Dependent Definitions and Required Documentation

 

IF PROVIDING DOCUMENTATION, SEND PHOTOCOPIES ONLY.  WE WILL NOT RETURN MATERIALS.

 

 

Husband or Wife

Who can be covered: the employee’s husband or wife.  Note: Same sex spouse and/or domestic partners are not eligible for coverage.

 

How to show eligibility: Submit one of the following:

 

(a)    For a ceremonial marriage (between a man and a woman),

 

                    √ A copy of your marriage certificate.

                    √ Your spouse’s social security number. If your spouse is Medicare eligible, the Medicare Health

                        Insurance Claim Number (HICN) is also required.

 

            (b) For a common law marriage (between a man and a woman),

                  (Acceptable only if you live in a state that recognizes common law marriage):

 

                   √ Statement Regarding Common Law Marriage form signed by both parties

                   √ An Application for Coverage of Common Law Husband or Wife form signed by both parties

                   √ The proof of joint habitation, such as:

·         A lease or mortgage in both parties’ names

·         A vehicle registration in both parties’ names

·         A copy of last year’s federal tax form 1040 showing you filed a joint tax return

                    √ Your spouse’s social security number. If your spouse is Medicare eligible, the Medicare Health

                       Insurance Claim Number (HICN) is also required.

 

Your children under the age of 26

Who can be covered: Your married or unmarried natural children, stepchildren, adopted children (including children placed with you for adoption) and children who are Alternate Recipients under a Qualified Medical Support Order.  Your children do not need to be living with you in order to be eligible for coverage. 

 

Note: Children age 19 but under age 26 cannot be eligible to enroll in an employer-sponsored group health plan other than a group health plan of the parent.

 

How to show eligibility: Submit one of the following for:  

 

(a)    Natural child or step-child

 

                   √ A copy of the child’s birth certificate identifying the parents

                   √ If you are not identified as a parent on the child’s birth certificate, submit, in addition to the birth

                      certificate, a paternity test showing you are the parent, or a court order declaring you are the parent

                   √ In the case of a stepchild, records that show your wife or husband is the child’s biological or adoptive

                      parent.  This would include the child’s birth certificate or an adoption decree, accompanied by a

                      marriage certificate or Statement Regarding Common Law Marriage form or a paternity test showing

                      your husband or wife is the child’s parent.

                   √ If you do not have a birth certificate for the child, you may submit a birth registration notice from the

                      hospital, on hospital letterhead, acknowledging the birth of the child.  This registration must include              

                      all of the following:

·         Father’s and Mother’s names,

              … For your natural child, one of these names must be yours

                                                  … For a stepchild, one of the names must be your spouse’s name.

·         Child’s name,

·         Birth date,

·         The signature of the attending physician or hospital official,

                    √ Your child’s social security number. If your child is Medicare eligible, the Medicare Health

                        Insurance Claim Number (HICN) is also required.

           

               (b) Adopted child

 

                   √ A copy of the child’s birth certificate or a birth registration notice (see above) and either:

·         A copy of the court order declaring the child’s adoption.  This decree must have a judge’s signature or a court stamp showing it has been filed; or               

·         If the adoption is not finalized, a copy of the application for adoption signed by all parties and by a representative of the court or state agency handling the adoption certifying that the child has been placed with you for adoption.

                    √ Your child’s social security number. If your child is Medicare eligible, the Medicare Health

                        Insurance Claim Number (HICN) is also required.

 

Note: If you are eligible to participate in the National Dental Plan and National Vision Plan, the Act has no impact to those plans.  Full-time student information is still required to maintain coverage under these plans if the unmarried child is age 19 but under 25 years of age.         

 

                  Need to submit any one of the following to show student status:

·         A copy of the child’s registration for the current semester                       

·         A copy of the class schedule for the current semester

·         A letter from the school’s registrar office certifying full-time enrollment

·         A receipt for tuition for the current semester

                                                            

                   The documentation must show:

·         Student’s name,

·         The number of credit hours for which the child is enrolled,

·         The semester for which the child is enrolled, and

·         The name of the school.

                   √ Your child’s social security number. If your child is Medicare eligible, the Medicare Health

                      Insurance Claim Number (HICN) is also required.

 

Your unmarried grandchild under the age of 19

Grandchild who is unmarried and under the age of 19 has his/her legal residence with you and is dependent for care and support mainly upon you and wholly, in aggregate, upon himself/herself, you, scholarships, and the like, and governmental disability benefits and the like. Please note: a step-grandchild is not eligible for coverage under the Plan.

 

How to show eligibility: Submit the following for:  

 

                     √ A copy of the child’s birth certificate or birth registration notice, and either:

·         A copy of the court order, if one has been issued, awarding  guardianship of the child to the employee, or                

·         In the absence of a court order, a current federal tax statement claiming the dependent, or

·         The Statement of Child’s Unmarried Status, Residence and Dependency form signed by you. 

                     √ Your grandchild’s social security number.  If your grandchild is Medicare eligible, the Medicare Health Insurance Claim Number (HICN) is also required.

 

Your unmarried grandchild between 19 and 25 Who are Full-Time Students

Grandchild who is:

 

                   √ A registered student in regular full-time attendance at an accredited school, and

                   √ Is dependent for care and support mainly upon you, and wholly, in aggregate, upon himself/herself,

                      you, and scholarships and the like, and

                   √ Have his/her legal residence with you.

 

How to show eligibility:  Submit the following:  

 

                   √ The same documents listed for “Your Unmarried Children under the age of 26” to show the parent-

                      child relationship, and

                   √ Any one of the following to show student status:

·         A copy of the child’s registration for the current semester                       

·         A copy of the class schedule for the current semester

·         A letter from the school’s registrar office certifying full-time enrollment

·         A receipt for tuition for the current semester

                                                             

                   The documentation must show:

·         Student’s name,

·         The number of credit hours for which the child is enrolled,

·         The semester for which the child is enrolled, and

·         The name of the school.

                    √ Your grandchild’s social security number. If your grandchild is Medicare eligible, the Medicare Health Insurance Claim Number (HICN) is also required.

 

Your unmarried children 26 and over or Your unmarried grandchildren 19 and over Who are Disabled

Who can be covered:  Your unmarried natural children, stepchildren, adopted children (including children placed with you for adoption), children who are Alternate Recipients under a Qualified Medical Support Order who are age 26 and over or your unmarried grandchildren who are age 19 or over who:

 

                  √ Are wholly dependent on you for care and support, mainly upon you, and wholly, in aggregate, upon

                     themselves, you, your spouse, and governmental disability benefits and the like, and

                  √ Have a permanent physical or mental condition that began prior to age 19, and                  

                  √ Are unable to engage in regular employment, and

                  √ Have their legal residence with you

 

How to show eligibility: Submit the following:  

 

                   √ The same documents listed for “Your children under the age of 26” or “Your unmarried grandchild

                       under the age of 19”  to show the parent-child relationship and

                   √ A Physician’s Statement of Disabling Condition form completed and signed by your child’s

                      Physician, and                      

                   √ Your child’s or grandchild’s social security number. If your child or grandchild’s is Medicare eligible, the Medicare Health Insurance Claim Number (HICN) is also required.