Changing Medical/Dental Enrollment
for Faculty, Staff & Librarians

Enroll yourself in medical and/or dental.

Within 60 days of the event submit this form to the Benefits Office:

• Employee Enrollment/Change Form.
• In addition, you may enroll, change, or cancel your participation in either of these tax-savings programs. Enrollment is optional.
  • Flexible Spending Account
  • Dependent Care Assistance Program

You must:

• Remove your ineligible dependent. Failure to do may have the following consequences:
  • Dependent's loss of eligibility to continue enrollment under one of the continuation options (i.e. COBRA)
  • You may be billed for claims paid by the health plan for services after the dependent lost eligibility
  • You will be responsible for all premiums (employee/employer) for the dependent's health plan enrollment after the dependent lost eligibility.

You can:

• Change your medical and/or dental plan.

Within 60 days of the event submit this form to the Benefits Office:

• Employee Enrollment/Change Form.
• In addition, you may enroll, change, or cancel your participation in either of these tax-savings programs. Enrollment is optional.
  • Flexible Spending Account
  • Dependent Care Assistance Program

• Coverage or Plan Change: Begins the first day of the month following the dependent's loss of eligibility
• Ineligible Dependent : Enrollment ends the last day of the month in which they are no longer eligible