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Employees - Extended Coverage - Non-Medicare Retirees - Medicare Retirees

Frequently Asked Questions on Eligibility

Q1.

Who is eligible to be covered as a dependent on my health plan?

A1.

Eligible dependents under the State Health Benefits Program include:

  • Legally married spouse*
  • Dependent child under age 23**
  • Disabled dependent child age 23 or older***

*A court order to provide coverage for a divorced spouse does not make the ex-spouse eligible for coverage under your health care plan.

** A dependent child must be unmarried, live at home or away at school and receive over one-half of his or her support from the employee. A dependent child is defined as: your biological child, your legally adopted child, your stepchild living with you in a parent-child relationship, a child placed in your home under a pre-adoptive agreement approved by the State Health Benefits Program, or a child placed in your home under a permanent custody court order. In the case of natural or adopted children, living at home may mean living with the other parent if the employee is divorced. With supporting documentation, the program may determine when other children may qualify as dependent children.

*** A disabled dependent child may continue coverage if the qualifying disability was diagnosed prior to the loss of eligibility due to age, and your request to continue coverage is approved by the health care plan. A disabled dependent child who later recovers is no longer eligible and must be removed from coverage.

Q2.

I need to change my plan or membership category. What should I do?

A2.

You may change your plan or membership each spring during the Open Enrollment period. These changes are effective on July 1 of each year.

There also are times during the year when you may make changes based on qualifying mid-year events (for a list of these events, see the Eligibility Rules or Enrolling or Making Changes). Most qualifying mid-year events allow you to change your membership. To make a change based on a qualifying mid-year event, you must provide notice within 31 days of the event.

There are currently two ways to give notice during Open Enrollment and for changes made during the year:

  • Visit EmployeeDirect on the Web.
  • Print the Enrollment Form from this Web site, or ask your agency’s Benefits Administrator for a copy of the form. Return it to your Benefits Administrator when completed.

Remember, most changes are effective the first of the month following receipt of the notice. For exceptions, see the Eligibility Rules.
If you change to the Kaiser Permanente plan, be sure to choose a primary care physician (PCP) to receive benefits.

Q3.

My wife and I are expecting a baby next month. I want to add the newborn to my health care coverage. What do I need to do?

A3.

Add the baby to your coverage by submitting notice within 31 days of the birth to your Benefits Administrator (see question 3 above). The effective date for the change will be the first of the month in which the child is born. If you are in the Kaiser Permanente HMO plan, it is essential to select a participating primary care physician (PCP) to coordinate the baby's care. If you fail to add the baby under either a statewide plan or the Kaiser Permanente HMO, there will be no coverage. There is one exception. If you are in Family membership, you may add the child at any time to receive benefits.

Q4.

We are thinking about adopting a two-year-old girl. Would she be eligible for my health plan?

A4.

Yes, as long as she is legally adopted. You must add the child to your health benefits membership within 31 days of the adoption date to have coverage from the first of the month in which the adoption occurred. See questions 1 and 4 above or the Eligibility Rules.

Q5.

I am a state employee. If I die while employed, how long will my dependents have health coverage?

A5.

Health coverage for a deceased state employee's dependents may continue in the active employee group for at least 30 days after the death of the employee. The deadline to enroll in continuation coverage varies according to the type of survivor. If you are the survivor of a state employee, contact the Benefits Administrator of the agency in which the employee worked to enroll in coverage. For additional information, consult the Survivor Benefits Retiree Fact Sheet #10 on the DHRM Web site and also available from your Benefits Administrator.

Q6.

If I leave state employment, am I still eligible for health benefits?

A6.

Yes. Under Extended Coverage, if you leave state employment, you and your covered family members may continue your state health benefits plan in certain situations at your own expense where coverage would otherwise end. Extended Coverage fulfills the same requirement that applies to non-government employees under the Consolidated Omnibus Budget Reconciliation Act of 1986 (COBRA). See your Benefits Administrator for more information or link to Extended Coverage Rules on this site.

Q7.

How long is my child eligible for coverage as a dependent on my health plan?

A7.

A child may be covered as a dependent under the State Health Benefits Program until the last day of the calendar year in which the child turns age 23. See question and answer #1.

Q8.

My son has a disability. Is he eligible for coverage as a dependent, and if so, for how long?

A8.

Yes. A child with a disability may be covered, just as any other child, until the last day of the calendar year in which he or she turns 23. If over age 23, the child may continue to be covered if incapable of self-support because of a severe physical or mental disability diagnosed while enrolled in your plan. There is an application process to continue the child's coverage. See the Eligibility Rules or contact your Benefits Administrator.

Q9.

If my spouse dies or I am divorced, at what point does the coverage end for my ex-spouse or deceased spouse?

A9.

A deceased or divorced spouse is no longer eligible for coverage as a dependent and must be removed from the State Health Benefits Program. Coverage will end on the last day of the month in which the spouse dies or the divorce is final. If the employee removes the ineligible dependent and reduces membership within 31 days of the event, any overpayment of premiums collected after the membership is reduced may be refunded.

Q10.

What does it mean to waive coverage in the State Health Benefits Program?

A10.

Waiving coverage means that you do not want to participate in the State Health Benefits Program. You may waive coverage each year during the annual Open Enrollment period or anytime during the year if you experience an event that is consistent with leaving the program. For example, if you are enrolled in the program and get married during the year, you can leave the program to enroll in your spouse's health benefits.

By the same token, once you have waived coverage, you may re-enroll during the annual spring Open Enrollment period or anytime during the year if you experience an event that is consistent with enrolling in the program. For example, if you have waived coverage and get married during the year, you can re-enroll and bring all eligible family members into the program as your dependents.

Q11.

Who should I contact if I have other questions about eligibility?

A11.

The best resource for your personal questions is your agency's Benefits Administrator. He or she can assist you with enrollment, plan or membership changes, eligibility requirements and other health benefits information. If you do not know who is responsible for this function at your agency, contact your agency's Human Resources Office.

In addition to your Benefits Administrator, other sources of information on health benefits eligibility include your health plan's Member Handbook and this Web site.

For more details about eligibility for the State Health Benefits Program, consult your plan's Member Handbook, see the Eligibility Rules on this site, or contact your agency's Benefits Administrator.