Navigating the complexities of health benefits can often feel overwhelming for state employees in New Jersey. The Ha 0780 0707P form serves as a crucial document for those looking to either waive or reinstate their State Health Benefits Program (SHBP) coverage. Essentially, this form caters to two main actions: the voluntary waiving of SHBP coverage for individuals who already have another health coverage in place and wish to opt-out of state-provided benefits to avoid payroll contributions, and the reinstatement of SHBP coverage for those who previously opted out but have since lost their alternative coverage. This process requires the employee to make a decisive declaration about their health benefits status, acknowledging the implications of their choice. Further complicating matters, the decision to waive or reinstate coverage is tightly bound by strict notification timelines, especially in the event of reinstatement, where proof of loss of the alternate coverage must be provided within 60 days to ensure continuous coverage. Both employee and employer play pivotal roles in completing the process, with specific sections of the form dedicated to each party to affirm the requested action. As such, understanding the nuances and deadlines associated with the HA-0780-0707P form is paramount for New Jersey state employees making informed decisions about their health benefits.
| Question | Answer |
|---|---|
| Form Name | Form Ha 0780 0707P |
| Form Length | 1 pages |
| Fillable? | No |
| Fillable fields | 0 |
| Avg. time to fill out | 15 sec |
| Other names | NJ_State_Health _Benefits_Waive r Reinstatement_Form ha 0780 0510p form |
STATE OF NEW JERSEY
DEPARTMENT OF THE TREASURY
DIVISION OF PENSIONS AND BENEFITS
PO BOX 299
TRENTON, NJ
STATE HEALTH BENEFITS PROGRAM COVERAGE
STATE EMPLOYEE WAIVER/REINSTATEMENT
Part 1: To be completed by the employee. Please print.
1.Name __________________________________________________ SS# ____________________________________
Check one box below.
Waiver of Coverage
I agree to voluntarily waive State Health Benefits Program (SHBP) coverage to which I am entitled because I am covered under other health coverage. I understand that while coverage is waived, I will not be required to make payroll contributions required for medical and/or prescription drug coverage.
I understand that I may resume State Health Benefits Program coverage if I lose coverage under the other health coverage, provided that I notify the SHBP within 60 days of the loss of the other coverage and provide proof of loss of that coverage.
Reinstatement of Coverage
I previously waived State Health Benefits Program coverage because I had other health coverage.
As of _____________________, I am no longer covered by the other health plan, request reinstatement of the State
(DATE)
Health Benefits Program coverage, and have provided proof of loss of the other coverage.
Employee’s Signature __________________________________________ Date ________________________________
Part 2: To be completed by the employer. Check one box below.
We understand that this employee is requesting to voluntarily waive State Health Benefits Program coverage.
We request reinstatement of this employee’s State Health Benefits Program coverage.
A completed State Health Benefits Program Application must be attached to either a waiver or a reinstatement.
The reinstatement application must be filed within 60 days of the loss of other health coverage. If this timetable is followed, the coverage will be retroactive to the date of loss. If the 60 day time limit has passed, the employee must wait until the next open enrollment period to reenroll.
Employer Name _________________________________________ SHBP Location # ______________________
Signature of Certifying Officer _____________________________________________ Date _______________________