Summary of Benefits and Coverage

A snapshot of a health plan's costs, benefits, covered healthcare services, and other important features.

Program Option
  • Local Traditional Health Plan (PO12) & Supplemental Benefits
  • Local Traditional Health Plan with Uniform Dental (PO2) & Supplemental Benefits
Plan Year
  • 2024

Summary of Benefits and Coverage

A snapshot of a health plan's costs, benefits, covered healthcare services, and other important features.

Program Option
  • Local High Deductible Health Plan (PO17) & Supplemental Benefits
  • Local High Deductible Health Plan with Uniform Dental (PO7) & Supplemental Benefits
Plan Year
  • 2024
ET-1313
Form Local Employer / State Employer

Designation of Agent

Employers, complete to designate an employee as the agent representing the employer in matters pertaining to the programs administered by the Department of Employee Trust Funds.

Cancellation or Termination of Health Coverage FAQs

Program Option
  • Local Deductible Health Plan (PO14) & Supplemental Benefits
  • Local Deductible Health Plan with Uniform Dental (PO4) & Supplemental Benefits
  • Local Health Plan (PO16) & Supplemental Benefits
  • Local Health Plan with Uniform Dental (PO6) & Supplemental Benefits
  • Local High Deductible Health Plan (PO17) & Supplemental Benefits
  • Local High Deductible Health Plan with Uniform Dental (PO7) & Supplemental Benefits
  • Local Traditional Health Plan (PO12) & Supplemental Benefits
  • Local Traditional Health Plan with Uniform Dental (PO2) & Supplemental Benefits
Plan Year
  • 2024