Benefits Change Form

If you are an existing employee or retiree and you want to make a change to your benefits such as:

  • Updating contact information. Updating Contact Information should be done if you have a new mailing address or email address. Phone numbers should also be updated.
  • Adding or removing coverage or adding dependents - This must be done within 31 days of an employee/retiree experiencing a special enrollment event. Each of the events below requires documentation, DOB and SSN.
    • Marriage (marriage license)
    • Birth (birth certificate if the mother is not on the MMIA Plan. Please note, newborns can be added before you receive their SSN and must be added within 31 days of birth.)
    • Adoption (court documents)
    • You or any dependent lost other coverage (proof of other coverage that includes date the coverage ends)
  • Removing dependents - This can be done at any time for any reason.
    • Divorced employees/retirees must remove the spouse within 31 days of the proceeding being final.
  • Letting your city and MMIA EB know you are retiring and would like to retain some of all of your current MMIA coverages.
  • Letting your city and MMIA EB know you or someone on your plan has become Medicare‐eligible.
    • If you are a retiree and you or your medically covered spouse reach the age of 65. The rate for medical coverage is different for those 65 and over.