Page 4 - Genesis Care 2022 Benefit Guide

Medical &
ary
Additional
M edic al & Spending Voluntary A dditional
Spending
V
olunt
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A
ounts
401(k)
Benefits
Disability
Life & AD&D
nformation
I
Vision
C ont ents P r escription Dental Vision Accounts Life & AD&D Disability Benefits 401(k) Information C ont acts
Contents
Contacts
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Dent
Prescription
ELIGIBILITY DEPENDENT DOCUMENTATION (ONE OF THE FOLLOWING)
Legal Spouse
Marriage certificate
Most recent Federal Tax Return Form 1040
Team Members Form 4868 (if applicable)
Domestic Partner Affidavit of Domestic Partnership
All new hire team members scheduled to work at least 30 hours a week (must be notarized)
are eligible for benefits on the first of the month following or coinciding Historical samples of supporting documentation:
with the date of hire.
– Bank account statement
Dependents – Insurance document such as homeowners,
renters or automobile
– Mortgage or current lease document
You also have the option of covering eligible dependents on your – Valid vehicle registration
GenesisCare plans. All newly added dependents will require
verification documents, which include the following: * Historical samples must be within the last 12 months,
showing both employee and Domestic Partner
Dependent Child Birth certificate
Certificate of live birth (if under 2 months old)
Most recent Tax Return Form 1040
Legal adoption documents
Copy of Qualified Medical Child Support Order
(QMCSO)
Over-Age Affidavit of Over-Age Dependent (must be
Dependents 26-30 notarized and submitted yearly)
– Unmarried and Full-Time student
– Financially dependent over 50%
– Copy of full-time schedule/paid tuition and
copy of utility or housing bills
Incapacitated Affidavit of Over-Age Dependent (must be
notarized and submitted yearly)
– Totally disabled
– 50% financially dependent
– Documentation stating dependent is disabled,
date of disability and recent tax return
listing dependent
Team Members are responsible for verifying eligibility of dependents
upon enrollment and notifying the GenesisCare Benefits Center
immediately when dependents no longer meet eligibility criteria. Failure
to properly report loss of eligibility can result in denied claims, loss of
coverage and any additional fees will become member’s responsibility.

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