BENEFIT ELIGIBILITY, REQUIREMENTS AND QUALIFYING EVENTS PDF Print E-mail

EMPLOYEE ELIGIBILITY AND ADULT DEPENDENT COVERAGE

To be eligible for benefit coverage, you must be a full-time employee working at least 35 hours per week. Benefits are effective on the 1st of the month following the employee’s date of hire. Benefit elections must be completed through the self enrollment system within 30 days of your benefit effective date.  All qualifying event changes must be reported to your benefit coordinator and employees must use the self-enrollment system to process their qualifying event within 30 days of the date of event.

Eligible dependents include:

The employee’s spouse or domestic partner

The employee, spouse or domestic partner’s:

    • Natural children
    • Stepchildren
    • Children placed for adoption or legally adopted children
    • Children for whom either the employee, spouse or domestic partner is the legal guardian or custodian
    • Any children who, by court order, must be provided health care coverage by the employee or employee’s spouse or domestic partner.

Eligibility verification is only required once upon enrolling in the County of Summit Benefit Plan for employees and dependents. You have 30 days from your effective date to enroll or waive your health benefits using the online self enrollment system. (See Required Documents section.) 

QUALIFYING EVENTS

Marriage/Domestic Partnership

Addition of Spouse or Domestic Partner. The Division of Employee Benefits Department must be notified within 30 days of an employee marriage or domestic partnership in order for the spouse/domestic partner to be enrolled on the County plan. Remember to update beneficiaries at this time if you choose.

Divorce/Termination of Domestic Partnership/Legal Separation

Employees must notify their Benefit Coordinator or the Division of Employee Benefits Department within 30 days when there is a change in martial or relationship status, such as, in the case of divorce, dissolution, termination of domestic partnership or legal separation so that COBRA can be offered within 60 days. Remember to update beneficiaries at this time if you choose.

Birth/Adoption of a Child

    • The addition of a dependent. Employees must notify the Division of Employee Benefits Department within 30 days of the birth or adoption of a child in order for coverage to begin on the event date.

Birthday/Dependent Age Limit

  • Check your plan to see if your dependent children are eligible beyond age 26. If your dependent no longer meets the eligibility criteria, employees must notify the Division of Employee Benefits Department immediately so that COBRA can be offered within 60 days of their 26th birthdate.

REQUIRED DOCUMENTS (Required for new hires and qualifying events)

Employee/Spouse/Domestic Partner

  • Copy of Marriage License (Legal Copy)
  • Copy of Divorce Decree (if applicable)/Separation Agreement
  • Domestic Partner Affidavit Child and proof listed on affidavit

Child

  • Legible copy of birth certificate (not proof of birth letter) listing employees name
  • Copy of adoption or guardianship papers listing employee and child (if applicable)

Step-Child

  • Legible copy of birth certificate showing one or both parent’s name.

Please note: In addition to the birth certificate you must be able to prove the employee/step-child relationship (a valid birth certificate along with a valid marriage certificate listing both employee and spouse would prove the employee is tied to the step-child).

  • Copy of a valid court order showing who is responsible for providing healthcare coverage with one or both parent’s name.

In addition to the court order you must be able to prove the employee/step-child relationship (a valid court order along with a valid marriage certificate listing both employee and spouse would prove the employee is tied to the step-child) Federal law allows eligible dependent married or unmarried children to be covered until they reach age 26. 

Change of Address

  • Notify your Benefit Coordinator anytime there is a change of address.

IMPORTANT ENROLLMENT REQUIREMENTS

YOU MUST REPORT ALL CHANGES IN FAMILY STATUS TO THE DIVISION OF EMPLOYEE BENEFITS WTITHIN 30 DAYS OF THE OCCURRENCE. FAILURE TO REPORT CHANGES IN A TIMELY MANNER MAY RESULT IN DELAY OR DENIAL OF COVERAGE OR THE LOSS OF THE OPTION TO EXERCISE COBRA CONTINUATION. IF ELIGIBLE EMPLOYEES, SPOUSES, DOMESTIC PARTNERS AND DEPENDENTS ARE NOT ENROLLED ON THE BENEFIT PLAN WITHIN 30 DAYS OF THEIR ELIGIBILITY DATE, ENROLLMENT WILL BE DEFERRED TO THE NEXT OPEN ENROLLMENT PERIOD.

SPECIAL ENROLLMENT RIGHTS

You or your Eligible Dependent who has declined the coverage offered by County of Summit may enroll for coverage under this plan during any special enrollment period if you lose coverage or add a dependent for the following reasons, as well as any other event that may be added by federal regulations:

  • In order to qualify for special enrollment rights because of loss of coverage, you or your Eligible Dependent must have had other group health plan coverage at the time coverage under this plan was previously offered.If you or your Eligible Dependent has COBRA coverage, the coverage must be exhausted in order to trigger a special enrollment right. Generally, this means the entire 18, 29 or 36-month COBRA period must be completed in order to trigger a special enrollment for loss of other coverage.
    • If coverage was non-COBRA, loss of eligibility or the Group's contributions must end. A loss of eligibility for special enrollment includes:
    • Cessation of dependent status (such as attaining the maximum age to be eligible as a dependent child under the plan)
    • Death of an Eligible Employee
    • Termination of employment
    • Reduction in the number of hours of employment that results in a loss of eligibility for plan participation (including a strike, layoff or lock-out)
    • Loss of coverage that was one of multiple health insurance plans offered by an employer, and the Eligible Employee elects a different plan during an open enrollment period
    • An individual no longer resides, lives, or works in an HMO Service Area (whether or not within the choice of the individual), and no other benefit package is available to the individual through the other employer
    • A situation in which a plan no longer offers any benefits to the class of similarly situated individuals that includes the individual
    • A situation in which an individual incurs a claim that would meet or exceed a medical plan lifetime limit on all benefits (additional requirements apply)
    • Termination of an employee's or dependent's coverage under Medicaid or under a state child health insurance plan (CHIP)
    • The employee or dependent is determined to be eligible for premium assistance in the Group's plan under a Medicaid or CHIP plan
  • Enrollment must be supported by written documentation of the termination of the other coverage with the effective date of said termination stated therein. With the exception of items "j" (termination of Medicaid or CHIP coverage) and "k" (eligibility for premium assistance) above, notice of intent to enroll must be provided to Medical Mutual by the Group no later than thirty-one (31) days following the triggering event with coverage to become effective on the date the other coverage terminated. For items "j" and "k" above, notice of intent to enroll must be provided to Medical Mutual by the Group within sixty (60) days following the triggering event, with coverage to become effective on the date of the qualifying event. If you have a new dependent as a result of marriage, birth, adoption or placement for adoption, you may be able to enroll yourself and your Eligible Dependents provided that you request enrollment within thirty (30) days after the marriage, birth, adoption or placement for adoption.

To request special enrollment or obtain more information, contact Kym Komaschka, Division of Employee Benefits (330) 643-2621. 

 

 
 
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