If an insured wishes to cancel health insurance and lives in Massachusetts, he/she must provide proof of other health coverage using the HIRD form.

  1. Employee completes and signs GIC Municipal Insurance Enrollment and Change Form (Form-1MUN) with appropriate cancel coverage box checked. 
  2. If the employee lives in Massachusetts and is canceling health insurance, the employee must also complete a Health Insurance Responsibility Disclosure (HIRD) form.  The Coordinator fills in the lowest available monthly employee share of GIC health insurance individual coverage premium using the most current GIC rate sheet on the HIRD form.  If the employee refuses to complete the HIRD form, document efforts to obtain the information from the employee.  Retain all HIRD forms for three years and make them available to the Health Connector Authority upon request.  Do not send the form to the GIC.
  3. If employee is withdrawing from health insurance and he/she has family coverage, the employee must provide proof of where spouse and/or dependents will be covered once GIC coverage is cancelled.  Acceptable proof examples: a copy of the health insurance card or a letter from the spouse’s employer on their letterhead.  Without this proof, the GIC can deny the request to withdraw from coverage. 
  4. Review and sign Municipal Insurance Enrollment and Change Form (Form-1MUN).
  5. Update your payroll system deductions.
  6. Photocopy Municipal Insurance Enrollment and Change Form (Form-1MUN) and proof of other coverage (if applicable) and file in employee’s personnel file.
  7. Send original Municipal Insurance Enrollment and Change Form (Form-1MUN) and proof of other coverage (if applicable) to the GIC.
  8.  The GIC will mail to the insured’s home a HIPAA Notice that includes a Certificate of Creditable Coverage indicating the coverage end date.

This information provided by the Group Insurance Commission.