Page 5 - Zelis 2022 Executive Benefits Guide

Qualifying Life Events
Other than during the annual open enrollment period, you may only change your benefit elections and covered dependents within 30 days following a qualifying life event.
Qualifying Life Events Include:
• Birth or adoption of a child by you or your spouse.
• Marriage, legal separation, annulment, or divorce of the associate, if you have met the requirements and criteria
established by the plan for covering your Domestic Partner or eligible dependents.
• Death of your spouse and/or dependent.
• Dependent’s loss of eligibility (see definition of Eligible Dependents).
• Termination or commencement of employment of your spouse or your dependent with health care coverage.
• You or your spouse becomes eligibile for Medicare benefits.
• Such other events as the plan administrator determines to be permitted under IRS Section 125 or any other applicable guidelines issued by the Internal Revenue Service.
Dependents who are added as a result of a qualifying life event are covered as shown in the table below, provided that enrollment for the dependent is requested and supporting documentation provided within 30 days from the date of the event.
Qualifying Event
Marriage
Divorce, legal separation or annulment
Birth, Adoption, placement for adoption, foster child, or legal guardianship of a child
Death of your spouse or dependent child
Your dependent child reaches maximum age for coverage
Significant change in or cost of your spouse’s health coverage due to spouse’s employment, including open enrollment
Spouse or covered dependent obtains coverage in another group health plan
Loss of other coverage, including COBRA coverage
CHIP Special Enrollment* – loss of eligibility for coverage under a state Medicaid or CHIP program, or eligibility for state premium assistance under Medicaid or CHIP
Domestic Partner and dependents or Domestic Partners
Effective Date
First of the month following the date of the event
Date of event
Date of event
First of the month following the date of the event
First of the month following the date of the event
First of the month following the date of the event
First of the month following the date of the event
Forms that must be received within 30 days
Marriage certificate
Divorce decree
Birth certificate, hospital discharge papers, adoption decree
Death certificate
Communication from spouse’s
employer regarding change in health coverage or open enrollment announcement
Proof of enrollment in another group health plan, such confirmation of enrollment, screen shot
Notice of termination (if advance notice is given)
Notice from state agency responsible for Medicaid must be submitted within sixty (60) days of loss of eligibility or eligibility date
Domestic Partner Affidavit
First of the month following the date of the event
First of the month following the date of the event
First of the month following the date of the event
Executive Employees 5