{"id":8792,"date":"2021-10-27T13:21:55","date_gmt":"2021-10-27T17:21:55","guid":{"rendered":"https:\/\/www.bates.edu\/hr\/?page_id=8792"},"modified":"2026-04-09T11:28:02","modified_gmt":"2026-04-09T15:28:02","slug":"2022-annual-enrollment-forms","status":"publish","type":"page","link":"https:\/\/www.bates.edu\/hr\/annual-benefits-enrollment-information\/2022-annual-enrollment-forms\/","title":{"rendered":"Enrollment Change & Flexible Spending Account Forms"},"content":{"rendered":"\n

Enrollment Coverage Change Form<\/h3>
<\/div><\/div>
\n

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. \u009f<\/p>\n\n\n\n

\u009f\u009f\u009f\u009fClick here to review a detailed document listing<\/a> for more information. (Please complete and send to Human Resources for processing)<\/p>\n\n\n\n

Click here for the Enrollment Coverage Change Form<\/a><\/p>\n<\/div><\/div>\n\n\n\n

Dependent Care Subsidy Form<\/h3>
<\/div><\/div>
\n

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 2024 tax return verifying your Adjusted Gross Income is less than $75,000.<\/p>\n\n\n\n

Click here for the Dependent Care Subsidy Form<\/a><\/p>\n<\/div><\/div>\n\n\n\n

Health Insurance Contribution Credit (HICC)<\/h3>
<\/div><\/div>
\n

Health Insurance Contribution Credit (HICC)<\/a>: For those employees who have lower household incomes, the cost of health insurance can be a major part of their monthly budget.\u00a0 The Health Insurance Contribution Credit will be available to those employees who elect either the PPO in 2026. <\/b>\u00a0as follows:<\/p>\n\n\n\n

<\/p>\n\n\n\n

 2024 Household income<\/b><\/td>

0 to 45,000<\/b><\/p><\/td>

45,001 to 60,000<\/b><\/td> 60,001 to 75,000<\/b> <\/td><\/tr>
Credit for <\/b>Level of Income<\/b><\/td> 30% <\/td>25%<\/td>20%<\/td><\/tr><\/tbody><\/table><\/figure>\n\n\n\n

<\/p>\n\n\n\n

Bates College employees who can provide documentation of their household income in the form of the front page of their 2024 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.<\/p>\n<\/div><\/div>\n\n\n\n

<\/p>\n\n\n\n

Health Savings Account Payroll Deduction Form<\/h3>
<\/div><\/div>
\n

Click here for the Health Savings Account Payroll Deduction Form<\/a> (you must elect the Aetna Consumer Choice (HSA) Plan to contribute to a Health Savings Account)<\/p>\n\n\n\n

\n

If you are currently contributing to the Health Savings Account, your contribution will continue into 2026 unless you change it.<\/strong><\/p>\n\n\n\n

I<\/strong><\/span>RS increased the maximum contribution to $4,400 for individual coverage and $8,750 for dependent level coverage (age 55 catch-up contribution remains at $1,000)<\/span> <\/strong><\/p>\n<\/section>\n\n\n\n

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. <\/span><\/p>\n\n\n\n

Bates College will match your contributions by 50% up to a calendar year<\/span> maximum of $300 for individual coverage and $600 for Dependent Coverage.<\/p>\n\n\n\n

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.<\/p>\n\n\n\n

Once complete, this form will automatically be routed to Human Resources.<\/p>\n<\/div><\/div>\n","protected":false},"excerpt":{"rendered":"","protected":false},"author":5,"featured_media":0,"parent":8595,"menu_order":0,"comment_status":"closed","ping_status":"closed","template":"","meta":{"_hide_ai_chatbot":false,"_ai_chatbot_style":"","associated_faculty":[],"_Page_Specific_Css":"","_bates_restrict_mod":false,"_table_of_contents_display":false,"_table_of_contents_location":"","_table_of_contents_disableSticky":false,"_is_featured":false,"footnotes":"","_bates_seo_meta_description":"","_bates_seo_block_robots":false,"_bates_seo_sharing_image_id":0,"_bates_seo_sharing_image_twitter_id":0,"_bates_seo_share_title":"","_bates_seo_canonical_overwrite":"","_bates_seo_twitter_template":""},"class_list":["post-8792","page","type-page","status-publish","hentry","with-sidebar"],"_links":{"self":[{"href":"https:\/\/www.bates.edu\/hr\/wp-json\/wp\/v2\/pages\/8792","targetHints":{"allow":["GET"]}}],"collection":[{"href":"https:\/\/www.bates.edu\/hr\/wp-json\/wp\/v2\/pages"}],"about":[{"href":"https:\/\/www.bates.edu\/hr\/wp-json\/wp\/v2\/types\/page"}],"author":[{"embeddable":true,"href":"https:\/\/www.bates.edu\/hr\/wp-json\/wp\/v2\/users\/5"}],"replies":[{"embeddable":true,"href":"https:\/\/www.bates.edu\/hr\/wp-json\/wp\/v2\/comments?post=8792"}],"version-history":[{"count":18,"href":"https:\/\/www.bates.edu\/hr\/wp-json\/wp\/v2\/pages\/8792\/revisions"}],"predecessor-version":[{"id":12745,"href":"https:\/\/www.bates.edu\/hr\/wp-json\/wp\/v2\/pages\/8792\/revisions\/12745"}],"up":[{"embeddable":true,"href":"https:\/\/www.bates.edu\/hr\/wp-json\/wp\/v2\/pages\/8595"}],"wp:attachment":[{"href":"https:\/\/www.bates.edu\/hr\/wp-json\/wp\/v2\/media?parent=8792"}],"curies":[{"name":"wp","href":"https:\/\/api.w.org\/{rel}","templated":true}]}}