2023 Cleveland-Cliffs Steel LLC VEBA RETIREE HEALTHCARE ELECTION FORM

Name(Required)

First

Last

Email(Required)

Enter Email

Confirm Email

Phone(Required)

Address(Required)

Street Address

Address Line 2

City

State / Province / Region

ZIP / Postal Code

Date of Birth(Required)

Social Security Number(Required)

Enrolled in Medicare(Required)

Yes
No

Medicare ID#

Part A Effective Date

Part B Effective Date

Program Disclaimer 1(Required)

If the election to enroll in the Cleveland-Cliffs Steel LLC VEBA Retiree Healthcare program effective 1/1/2023, I understand that I will not qualify for the Medicare Part B Reimbursement from 1/1/2023-12/31/2023, but I may change my election for the calendar year 2024.

I wish to enroll in Premier Plan – which is $90 per month for both Medical and Rx Benefits for January 1, 2023.
I wish to enroll in Plus Plan – which is $40 per month for both Medical and Rx Benefits for January 1, 2023.
I wish to enroll in Basic Enhanced Plan – which is $5 per month for both Medical and Rx Benefits for January 1, 2023.
I do NOT elect to enroll in any MAPD plans for January 1, 2023 and would like to remain eligible for the Medicare Part B Reimbursement for 2023. I acknowledge that I cannot change this election until January 1, 2024.

YOU MUST SELECT ONE OF THE BOXES ABOVE

I have received, read, and understood the information explaining the Cleveland-Cliffs Steel LLC VEBA options.
I request membership in the plan that I have elected on this form for which I am eligible.
I understand that if I enroll in the Cleveland-Cliffs Steel LLC VEBA Medicare Advantage Plans with Prescription Drugs which are listed above, by signing this form, I am making a binding election that I will not be able to change my election until 1/1/2024.
I understand that if I do not return this election form by December 10, 2022, I will NOT be enrolled in the Anthem MAPD Plan with Prescription drugs for 1/1/2023, but will remain eligible for the Medicare Part B Reimbursement Benefit.
I also understand that I will have another opportunity in the Fall of 2023 to make an additional selection into either Retiree Healthcare or the Medicare Part B Reimbursement which would be effective January 1, 2024.

Retiree Signature(Required)

Consent(Required)

(Required)

By checking this form and providing my signature, I attest that all information is true and accurate to the best of my knowledge.

My spouse is enrolled in Medicare and wishes to enroll in the program.

My spouse is enrolled in Medicare and wishes to enroll in the program.

Spouse Application

Complete this section if you are the spouse of a living retiree.

Spouse Name(Required)

First

Last

Spouse Phone

Address

Street Address

Address Line 2

City

State / Province / Region

ZIP / Postal Code

Spouse Date of Birth(Required)

Spouse Social Security Number

Enrolled in Medicare

Yes
No

Spouse Medicare ID#

Part A Effective Date

Part B Effective Date

Program Disclaimer(Required)

If the election to enroll in the Cleveland-Cliffs Steel LLC VEBA Retiree Healthcare program effective 1/1/2023, I understand that I will not qualify for the Medicare Part B Reimbursement from 1/1/2023-12/31/2023, but I may change my election for the calendar year 2024.

I wish to enroll in Premier Plan – which is $90 per month for both Medical and Rx Benefits for January 1, 2023.
I wish to enroll in Plus Plan – which is $40 per month for both Medical and Rx Benefits for January 1, 2023.
I wish to enroll in Basic (Formerly Plan C) – which is $0 per month for both Medical and Rx Benefits for January 1, 2022.
I do NOT elect to enroll in any MAPD plans for January 1, 2023 and would like to remain eligible for the Medicare Part B Reimbursement for 2023. I acknowledge that I cannot change this election until January 1, 2024.

YOU MUST SELECT ONE OF THE BOXES ABOVE

I have received, read, and understood the information explaining the Cleveland-Cliffs Steel LLC VEBA options.
I request membership in the plan that I have elected on this form for which I am eligible.
I understand that if I enroll in the Cleveland-Cliffs Steel LLC VEBA Medicare Advantage Plans with Prescription Drugs which are listed above, by signing this form, I am making a binding election that I will not be able to change my election until 1/1/2022.
I understand that if I do not return this election form by December 1, 2021, I will NOT be enrolled in the Aetna MAPD Plan with Prescription drugs for 1/1/2022, but will remain eligible for the Medicare Part B Reimbursement Benefit.
I also understand that I will have another opportunity in the Fall of 2021 to make an additional selection into either Retiree Healthcare or the Medicare Part B Reimbursement which would be effective January 1, 2022.

Spouse Signature(Required)

Please enter your spouse's signature.