Enrollment Change & Flexible Spending Account Forms
Enrollment Coverage Change Form
Use this form to add or delete dependents from your medical or dental insurance plans. To add a dependent you must also submit documentation of their eligibility such as a birth certificate, marriage license, tax return, or other documents.
Click here to review a detailed document listing for more information. (Please complete and send to Human Resources for processing)
Click here for the Enrollment Coverage Change Form
Dependent Care Subsidy Form
If you elect to contribute to the Dependent Care Reimbursement Account you must complete this form and send it to Human Resources. If applying for a higher-level subsidy you must also submit a copy of your 2022 tax return verifying your Adjusted Gross Income is less than $75,000.
Click here for the Dependent Care Subsidy Form
Health Insurance Contribution Credit (HICC)
Health Insurance Contribution Credit (HICC): For those employees who have lower household incomes, the cost of health insurance can be a major part of their monthly budget. The Health Insurance Contribution Credit will be available to those employees who elect either the Whole Health ACO or PPO in 2024. as follows:
|2022 Household income
0 to 45,000
|45,001 to 60,000
|60,001 to 75,000
|Credit for Level of Income
Bates College employees who can provide documentation of their household income in the form of the front page of their 2022 Income Tax Return will receive a credit based on the level of their income. The amount reported on your tax return as adjusted gross is used in determining your household income.
Health Savings Account Payroll Deduction Form
Click here for the Health Savings Account Payroll Deduction Form (you must elect the Aetna Consumer Choice (HSA) Plan to contribute to a Health Savings Account)
If you are currently contributing to the Health Savings Account, your contribution will continue into 2024 unless you change it.
IRS increased the maximum contribution to $4,150 for individual coverage and $8,300 for dependent level coverage (age 55 catch-up contribution remains at $1,000)
This form allows you to have additional HSA contributions deducted from your payroll. You may use this form to authorize either a one-time transaction or periodic transfers.
Bates College will match your contributions by 50% up to a calendar year maximum of $300 for individual coverage and $600 for Dependent Coverage.
If you authorize periodic deductions, you may change or terminate that authorization at any time prior to the next payroll processing by completing a new form.
Once complete, this form will automatically be routed to Human Resources.