If you are electing coverage or changing your coverage option (from Single to Family or Family to Single) or adding/dropping a dependent to or from your medical plan, you must:

1. Complete and return the IBEW Local No. 43 Health and Prescription Benefit Enrollment Form;


2. For each new dependent, you must include their name, date of birth, Social Security number, gender, copy of birth certificate and if adding a spouse, a completed Spousal Affidavit form and marriage certificate.

1. You must confirm on the Waiver (Opt-Out) of Participation form that your eligible dependents are enrolled in group coverage that meets the Patient Protection Affordable Care Act “minimum value” criteria. To validate that your dependent has group coverage that meets the minimum value criteria you must submit a copy of your spouse’s employer’s current Group Health Insurance Plan’s Summary of Benefits and Coverage (SBC) and a photocopy of the Group Health Insurance ID Card.


2. If the above documentation is not available, you must submit a letter from the applicable employer confirming the group coverage.


3. For each dependent for whom you intend to seek reimbursement from your HRA, you must also include their name, date of birth, Social Security number, gender, copy of birth certificate and if adding a spouse, a marriage certificate.

You may elect the Opt-Out of Coverage (Waiver of Participation) if you have medical coverage through your spouse’s employer or if you have medical coverage through your employment with another employer. In addition, you must confirm and provide the following documentation:

1. Complete and return the Waiver (Opt Out) of Participation in the IBEW Local No. 43 Welfare Fund Group Health Plan form.


2. You must confirm you are enrolled in group coverage that meets the Patient Protection Affordable Care Act “minimum value” criteria. To validate that you have group coverage that meets the minimum value criteria you must submit a copy of your spouse’s or your own other employer’s current Group Health Insurance Plan’s SBC and a photocopy of your current Group Health Insurance ID Card. If the above documents are not available, a letter from your spouse’s employer or your own other employer confirming your coverage must be submitted.


3. For each dependent for whom you intend to seek reimbursement from your HRA, you must include their name, date of birth, Social Security number, gender, copy of birth certificate and if adding a spouse as a dependent, a marriage certificate. You must also submit an SBC and Health Insurance I.D. card establishing each dependent’s other group health coverage. If the SBC and I.D. Card are not available, you must submit a letter from the employer confirming the coverage. If renewing coverage with no changes, you do not need to resubmit birth or marriage certificates.

You may also choose to “Opt-out” of medical coverage and to waive all future reimbursements from your Health Reimbursement Account (HRA) benefits offered through the Fund Office annually. Although “opting-out” of ALL Fund coverage is not recommended, because you will be choosing to decline all medical coverage and Health Reimbursement (HRA) benefits despite the fact that contributions will continue to be made to the Fund for your work in covered employment, the Fund will comply with this requirement as part of implementing the health-care reform laws. Once such election is made, it is irrevocable and cannot be changed until the 2019 Open Enrollment Period. To completely decline Fund benefits, contact the Fund Office for pertinent documents. You should carefully consider the consequences of declining all medical and Health Reimbursement Account (HRA) benefits, and you should discuss any such decision with your tax advisor.

The Fund Office will not process claims for you or your dependents until the Fund receives the necessary enrollment forms. Until the completed forms are received by the Fund Office, the Fund’s Trustees reserve the right to suspend claim payments.