Name and Re la t ionsh ip Premium Type Star t Da te End Date Amoun
t
John Doe – Spouse Medical 01/01/20XX 12/31/20XX $XXX.XX
PARTICIPANT CERTIFICATION I have read this document and understand
and confirm that as a Participant in the Plan, premiums itemized
above for myself and any eligible dependents will be deducted from
my subsidy Account and reimbursed to me directly every month
beginning ______ (date). I understand the Plan will reimburse me
based on the expenses I submit provided there are sufficient funds
in my subsidy Account. I understand it is my sole responsibility to
inform the Plan administrator if my coverage ends or my monthly
premium amount changes from the amount shown above. I accept full
liability for timely notification of any changes. I, the
undersigned, certify that all expenses for which reimbursement is
requested by submission of this form were incurred by myself or an
eligible dependent and that the expenses have not been reimbursed,
or are not reimbursable, from any other source. I certify that I
will not take any of such expenses as an income tax deduction or
tax credit on my personal federal income tax return. I understand
that I alone am fully responsible for the sufficiency and accuracy
of all information relating to the claim which is provided by me,
and that if an expense for which payment or reimbursement is
subsequently determined to not be a proper expense under the Plan,
I may be liable for payment of all related taxes on amounts paid
from the Plan which relate to such expense.
ACCOUNT HOLDER SIGNATURE DATE
RECURRING PREMIUM REIMBURSEMENT CLAIM FORM
USE THIS FORM for reimbursement of eligible healthcare premiums for
plans purchased through Mercer Marketplace 365 Retiree. Do not
submit this form if you have signed up for Automatic Premium
Reimbursement. Refer to the online portal for more information on
Automatic Premium Reimbursement. Remember, for a faster, more
convenient method, submit online, using the website shown in your
Reimbursement Instructional Guide.
Submit the completed claim form and required documentation through
one of the following methods:
Mail: Mercer Health & Benefits Admin., P.O. Box 14401, Attn:
Claims Department Des Moines, IA 50306-3401
Fax: 1-857-362-2999, Attn: Claims Department
Please include the participant’s name in all correspondence,
regardless of submission method. If mailing, retain all originals
and only mail copies.
Submitting this form provides ongoing monthly reimbursements for
premiums for the calendar year. Annual submission is required each
year even if your plan does not change. If submission occurs after
the start of the year previous months will be paid retroactively.
Please note: Your first premium reimbursement may take 4 to 6 weeks
to arrive.
Documenting Your Reimbursement
Request — All premium reimbursement requests require third-party
documentation showing each item below:
Covered Participant’s Name (e.g. John Doe) Premium Type (e.g.
Medical) Date of Service (e.g. 01/01/20XX–12/31/20XX) Monthly
Amount (e.g. $XXX.XX) Name of Provider (e.g. AARP)
For Medicare premiums deducted from your Social Security check, use
the Social Security Benefit Award Letter issued by the Social
Security Administration (SSA) each year, typically during the month
of October or November, as your third party documentation. Watch
for this document to arrive in the mail.
For lost documents you can request a “Proof of Income” letter by
contacting the Social Security Administration at 1-800-772-1213
(TTY 1-800-325- 0778) or www.ssa.gov, or contact your insurance
carrier and request a document that contains the five items listed
above.
Account Holder Information:
The account holder may be the retiree or spouse, depending on your
plan’s rules. If you have a Household account, the primary account
holder must sign; if you have an Individual account, the account
holder must sign. Please refer to the letter you received from
Mercer Marketplace 365 Retiree to understand if you have a
Household or Individual account. Call Mercer if you have questions
about your account type.
Reimbursement Request Information:
This section must be completed with a line for each premium
reimbursement requested.
Action: A request must be submitted each time you have a new
policy, at the first of a new year, when a change in your premium
occurs or if a policy ends for any reason during the calendar year.
Enter: “New Policy”, “Premium Change” or “End of Policy.”
Relationship: Include the relationship between the account holder
and the person requesting the premium reimbursement (e.g.
self).
Premium Type: Refer to your Reimbursement Instructional Guide (e.g.
Medical, Prescription Drug).
Start Date: This is usually January 1st of each new year or the
effective date of the coverage period, such as when a participant
becomes Medicare-eligible.
End Date: This is typically December 31st, or could be earlier if
there is a change in your current plan, there is a change in
reporting by your carrier, or the death of a covered
participant.
Monthly Amount: This amount must match the amount on the supporting
document.
Certification Requirement:
Carefully read the certification requirements before signing.
DIRECT DEPOSIT! Expedite your payments by signing up for direct
deposit today. Refer to your Reimbursement Guide for instructions
on how to log into the portal and complete the necessary
information for your reimbursements to be made by direct
deposit.
O N E - T I M E R E I M B U R S E M E N T C L A I M F O R M Use
this form for reimbursement of any eligible expenses. You should
only choose this option for your premium reimbursement if you have
NOT established an Automatic Premium Reimbursement or Recurring
Premium Reimbursement for the premium expense. Refer to the back
page of this form for instructions on how to complete the
information below. To qualify for reimbursement, you must provide
third-party documentation that includes the information on the back
of
this form. Please CHECK each reimbursement qualification item as
you complete them.
Account Holder SSN (No dashes) Former Employer Name Total
Pages
Date o f Serv i ce Type o f Expense Covered
Par t i c ipan t Name Re la t ionsh ip Amoun t Reques ted
01/01/20XX Medical John Doe Spouse $XXX.XX
PARTICIPANT CERTIFICATION
I, the undersigned, certify that all expenses for which
reimbursement is requested by submission of this form were incurred
by myself or an eligible dependent and that the expenses have not
been reimbursed, or are not reimbursable, from any other source. I
certify that I will not take any of such expenses as an income tax
deduction or tax credit on my personal federal income tax return. I
understand that I alone am fully responsible for the sufficiency
and accuracy of all information relating to the claim which is
provided by me, and that if an expense for which payment or
reimbursement is subsequently determined to not be a proper expense
under the Plan, I may be liable for payment of all related taxes on
amounts paid from the Plan which relate to such expense.
ACCOUNT HOLDER SIGNATURE DATE
ONE-TIME REIMBURSEMENT CLAIM FORM
USE THIS FORM for reimbursement of any eligible expenses. You
should only choose this option for your premium reimbursement if
you have NOT established an Automatic Premium Reimbursement or
Recurring Premium Reimbursement claim for the premium expense.
Remember, for a faster, more convenient method, submit online,
using the website shown in your Reimbursement Instructional
Guide.
Submit the completed claim form and required documentation through
one of the following methods:
Mail: Mercer Health & Benefits Admin., P.O. Box 14401, Attn:
Claims Department Des Moines, IA 50306-3401
Fax: 1-857-362-2999, Attn: Claims Department
Please include the participant’s name in all correspondence,
regardless of submission method. If mailing, retain all originals
and only mail copies.
A One-Time Reimbursement claim provides a single reimbursement for
any eligible expenses. Please refer to your company-specific plan
rules for details on medical expenses your plan allows.
Eligible reimbursement requests may include deductibles and copays,
and insurance premiums for plans for which Recurring or Automatic
Reimbursement is either not available or set up. Other qualifying
out-of-pocket expenses may include Social Security premiums such as
Part B related expenses.
Documenting Your Reimbursement
FOR OUT-OF-POCKET EXPENSES:
Covered Participant Name (e.g. John Doe) Provider Name Date of
Service (e.g. 01/01/20xx) Expense Type (e.g. Medical premium,
office visit
co-pay, etc.) Proof of Expense Amount (e.g., invoice or
receipt
from provider that identifies the participant name and service date
and description, an Explanation
of Benefits from insurer that identifies amount owed by
participant)
Proof of Payment (e.g., front and back side of cancelled check,
receipt, statement from provider showing payment, bank or credit
card statement)
FOR PREMIUM EXPENSES:
Covered Participant Name (e.g. John Doe) Insurer Name Premium Type
(e.g. medical, dental) Date of Coverage (e.g.
01/01/20xx–12/31/20xx) Premium amount (e.g., statement or invoice
from
insurer) Proof of Payment (e.g., front and back side of
cancelled check, receipt or statement from insurer, bank or credit
card statement)
For Medicare premiums deducted from your Social Security check, use
the Social Security Benefit Award Letter issued by the Social
Security Administration (SSA) each year, usually during the month
of October or November, as your third party documentation. Watch
for this document to arrive in the mail.
Account Holder Information:
The account holder may be the retiree or spouse, depending on your
plan’s rules. If you have a Household account, the primary account
holder must sign; if you have an Individual account, the account
holder must sign. Please refer to the letter you received from
Mercer Marketplace 365 Retiree to understand if you have a
Household or Individual account. Call Mercer if you have questions
about your account type.
Reimbursement Request Information:
Date of Service
Covered Participant Name
Amount Requested, which should be the entire expense you
incurred/paid.
Certification Requirement:
Carefully read the certification requirements before signing.
DIRECT DEPOSIT! Expedite your payments by signing up for direct
deposit today. Refer to your Reimbursement Instructional Guide for
instructions on how to log into the portal and complete the
necessary information for your reimbursements to be made by direct
deposit.
D I R E C T D E P O S I T F O R M - f o r q u a l i f i e d e x p e
n s e s
This is an optional form.
I M P O R T A N T I N F O R M A T I O N : To allow payments for
reimbursement of eligible expenses and/or premium(s) under your
subsidy to be directly deposited into your bank account, please
complete this form. We will be unable to process forms with missing
information. P L E A S E C H O O S E T H E T Y P E O F A C C O U N
T :
CHECKING
Submit a voided check (required) for the account you wish the
deposit to be made. The routing number is the 9-digit number
located in the lower left hand corner of the check. Your account
number is the next set of digits following your routing
number.
SAVINGS
List your account number and routing/transit number below. Ask your
bank to provide you with the routing/transit number for your
account. The routing/transit number is not always the same as the
number on a savings deposit slip. Please provide the following
information regarding the bank account to receive direct deposits
for reimbursements from your subsidy:
Name(s) on the Account:
Routing/Transit Number:
Account Number:
A C C O U N T A U T H O R I Z A T I O N : Please read and sign
before completing and submitting.
I hereby authorize my former employer and the Program Manager,
Mercer Health & Benefits Administration,
(hereinafter collectively referred to as “Company”) to deposit any
amounts owed me by initiating credit entries to
my account at the financial institution (hereinafter “Bank”)
indicated on this form. Further, I authorize Bank to
accept and to credit any credit entries indicated by Company to my
accounts. In the event Company deposits
funds erroneously into my account, I authorize Company to debit my
account for an amount not to exceed the
original amount of the erroneous credit.
This authorization is to remain in full force and effect until
Company and Bank have received written notice from
me of its termination in such time and in such manner as to afford
Company and Bank reasonable opportunity to
act on it.
SIGNATURE DATE
Me rc er He a l t h & B en e f i t s Ad min i s t r a t i on ,
ATTN: C la i ms De p t . , PO Bo x 14 40 1 , Des M o in es , IA 5
03 0 6 -34 01 | Fax 8 57 -3 62 -29 99
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