Benefits Human Resources

Dental coverage is available during the first 18 months following retirement. See the Summary Plan Description (SPD) for detailed information.

Please mark the check box by selecting the level of coverage below:

Enrolled Dependents
Add eligible dependent(s) by entering the information below and checking the "add" dependent option. To drop a dependent, check the “drop” box following the dependent’s information.

Dental Coverage: Dental coverage is available to retirees through the University only during the first 18 months of retirement. For information on individual dental coverage after the 18-month period, contact Regence BlueCross BlueShield at (888) 370-6159.

Eligible Dependents: The person to whom you are legally married or your eligible domestic partner and your (or your spouse’s or your domestic partner’s) unmarried children by birth, placement for legal adoption or foster care, or legal (court-appointed) guardianship, who are under age 26 and dependent on you for more than 50% of their support. Coverage may be continued at age 26 under certain circumstances. Contact University Human Resource Management at askHR@utah.edu for additional information.

Dental Coverage Information
• I hereby make application on behalf of myself and listed eligible family dependents for enrollment in the University of Utah Retiree Dental Plan as indicated hereon.
• To the extent authorized under applicable law, I accept binding arbitration as the method of resolving any disputes arising between me or the covered family member and the Plan, or a participating physician, concerning the applicability of benefits payable under the plan.
• I understand that dental coverage is only available during the first 18 months of eligibility for enrollment in the University’s Retiree Dental Plan. I understand I may enroll in a group dental policy through Regence BlueCross BlueShield when the 18-month period expires.
• I understand that to continue my enrollment in the Retiree Dental Plan, I must make timely payments of the full amount due each month.
• To the minimum extent necessary to implement coverage, and in accordance with rules set forth in the HIPAA Privacy Regulations, I authorize Regence BlueCross BlueShield to request any medical, health, employment, and/or insurance information necessary to complete my enrollment and process my claims.
• I certify that all information on this form is true and correct and acknowledge that the University may take corrective action against Participants who (a) enroll an individual in the Retiree Dental Plan that they know or should know is ineligible and/or (b) file claims (either directly or indirectly through a health care provider) for an individual that they know or should know is ineligible for coverage under the Plan. Corrective action includes legal action for reimbursement of all claims and cancellation of coverage without the right to elect COBRA continuation coverage.
• I understand that the University intends to continue the Plan; however, it reserves the right to amend, suspend or discontinue it at any time.

Social Security Numbers are Required for All Dependents
Beginning January 1, 2009, Section 111 of the Medicare, Medicaid, and SCHIP Extension Act of 2007 requires all health plans in the United States to report group and member information to the Centers for Medicare and Medicaid Services (CMS). This law helps CMS accurately coordinate Medicare and group benefits for people who have both types of coverage. Since individuals under age 65 who have end stage renal disease or other disabilities are eligible for Medicare, we need to provide information, including social security numbers, for all enrolled members.