Page 4 - PDF QR Code Book

The Qualified Changes of Status below are allowable benefit changes made in accordance with
the Consistency Rule, Department of Labor Regulations, and the Employer’s Plan Document.

**Consistency Rule: In all cases, any election change because of any change in status must be
on account of and correspond with a change in status that affects eligibility for coverage
under the plan. For example, if the change in status is the employee’s divorce, annulment or
legal separation from a spouse, the death of a spouse or dependent child, or a dependent
ceasing to satisfy the eligibility requirements for coverage, an employee’s election to cancel
health coverage will apply only to the spouse involved in the divorce, annulment or legal
separation, the deceased spouse or dependent child, or the dependent that ceased to
satisfy the eligibility requirements.

For a complete description of allowable election changes associated with Changes in Status,
please refer to the Plan Document.

1. What if I get divorced?

MEDICAL/DENTAL/VISION INSURANCE: If your spouse and stepchild(ren), if applicable, are
on your medical, dental, vision, and/or voluntary life insurance, your spouse and
stepchild(ren) will lose coverage the date the divorce is final and be offered COBRA. If you
are on your spouse’s insurance and lose coverage, you can elect coverage effective the day
following loss of coverage. These changes must be reported within 60-days of the divorce
being finalized.

Necessary documentation: Copy of the divorce decree containing judge’s signature and
date. If the divorce decree requires you to provide medical, dental and vision coverage for
your biological child(ren), you must provide a copy of the page(s)from the divorce decree
regarding this. You will need to submit a copy of the divorce decree within 60-daysto the HR
Department.

Action Required: You have 60-days from the date of divorce to remove your spouse from
your medical, dental, vision, and/or voluntary life insurance plan(s), and to elect coverage if
you were insured through your spouse, and/or make changes to the voluntary life
insurance. If you do not submit the appropriate paperwork within the 60-day deadline,
you may be required to wait until the annual Open Enrollment to make these changes. Be
sure to update your beneficiary designation.
Note: When you remove your ex-spouse from your medical, dental and vision insurance
due to a divorce, your ex- spouse will be entitled to COBRA; paperwork will be sent to the
last known address on file, unless you advise the Human Resource Department otherwise.

2. What if my Spouse has a change in employment, resulting in loss or eligibility of coverage?

MEDICAL/DENTAL/VISION INSURANCE: If your spouse has a change in employment and
loses coverage, you may request to have your spouse, and any other eligible dependent(s)
that have lost coverage be added to your coverage. If your spouse is newly eligible for
insurance through his/her employer, you may cancel your current medical, dental and/or
vision coverage or remove covered dependent(s).

4