Benefit Forms & Information

Medical / Prescription Drug, Dental & Vision

• Wayne County Notice of Creditable Coverage for 2024(PDF, 155KB)
• Side-by-Side Benefit Comparisons for medical, dental, vision and hearing information specific to various collective bargaining agreements, benefit plans, and/or retirees
• Plan Summaries and Benefits-at-a-Glance for each plan
• BCBSM Right Care information on lower-cost alternatives for Emergency Care(PDF, 332KB)
• BCBSM Preventive Care Saves Lives(PDF, 3MB)
• BCBSM / BCN Custom Select Formulary Quick Guide(PDF, 1023KB)
  • More info on BCBSM website
• DENCAP Retiree FAQ(PDF, 169KB)
• DENCAP Retiree Advantage Schedule(PDF, 159KB)

Flexible Spending Accounts (FSA), Health Savings Accounts (HSA) & Retiree Medical Savings Accounts (RMSA)

Plan Documents & Account Access

• Flexible Spending Account (FSA) - American Fidelity
• Health Savings Account (HSA) - Health Equity
• Retiree Medical Savings Accounts (RMSA) - MERS of Michigan (also known as Health Care Savings Plan or Employee Health Trust Plan)

Frequently Asked Questions (FAQs)

• FSA FAQs(PDF, 105KB)
• HSA FAQs(PDF, 95KB)
• RMSA FAQs

Additional Resources

• HSA Guide
• Qualified Medical Expenses(PDF, 120KB)
• Tax Benefit Example(PDF, 15KB)
• HSA Annual Tax Saving Potential Flyer(PDF, 416KB)
• HSA Member Brochure(PDF, 1MB)

Webinars

• HSA Basics- Harness the Power of an HSA- Webinar Register
• HSA Your Way: Spend, Save, and Invest in Your Healthcare Presentation
• MERS-Health Care Savings Program-Webinar
• MERS-Health Care Savings Program-Webinar

FSA Enrollment Forms

• American Fidelity website
• American Fidelity FSA Flyer(PDF, 302KB)

Employee Assistance Program (EAP)

• Employee Assistance Program (EAP)(PDF, 2MB) - Free & Confidential counseling services available 24/7/365 to employees and family members through HMSA
• Employee Benefit Summary 5FTF Wayne County(PDF, 702KB)
• EAP Recorded Message

Life Insurance

Basic Group Life Insurance: Basic (employer-paid) life benefits are determined by the terms and provisions of applicable collective bargaining agreements and benefit plans.

• Supplemental Group Life Information(PDF, 199KB)
• Beneficiary Designation Information(PDF, 602KB)
• Notice of Conversion and/or Portability Rights Form(PDF, 555KB)

Other Value-Added Benefits & Voluntary / Supplemental Benefits

Value-Added Benefits for Active Employees

• Virtual Well-Being Webinars(PDF, 257KB)
• More webinar info on the BCBSM website

LIVONGO by Teladoc Health Diabetes

• Webinar - Health Diabetes by LIVONGO(PDF, 2MB)
• Livongo for Diabetes Enrollment FAQ(PDF, 2MB)

Voluntary Benefit Plan Options

• TMR & Associates(PDF, 343KB)
• American Fidelity

Benefit Forms

• IRS 4506T Form (use for dependent and/or income verification)(PDF, 98KB)
• Medicare Advantage Enrollment Form (Exec/Legislative)(PDF, 352KB)
• Medicare Advantage Enrollment Form (Legislative)(PDF, 185KB)
• Medicare Advantage Enrollment Form (All Other)(PDF, 2MB)
• Information: 2021 Wayne County Medicare Advantage PPO BCN(PDF, 2MB)
• Health Equity Refund Form(PDF, 431KB)
• HSA Annual Wage Bonus Contribution(PDF, 529KB)
• HSA One-Time Payroll Deposit Authorization(PDF, 227KB)
• HSA Regular / On-Going Contribution Form(PDF, 488KB)
• HSA Prorated Bonus Form(PDF, 181KB)
• The Hartford Charter of Wayne Benefits Enrollment/Supplemental Group Life Insurance Form(PDF, 345KB)
• The Hartford Beneficiary Designation Form(PDF, 1MB)
• Notice of Conversion and/or Portability Rights Form(PDF, 555KB)
• Enrollment Change of Status Form(PDF, 827KB)
• Optical Reimbursement Form(PDF, 2MB)
• Flexible Spending Account Election Form(PDF, 80KB)

Frequently-Used Links

• American Fidelity
• Blue Cross Blue Shield of Michigan (BCBSM)/ Blue Care Network (BCN)
• Dencap Dental Plan (employees)
• Dencap Dental Plan (retirees)
• Delta Dental Plans
• Hartford Life
• Health Equity
• Health Management Systems of America (HMSA)
• Heritage Vision Plans
• Municipal Employees Retirement System (MERS)
• Wayne County Employee Retirement System