Page 33 - Open Enrollment Guide Sample
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Dependent Coverage
1. The Employee’s lawful spouse.
2. Adult children up to age 26 regardless if they are an income tax dependent,
student, married, or residing with the team member.
3. An Employee who has children qualiied for coverage under a Qualiied Medical
Child Support Order must be covered by the Employee.
4. Coverage will also be extended for Dependent Children, regardless of age who are
mentally, or physically handicapped, classiied as disabled before the limiting age
of 26.
[Client Name] will also allow a special enrollment opportunity if you or your eligible
dependents either:
Lose Medicaid or Children’s Health Insurance Program (CHIP) coverage because
you are no longer eligible or,
Become eligible for a state premium assistance program under Medicaid or CHIP.
For these new special enrollment opportunities, you will have 60 days—instead of
30—from the date of the Medicaid/CHIP eligibility change to request enrollment in the
[Client Name] group health plan. Note that this new 60-day extension doesn’t apply to
enrollment opportunities other than the Medicaid/CHIP eligibility change.
Eligible But Do Not Enroll
If you do not enroll at the time you are eligible, you can elect to enroll
within 30 days of you experiencing a life event.
Creditable Coverage
If enrolling due to loss of coverage, you must provide proof within 30 days
of loss of coverage for each person you are enrolling.
Please fax or mail the Creditable Coverage Certiicates to Cheryl Johnson in
the Beneits Department. The Beneits fax number is
314-428-7798.
(In accordance with the Health Insurance Portability and Accountability Act of 1996,
we are required to provide you with this notice pertaining to special enrollment
periods in the plan.)
2016 Open Enrollment
Dependent Coverage
1. The Employee’s lawful spouse.
2. Adult children up to age 26 regardless if they are an income tax dependent,
student, married, or residing with the team member.
3. An Employee who has children qualiied for coverage under a Qualiied Medical
Child Support Order must be covered by the Employee.
4. Coverage will also be extended for Dependent Children, regardless of age who are
mentally, or physically handicapped, classiied as disabled before the limiting age
of 26.
[Client Name] will also allow a special enrollment opportunity if you or your eligible
dependents either:
Lose Medicaid or Children’s Health Insurance Program (CHIP) coverage because
you are no longer eligible or,
Become eligible for a state premium assistance program under Medicaid or CHIP.
For these new special enrollment opportunities, you will have 60 days—instead of
30—from the date of the Medicaid/CHIP eligibility change to request enrollment in the
[Client Name] group health plan. Note that this new 60-day extension doesn’t apply to
enrollment opportunities other than the Medicaid/CHIP eligibility change.
Eligible But Do Not Enroll
If you do not enroll at the time you are eligible, you can elect to enroll
within 30 days of you experiencing a life event.
Creditable Coverage
If enrolling due to loss of coverage, you must provide proof within 30 days
of loss of coverage for each person you are enrolling.
Please fax or mail the Creditable Coverage Certiicates to Cheryl Johnson in
the Beneits Department. The Beneits fax number is
314-428-7798.
(In accordance with the Health Insurance Portability and Accountability Act of 1996,
we are required to provide you with this notice pertaining to special enrollment
periods in the plan.)
2016 Open Enrollment
