A member who is enrolled in the DHMO program is permitted to drop enrollment if there is no participating general dentist within a 25-mile driving distance of the member’s home address.
To do so, a member, or an agency benefits coordinator on behalf of the member, should submit an Insurance Cancel Request Application to Benefits Administration. This form can be found by following this path:
- Partners for Health Website > Publications > Forms > Active Employees and COBRA > Insurance Cancel Request Application
Benefits Administration will confirm with Cigna that there is no participating general dentist within a 25-mile driving distance of the member’s home address once the Insurance Cancel Request Application is received.
Additionally, a member who is cancelling DHMO enrollment for this reason can enroll in the DPPO program at this time.
To do so, a member, or an ABC on behalf of the member, should submit an Enrollment Change Application to Benefits Administration. This form can be found by following this path:
- Partners for Health Website > Publications > Forms > Active Employees and COBRA > Enrollment Change Application
Retirees wanting to enroll in the DPPO program at this time should submit a Dental Insurance Application or the Retiree Insurance Change Application. Both forms can be found by following this path:
- Partners for Health Website > Publications > Forms > Retirement > Dental Insurance Application or Retiree Insurance Change Application
Note: The Insurance Cancel Request Application and Enrollment Change Application should be submitted at the same time for those wanting to enroll in the DPPO program.
Note: “Change Coverage” should be selected when filling out the Enrollment Change Application.