Office of Group Insurance
Department of Administration

Retiree Group Insurance Benefits

Enrollment Snapshot

To enroll for coverage, complete the form and submit it to the Office of Group Insurance. In order for the coverage to be effective on the first day of the month following the date active employee coverage terminates, your enrollment form must be submitted within sixty (60) days of the date that the active employee policy ends. If your enrollment form is submitted after the sixty (60) day enrollment period, you will be considered a late enrollee and coverage will be effective the first day of the month following the date of application.

FY2013 Enrollment Snapshot

	Documents
	Forms	Traditional	PPO	High Deductible
Plan Year: July 1, 2012 through June 30, 2013	Enrollment Form	Plan Contract	Plan Contract	Plan Contract

FY2012 Enrollment Snapshot

	Documents
	Forms	Traditional	PPO	High Deductible
Plan Year: July 1, 2011 through June 30, 2012	Enrollment Form	Plan Contract	Plan Contract	Plan Contract

Disenrollment Snapshot

If you enroll in a Medicare Supplement or Advantage plan, your membership in the state’s retiree group medical plan will not automatically end. If you decide that you want to terminate your enrollment in our group plan, you need to print the Declination of Benefits form, complete the section to decline coverage, and mail it to us.

	Documents
	Forms	Traditional	PPO	High Deductible
Plan Year: July 1, 2011 through June 30, 2012	Declination of Benefits Form	Plan Contract	Plan Contract	Plan Contract

QUESTIONS?

Phone:
Fax:
Email:

(208) 332-1860 or (800) 531-0597
(208) 332-1888
ogi@adm.idaho.gov