$30 copay
$45/$50 copay
Serious and life-threatening illnesses and injuries such as trouble breathing, heart attack and stroke, serious accidents and severe bleeding. 20% after deductible
Medical Plan Resources
Aetna Website
Your Aetna member website helps you understand your benefits so you can make the most of your plan. At home, at the doctor, or in line at your local pharmacy. Wherever you are, you can rest assured knowing that trusted benefits information is here when you need it. You can:
• Find in-network doctors, walk-in clinics and urgent care centers near you
• Learn what your healthcare costs and how much your plan covers
• Search medicine and side effects, find a pharmacy, refill your prescription, and estimate drug costs
• Take a health survey, try health coaching, start a wellness program, and get treatment options
Visit aetna.com and click the Member log-in button to sign in, or create a new member account.
Aetna Health App
The Aetna Health mobile app can help you navigate your benefits, connect to quality care, and manage your costs. Use the Aetna Health app for:
• ID cards: Pull up your ID card whenever you need it
• Benefit details: Get coverage specifics for your plan
• Deductibles: Track spending and progress to meet your deductible
• Claims: Check and pay claims for your whole family
• Providers: Find network providers near you by location or specialty
• Cost estimates: Compare costs for doctor visits and procedures
• Health reminders: Get personalized tips to improve your health
The Aetna Health app is more personalized than ever to help you see what’s covered, view claims, find quality care and more. The Aetna Health app is now available in Spanish. Download the Aetna Health app from the Apple app store or Google Play store.
Aetna Nurse Line
Sometimes you need a quick answer to a health question. Maybe your concern can’t wait until you see your doctor. You can talk to our registered nurses day or night on the Aetna 24/7 Nurse Line. Call the Aetna Nurse Line to get help with recommending whether to visit a doctor or urgent care center, understanding your symptoms, managing chronic conditions, and more. Call the Aetna Nurse Line at 800-556-1555.
Virtual Visits
See and talk to a doctor from a mobile device or computer without an appointment, 24/7 through Teladoc. Most visits take 10-15 minutes, and virtual visits are a part of your health benefits. Telemedicine doctors can diagnose and treat many non-emergency medical conditions and provide services such as writing a prescription if needed.
Common conditions treated with virtual care include allergies, cough, fever, headaches, sinus problems, skin rashes, pink eye, bladder infections, and more. To get started, visit teladoc.com/aetna or download the app.
Wellness Program
We’re excited to offer a wellness program that’s all about supporting your overall health and wellbeing. Whether you’re looking to build new healthy habits or keep up the great ones you already have, there’s something here for you. Have questions or want to learn more? Reach out anytime at wellbeing@ouc.com. We’re here to help you thrive!
Who Can Participate
The WELLbeing Program is a voluntary wellness program available to all retirees, spouses, and dependents (ages 18 - 26) on the OUC medical plan. Eligible members who choose to participate in the WELLbeing program will have the opportunity to earn up to $400 at the highest level.
Registration and Tracking Your Watts
• Scan the QR code at the bottom of this page, go to oucwellbeing.com, or download the app on your GooglePlay or Apple Store. Connection code: OUC
• Register or login using your credentials
• To track your Wellness Watts, click on the “Rewards” tab
• Make sure to self-report activities and periodically check rewards
• Watt opportunities will be communicated throughout the platform, Commission-wide communications, and on OUC360
Wellness Program – Reasonable Alternative Standard
The program is administered according to federal rules permitting employer-sponsored wellness programs seeking to improve population health and prevent disease. This includes the Americans with Disabilities Act of 1990, the Genetic Information Nondiscrimination Act of 2008, and the Health Insurance Portability and Accountability Act. Rewards for participating in a wellness program are available to all retirees. If you think you may be unable to meet a standard for a reward under this wellness program, you may qualify for an opportunity to earn the same reward through different means. Email wellbeing@ouc.com to find a solution that will work for you.
Health Reimbursement Arrangement (HRA)
Money is added to your HRA fund to help you manage healthcare costs. This contribution helps lower your deductible by covering eligible expenses, making it easier to get the care you need without the full out-of-pocket costs.
HRA Funds
We provide HRA funds per member who is enrolled in the Health Reimbursement medical plan in January. Once you exhaust your HRA fund amount, you must cover the remainder of the deductible before Aetna pays for eligible medical expenses. Preventive coverage is paid 100% by Aetna using an in-network provider, so there are not out-of-pocket expenses for members to receive their wellness exams.
Eligible medical expenses by network providers will still receive a substantial discount (up to 60%) by Aetna even if you have not yet met your deductible.
Description Health Reimbursement Account (HRA)
Eligibility Requires coverage under OUC’s HRA medical plan
Eligible Expenses
Medical, prescriptions, dental, vision (copays, coinsurance, and deductible) durable medical supplies, and over-the-counter medications
Maximum Contribution by Retiree N/A
Retiree Only: $1,260
Employer Contributions (Non-Medicare)
Employer Contributions (Medicare Eligible)
Retiree + 1: $1,500
Retiree + Family: $2,760
Retiree Only: $630
Retiree + 1: $750
Retiree + Family: $1,380
Funds Availability January 1
Rollover Maximum Unlimited
Accessibility
Forfeitures
Debit card. Submit claim for reimbursement
Unused funds forfeited if employee does not directly retire from OUC
Dental Benefits
Dental coverage is offered through Aetna. If you are not Medicare eligible, you are automatically enrolled in the Aetna PPO dental plan when you enroll in either the Core or HRA medical plans. If you are Medicare eligible, your dental plan is separate from your medical plan. This plan allows you to use in-network or out-of-network benefits. If you choose to see an out-of-network dentist, you may be responsible for paying the difference between what the provider charges and what the plan covers, this is called “balance billing.” To find an in-network provider, go to aetna.com. For more information, visit the OUC360 Retiree resource site at OUC360.com/retiree.
PPO Dental Plan
Preventive Care (two visits per plan year)
Oral exams, cleanings, routine x-rays, fluoride
Basic Services
Sealants, fillings, oral surgery, root canals, repairs to dentures, bridges, and crowns
This is meant to be a brief summary only. For full plan details refer to the SPD.
Visit Your Dentist Regularly
up to $2,500 lifetime maximum
Regular dental visits do more than keep your smile bright they help protect your overall health. Poor oral hygiene has been linked to serious conditions like heart disease, diabetes, and even cancer. Make the most of your preventive dental benefits, including routine exams and cleanings, all at no cost to you. It’s a simple way to stay ahead of health issues and feel your best.
Vision Benefits
Vision coverage (glasses and/or contacts) is offered through Aetna The Aetna vision network includes chains such as Pearle Vision, LensCrafters, JCPenney Optical, and Target Optical, along with many other neighborhood eye doctors and optical shops.
If you are enrolled in an OUC Aetna medical plan, a vision exam is considered a preventive coverage by your medical plan and covered at 100% . To find in-network providers visit aetnavision.com and enter your search criteria. For more information, visit the OUC360 Retiree resource site at OUC360.com/retiree
Standard Lenses
• Single vision
• Bifocal
• Trifocal
• Lenticular
Standard Progressive Vision Lenses
$25 copay
$90 copay
Any Frames, including Frames for Prescription Sunglasses $145 allowance plus 20% off balance
Contact Lenses in Lieu of Glasses
• Medically Necessary
• Elective Covered in full $145 allowance plus 20% off balance
Frequency of Services
• Lenses
• Frames Once every 12 months Once every 24 months
This is meant to be a brief summary only. For full plan details refer to the Summary Plan Description.
Eye Exams are Good for Your Overall Health
Annual eye exams help detect vision problems like glaucoma, cataracts, and macular degeneration, and can even reveal signs of other health conditions, such as diabetes, high blood pressure, and high cholesterol. Early detection can lead to timely treatment and better overall health.
Important Notices
A printed copy of the full versions of the below notices along with the plan summaries can be obtained from Human Resources/Benefits or by logging in to OUC360 at ouc360.com/retiree.
Creditable Coverage Notice About Your OUC Prescription Drug Coverage and Medicare
Notice for employees, retirees, eligible dependents and COBRA participants who may be approaching 65 years of age or have just become disabled and will be eligible for Medicare enrollment.
Please read this notice carefully and keep it where you can find it. This notice has information about your current prescription drug coverage with OUC and your options under Medicare’s prescription drug coverage. This information can help you decide whether or not you want to join a Medicare drug plan. If you are considering joining, you should compare your current coverage, including which drugs are covered at what cost, with the coverage and costs of the plans offering Medicare prescription drug coverage in your area. Information about where you can get help to make decisions about your prescription drug coverage is at the end of this notice.
THERE ARE TWO IMPORTANT THINGS YOU NEED TO KNOW ABOUT YOUR CURRENT COVERAGE AND MEDICARE’S PRESCRIPTION DRUG COVERAGE:
Medicare prescription drug coverage became available in 2006 to everyone with Medicare. You can get this coverage if you join a Medicare Prescription Drug Plan or join a Medicare Advantage Plan (like an HMO or PPO) that offers prescription drug coverage. All Medicare drug plans provide at least a standard level of coverage set by Medicare. Some plans may also offer more coverage for a higher monthly premium.
OUC has determined that the prescription drug coverage offered by the OUC group health plan is, on average for all plan participants, expected to pay out as much as standard Medicare prescription drug coverage pays and is therefore considered creditable coverage. Because your existing coverage is creditable coverage, you can keep this coverage and not pay a higher premium (a penalty) if you later decide to join a Medicare drug plan.
WHEN CAN YOU JOIN A MEDICARE DRUG PLAN?
You can join a Medicare drug plan when you first become eligible for Medicare and each year from October 15 to December 7. However, if you lose your current creditable prescription drug coverage, through no fault of your own, you will also be eligible for a two-month Special Enrollment Period (SEP) to join a Medicare drug plan.
WHAT HAPPENS TO YOUR CURRENT COVERAGE IF YOU DECIDE TO JOIN A MEDICARE DRUG
PLAN?
If you decide to join a Medicare drug plan, your current OUC coverage will not be affected. You can keep this coverage if you elect Part D, and this plan will coordinate with Part D coverage. See pages 7- 9 of the CMS Disclosure of Creditable Coverage to Medicare Part D Eligible Individuals Guidance (available at cms.hhs.gov/CreditableCoverage/), which outlines the prescription drug plan provisions/options that Medicare eligible individuals may have available to them when they become eligible for Medicare Part D. If you do decide to join a Medicare drug plan and drop your current group health coverage through OUC, be aware that you and your dependents will be able to get this coverage back. However, reentry is subject to the underlying terms of the plan.
Retail Pharmacy Prescription (30-day supply)
• Generic
• Brand Name
• Non-Formulary Brand Name
Mail Order Prescription (90-day supply)
• Generic
• Brand Name
• Non-Formulary Brand Name
Specialty Prescriptions
Core Plan HRA Plan
$0 copay
$50 copay
$75 copay
$0 copay
$100 copay
$150 copay
20% deductible waived; maximum coinsurance $200
WHEN WILL YOU PAY A HIGHER PREMIUM (PENALTY) TO JOIN A MEDICARE DRUG PLAN?
$0 copay
$50 copay
$75 copay
$0 copay
$100 copay
$150 copay
20% deductible waived; maximum coinsurance $200
If you drop or lose your coverage with OUC and don’t join a Medicare drug plan within 63 continuous days after your current coverage ends, you may pay a higher premium (a penalty) to join a Medicare drug plan later. If you go 63 continuous days or longer without creditable prescription drug coverage, your monthly premium may go up by at least 1% of the Medicare base beneficiary premium per month for every month that you did not have that coverage. For example, if you go 19 months without creditable coverage, your premium may consistently be at least 19% higher than the Medicare base beneficiary premium. You may have to pay this higher premium (a penalty) as long as you have Medicare prescription drug coverage. In addition, you may have to wait until the following October to join.
FOR MORE INFORMATION ABOUT THIS NOTICE OR YOUR CURRENT PRESCRIPTION DRUG COVERAGE
For further information, contact the HR/Benefits team. NOTE: You’ll get this notice each year. You will also get it before the next period you can join a Medicare drug plan, or if this coverage through OUC changes. You also may request a copy of this notice at any time.
FOR MORE INFORMATION ABOUT YOUR OPTIONS UNDER MEDICARE PRESCRIPTION DRUG COVERAGE
More detailed information about Medicare plans that offer prescription drug coverage is in the “Medicare & You” handbook. You’ll get a copy of the handbook in the mail every year from Medicare. You may also be contacted directly by Medicare drug plans.
FOR MORE INFORMATION ABOUT MEDICARE PRESCRIPTION DRUG COVERAGE:
• Visit medicare.gov.
• Call your State Health Insurance Assistance Program (see the inside back cover of your copy of the “Medicare & You” handbook for their telephone number) for personalized help.
If you have limited income and resources, extra help paying for Medicare prescription drug coverage is available. For information about this extra help, visit Social Security on the web at www.ssa.gov, or call them at (800) 772-1213 (TTY (800) 325-0778).
REMEMBER: Keep this creditable coverage notice. If you decide to join one of the Medicare drug plans, you may be required to provide a copy of this notice when you join to show whether or not you have maintained creditable coverage and, therefore, whether or not you are required to pay a higher premium (a penalty).
Name of Entity/Sender & Address: HR Benefits, 100 W. Anderson Street, Orlando, Florida 32801 10/1/2024
Vendor Mobile Apps: Key Benefits
Aetna Mobile App Features:
• Access to ID cards
• Locate in-network providers, clinics, and urgent care centers near you
• View claims and EOBs
Teladoc Mobile App Features:
• 24/7 access to care, set up appointments ASAP, or schedule for a later time / date
• Track previous appointments and prescriptions
• Mental health and dermatology appointments also available through the app
Inspira Mobile App Features:
• Check account balance, deposits and payments
• Verify card purchases
• Request reimbursement for eligible expenses
Fidelity NetBenefits Mobile App Features:
• View workplace retirement savings account balances, investments, contributions, etc.
• Access educational articles, videos, and more
Aetna Mobile App Download
Inspira Mobile App Apple App Store Download
Inspira Mobile App Google Play Store Download
Teladoc Mobile App Download Fidelity NetBenefits Mobile App Download
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OUC Retiree Health Insurance Enrollment / Change Form
Retiree or Surviving Dependent (please print clearly)
Last Name First Name MI SSN
Home Address (Apt.#)
Health Insurance Coverage Enrollment Information
• You have the choice to elect or decline OUC’s health insurance coverage.
• If you are making changes, ADD/DROP dependent(s) or change health coverage (CORE, HRA, Medicare Advantage) options or DROP dental, complete and return this form to HR/Benefits.
• If a Medicare eligible Retiree and/or a Medicare eligible dependent enroll in the Aetna Medicare Advantage Plan, the following forms must be completed and sent to HR/Benefits:
» The Aetna Medicare Advantage PPO Plan Employer Group Enrollment Form for each enrollee.
» Contact HR/Benefits to receive the Medicare Advantage Enrollment Form.
» This Enrollment Form electing your medical and prescription and/or dental option(s).
• If you decline any of the OUC’s Health Insurance Coverage, complete and return this form.
• The Plan Option the retiree chooses is the same Plan for eligible dependent(s) except for the Aetna Medicare Advantage Plan. To ADD a dependent, type an “A”, dependent information.
• If adding dependent(s), a copy of the dependent’s Social Security card(s) and birth certificate(s) must be provided.
• If adding a spouse, a marriage certificate must also be provided.
• If adding a dependent during the year, a qualifying event document must be provided.
• To DROP a dependent, write a “D”, the reason for dropping, and the dependent’s information.
• If dropping a dependent during the year, a qualifying event document must be provided. Eligible dependents include:
» Your legal spouse (opposite-sex or same-sex)
» Children under age 26 who are your biological children; or are your stepchildren; or are your legally adopted children; or are your foster children; or is a child for whom the retiree is the court-ordered legal guardian; or lives with you and whose parent is your child and the parent is covered as a dependent under the plan; or is fully handicapped and the child is not able to earn his/her own living because of mental retardation or a physical handicap which started before the date he/she reaches the maximum age for dependent children under your plan and he/she depends chiefly on you for support and maintenance and must live with you.
• When you become Medicare eligible you must enroll in Medicare Part A and Part B. OUC medical insurance coverage will become secondary and dental insurance coverage will become optional.
• If you and/or your dependent become Medicare eligible and want to enroll in dental coverage for a premium cost, please complete this form and check the Dental box that applies to you. Dental coverage must remain in effect for a minimum of two (2) years.
• During the rest of the plan year, a change to your enrollment can only be made if the change falls into the definition of a qualifying status change. It is the retiree’s responsibility to inform HR/Benefits of a qualifying status change within 30 days of the change date.
• Fax 407-434-5003, scan and email to benefits@ouc.com, or mail OUC HR/Benefits, PO BOX 3193, Orlando, FL 32802) required form(s) to HR/Benefits.
• If you have any questions, contact HR/Benefits via e-mail at benefits@ouc.com or phone 407-434-2284.
TURN PAGE TO COMPLETE
Retiree Authorization for Enrollment and / or Changes in the OUC Health Plan
I hereby elect the plan(s) indicated above. I understand that this election applies to the retiree and/or any covered dependent. I authorize OUC to adjust the monthly health deduction in my pension benefit or if applicable OUC will invoice for the monthly amount necessary to cover my contributions for medical and/or dental coverage. I understand that if I cease to make the required monthly payments, coverage will be dropped. This authorization will remain in effect for Plan Year. My signature below affirms that all information and statements provided on this form are full, complete, and true to the best of my knowledge. Sign and date below.
Retiree Signature: Date:
Surviving Dependent Signature: Date:
Declination of Aetna Medicare Advantage for Retiree and / or Dependent(s)
☐ I do not want to enroll myself in the Aetna Medicare Advantage Plan. I have elected one of the other options. I understand I will not have the opportunity to enroll again until the next open enrollment.
Declination of OUC Health Plans
☐ I do not want to enroll myself and (if applicable) dependents in any of the three (3) OUC health insurance coverage options. I understand I will not have the opportunity to enroll again unless I have a qualifying event during the plan year or at annual enrollment, and I must provide proof of other health insurance coverage. Sign and date below.
Retiree Signature:
Surviving Dependent Signature:
Date:
Date:
Orlando Utilities Commission Human Resources/Benefits
100 West Anderson Street Orlando, FL 32801 ouc360.com/retiree
The information in this Benefits Summary is presented for illustrative purposes and is based on information provided by your employer. The text contained in this Summary was taken from various summary plan descriptions and benefits information. While every effort was taken to report your benefits, discrepancies or errors accurately are always possible. In case of a discrepancy between the Benefits Summary and the actual plan documents, the actual plan documents will prevail. All information is confidential, pursuant to the Health Insurance Portability and Accountability Act of 1996. If you have any questions about this Summary, contact Human Resources. OUC reserves the right to modify, add, or remove benefits at any time, with or without prior notice.
