Virginia Department of Human Resource Management

Health Benefits

Eligibility for Coverage

Who is eligible

You are eligible for coverage if you are a part-or full-time, salaried, classified employee; or a regular, full-time or part-time salaried faculty. Your eligible dependents also may be covered. Retirees, long-term disability participants and survivors may also be eligible for coverage. Contact your agency’s Benefits Administrator for assistance.

You may choose your type of membership as follows:

  • Employee/retiree single – to cover yourself only
  • Employee/retiree plus one – to cover yourself and one eligible dependent
  • Family – to cover yourself and two or more eligible dependents

Members who cover ineligible persons may be removed from the program for a period of up to three years. In addition, the member will be responsible for claims paid in error and will be unable to reduce health benefits membership except within 60 days of the dependent’s loss of eligibility or during Open Enrollment.

Note: No person can be enrolled in more than one state health benefits plan under any circumstances. If it is determined that a person is covered in error, the plan has the right to take corrective action.

Dependent Eligibility Definitions and Required Documentation
Effective July 1, 2023
Dependent: Spouse

Eligibility Definition:

The marriage must be recognized as legal in the Commonwealth of Virginia.

Note: Ex-spouses will not be eligible, even with a court order.

Documentation Required

  • Photocopy of certified or registered marriage certificate, and
  • Photocopy of the top portion of the first page of the employee’s most recent Federal Tax Return that shows the dependent listed as “Spouse”. NOTE: All financial information and Social Security Numbers can be redacted.
Dependent: Natural or Adopted Son/Daughter

Eligibility Definition:

A son or daughter may be covered to the end of the year in which he or she turns age 26.

Documentation Required

  • Photocopy of birth certificate or legal adoptive agreement showing employee’s name (Note: If this is a legal pre-adoptive agreement, it must be reviewed and approved by the Office of Health Benefits.)
Dependent: Stepson or Stepdaughter

Eligibility Definition:

A stepson or stepdaughter may be covered to the end of the year in which he or she turns age 26.

Documentation Required

  • Photocopy of birth certificate (or adoption agreement) showing the name of the employee’s spouse; and
  • Photocopy of marriage certificate showing the employee and dependent parent’s name and
  • Photocopy of the most recent Federal Tax Return that shows the dependent’s parent listed as “Spouse”.
Dependent: Other Female or Male Child

Eligibility Definition

An unmarried child in which a court has ordered the employee (and/or the employee’s legal spouse) to assume sole permanent custody may be covered until the end of the year in which he or she turns age 26 if:

 

  • The principal place of residence is with the employee;
  • They are a member of the employee’s household;
  • They receive over one-half of their support from the employee, and
  • The custody was awarded prior to the child’s 18th birthday.

Documentation Required

  • Photocopy of the Final Court Order granting permanent custody with presiding judge’s signature.
Dependent: Other Female or Male Child -Exception

Eligibility Definition

If the employee (or employee’s spouse) shares custody with their minor child who is the parent of an “other female or male child”, then that “other child” may also be covered if the other child, the minor child (who is the parent), and the employee’s spouse (if applicable)
  • All live in the same household as the employee
  • Both children are unmarried
  • Both children received over one-half of their support from the employee.

Documentation Required

  • Photocopy of the other child’s birth certificate showing the name of the minor child as the parent of the other child
  • Photocopy of the birth certificate (or adoptive agreement) for the minor child showing the name of the employee, and
  • Photocopy of the Final Court Order with presiding judge’s signature.
Dependent: Incapacitated Adult Dependents

Eligibility Definition

The employee’s adult children who are incapacitated due to a physical or mental health condition may be covered beyond the end of the year in which they turn age 26 if:
  • They are unmarried,
  • Reside full-time with the employee, the other natural/adoptive parent or in a facility receiving residential support services,
  • The employee provides more than half of the dependent’s support,
  • They are deemed incapacitated prior to the end of the year in which they reach age 26, and
  • They have maintained continuous coverage under an employer-sponsored plan of the employee (or the other natural/adoptive parent).

Documentation Required

  • Photocopy of birth certificate or legal adoptive agreement showing employee’s name.
  • In the case of a new employee, copy of the HIPAA Certificate showing prior employer-sponsored coverage.
  • Other medical certification and eligibility documentation as needed.
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