Active State Administration Manual


Administrative Manual |

Appendices

A. Kansas Administrative Regulation 108-1-1 |

B. SEHP Enrollment Form |
B1. SEHP Enrollment Form Key |
B2. SEHP Enrollment Form Instructions |

C. SEHP Change Form |
C1. SEHP Change Form Key |
C2. SEHP Change Form Instructions |

D. SEHP TEFRA Form |
D1. Sample TEFRA Letter - Employee 65 |
D2. Sample TEFRA Letter - Spouse 65 |

E. SEHP Employer's Waiver of Health Plan Participation |

F. SEHP Request for Waiver of Thirty Day Waiting Period |

G. SEHP Health Plan Communication Form |

H. SEHP Caremark Prescription Reimbursement Standard Claim Form |

I. SEHP Prescription Drug Advance Purchase Certificate |
I1. SEHP Prescription Drug Advance Purchase Policy |

J. SEHP Sample Agency Medicare Part B Memo |

K. SEHP End State Renal Disease Questionnaire |

L. SEHP Dependent Grandchild Affidavit |

M. SEHP Affidavit and Application for Coverage of Permanent and Totally Disabled Dependent Child |

N. SEHP Affidavit of Common Law Marriage |

O. SEHP Staff Contact List |

P. SEHP Health Plan Providers' Contact Information |

Q. SEHP Health Plan and FSA Coverage Begin Dates for Newly Hired Employees |

R. SEHP FSA Eligibility Table |

S. SEHP Plan Year 2012 COBRA Rates |

T. SEHP Sample FMLA Billing Letter |
T1. SEHP Sample FMLA Termination Letter |
T2. SEHP Sample FMLA 15 Day Letter |

U. SEHP Sample Worker's Compensation Employee on TDD |

V. SEHP Specific HIPAA Authorization |

W. SEHP Appointment of Personal Representative Form |
W1. SEHP Revocation of Personal Representative Form |

X. SEHP Paid Extended Absence of Sabbatical Leave |

Y. SEHP FSA Enrollment Change Form |
Y1. SEHP HSA Enrollment Change Form |

Z. SHaRP Table for COBRA Eligible Individuals |