Experiencing Some Life Changes

Whatever your life change, you’ll likely need this form to report a change in your benefits status. Once it’s completed, return it with supporting documentation to:

Human Resources

By Mail: 1 Hospital Drive, Suite 6300, Asheville, NC 28801

By Fax: (828) 213-4223

By Email: NCDV.HRDirectConnect@HCAHealthcare.com

Contact HR Direct Connect by phone at (828) 213-5600

I Have…


Changes in my marital status


Changes in my family/dependents


Changes in my benefits coverage


Changes in my employment status


Other changes


When your life changes—such as marriage, divorce, birth or adoption, a change in your or your spouse’s employment—chances are your benefits will need to change, too. You have 31 days from the date of your Qualifying Life Event (QLE) to request benefit changes. (Note: For certain QLEs, such as death of a spouse, you have 60 days to request changes.

Under IRS regulations, any changes you make must be consistent with, and correspond to, the qualifying life event. For example, if you are divorcing and have been covered under your spouse’s medical plan, it would be consistent to elect medical coverage under a Mission Health Plan. However, if you didn’t lose coverage as the result of the divorce, it would not be consistent for you to elect medical coverage.

You MUST provide supporting documentation within 31 days of your QLE (60 days in some instances—see specific issue for details) in order to make changes, cancel, and/or add dependents to your benefit plan coverage. If you do not provide adequate documentation, changes will NOT be made.

For more details about the requirements for changing benefits, see the Summary Plan Description for the Mission Health System, Inc. Health and Welfare Benefits Plan).

(Visited 6,743 times, 1 visits today)