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State Health Plan Required Documentation for Qualifying Life Events & Dependent Eligibility
Section 125 of the Internal Revenue Code (IRS) provides guidelines for a Qualifying Life Event (QLE) status change. Employees must
upload documents into eBenefits or provide supporting documentation to their Health Benefits Representative to verify the QLE in
accordance with State Health Plan rules within 30 days of the QLE or 60 days of becoming entitled to or losing eligibility for Medicaid
or the Children’s Health Insurance Program (CHIP). Employees are also required to provide documentation of a dependent’s
eligibility when added to the Plan due to a New Hire event, a QLE, or during Open Enrollment. Please refer to the chart on page 3 for
the list of acceptable documents.
Qualifying Life Events
Required Documentation from Employee
Adoption
Refer to chart on page 3.
Birth
Refer to chart on page 3.
Court Order
(Court Orders may only be used to add
dependents and cannot be used to drop
dependents.)
Refer to chart on page 3.
Death of a Dependent
Death Certificate / Obituary
Dependent Gains Medicaid Coverage
Written notification showing effective date of Coverage or ID card with an
effective date.
Divorce
Divorce Decree / Judgment
Enroll in 12-Month Reduction in Force (RIF)
See your HBR to process event. HBR must submit an exception and materials
provided by member to demonstrate the cost increase. Refer to chart on
page 2 for additional requirements for adding a dependent.
Guardianship or Legal Custody of a Child
Refer to chart on page 3.
Legal Separation
Separation Agreement or affidavit (sworn, notarized statement) from
employee to validate legal separation.
Loss of Medicaid or CHIP Coverage
Written notification showing termination date and current notification
date. Refer to chart on page 2 for additional requirements for adding a
dependent.
Loss of Other Coverage
Certificate of creditable coverage or written notification from employer
listing affected members and the effective date. Refer to chart on page 2 for
additional requirements for adding a dependent.
If you or your dependents change your country of permanent residence by
moving to or from the United States a signed written statement
documenting the event and proof of the date you or your dependent
changed your county of permanent residence is required.
Please note: Losing individual coverage doesn’t qualify as a qualifying life
event if you voluntarily drop coverage, if you lose coverage because you
didn’t pay your premiums, or if you lose coverage because you didn’t provide
required documentation when asked for more information.
Marriage (Employee)
Refer to chart on page 3.
Military Leave
See your HBR to process event. Requires copy of Active Duty
documentation, including date active duty begins.
Newly Eligible for Coverage
Refer to chart on page 3 for adding dependents.
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Now Eligible for Other Coverage
Written notification from employer, Medicaid or CHIP showing effective
date or Insurance Card with an effective date and notification date.
If you or your dependents change your country of permanent residence
by moving to or from the United States a signed written statement
documenting the event and proof of the date you or your dependent
changed your county of permanent residence is required
Return from Family and Medical Leave (FMLA)
Refer to chart on page 3 for additional requirements for adding a dependent.
Return from Leave of Absence
Refer to chart on page 3 for additional requirements for adding a dependent.
Return from Military Leave
Requires copy of Active Duty documentation that includes date active duty
ends. Refer to chart on page 3 below for additional requirements when
adding a dependent.
Significant Change in Cost of Existing Coverage
See your HBR to process event. HBR must submit an exception and materials
provided by member to demonstrate the cost increase. Refer to chart on
page 3 for additional requirements for adding a dependent.
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State Health Plan Required Documentation for Qualifying Life Events & Dependent Eligibility
Dependent Verification Requirements
Required Documentation from Employee
Legal Married Spouse
Defined as legally married spouse and includes same
and opposite gender spouses.
•
Page 1 of subscriber’s most recent Federal Income Tax Return* (1040, 1040A
or 1040EX) as filed with the IRS, listing the spouse (may be joint or separate
as long as the spouse is listed) & signed page or official taxtranscript
OR
Official Marriage Certificate** PLUS one of the following to show current joint
tenancy:
•
Current joint lease or lease showing residency
•
Current joint of one of the below, or two separate of any of the below
showing the same address, one listing the employee and the other listing
the spouse:
•
Monthly bill or financial statement
•
Current year’s property/vehicle tax or registration bill
•
Current insurance statement or bill
•
Designation of the spouse as a primary beneficiary of the employee’s
life insurance or retirement benefits and listing primary residence
Biological Child under the age of 26
Defined as your biological child and Includes child of
same gender spouse.
•
Page 1 of subscriber’s most recent Federal Income Tax Return* (1040,
1040A or 1040EX) as filed with the IRS, listing the child as dependent &
signed page or official tax transcript
OR
•
Birth Certificate or Mother’s Copy with subscriber’s name listed asparent
•
Verification of Facts within 6 months of birth
Stepchild under the age of 26
Defined as your stepchild.
•
Page 1 of subscriber’s most recent Federal Income Tax Return* (1040,
1040A or 1040EX) as filed with the IRS, listing the step child as dependent &
signed page or official tax transcript
OR
•
Birth Certificate or Mother’s Copy with subscriber’s name listed as parent
AND Marriage Certificate (indicating employee’s spouseis married to
employee)
•
Verification of Facts within 6 months of birth
Adopted Child under the age of 26
Child you have legally adopted or has been placed
with you for adoption or in anticipation of legal
adoption.
•
Page 1 of subscriber’s most recent Federal Income Tax Return* (1040,
1040A or 1040EX) as filed with the IRS, listing the step child or adopted child
as dependent & signed page or official tax transcript
OR
•
International adoption papers from country of adoption
•
Official adoption agreement for the dependent being added from the adoption
agency showing intent to adopt
Foster Child under the age of 26
Defined as your foster child or child placed with you for
foster care.
•
Official State Agreement for placement specific to the dependent(s)being
added
Child under the age of 26 for whom the Subscriber is
Court Appointed Guardian
Defined as a child for whom the subscriber has become
the child’s court-ordered guardian or has been
awarded legal and physical custody of the child,
pursuant to a valid court order.
•
Page 1 of subscriber’s most recent Federal Income Tax Return* (1040,
1040A or 1040EX) asfiled with the IRS, listing the child as a dependent &
signed page or official tax transcript
OR
•
Court documents signed by a judge verifying legal custody of the child
Child under age 26 for whom the Plan has received a
Qualified Medical Child Support Order (QMCSO)
Defined as any recognized child(ren) you are required
to cover under the Plan due to a Qualified Medical
Child Support Order (QMCSO).
•
Court documents signed by a judge
•
Medical support orders issued by a State
*Most recent tax form from the previous year. If not available, the year prior will be accepted along with a letter indicating you
have an extension. **Employees that have been married less than a year are able to submit a marriage certificate only.
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Paternity Results
Birth Certificate Application
Immunization Records
Unacceptable Documentation for Dependents:
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Tax Form Signature Page
Qualified Medical Child Support Order
Acceptable Documentation for Dependents:
Tax Transcript
1040 Tax Form
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Verification of Facts for Dependents
under 6 months of age
Affidavit Out of Wedlock
Lease Agreement Lease Agreement
Confirmation Statement
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Legal Separation w/ Notary
Beneficiary Designation
Adoption Decree
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Medicaid Termination Letter
Property/Vehicle Tax
Medicaid Approval Letter Court Appointed Guardian
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Loss of Other Coverage Letter
Now Eligible for Other Coverage Letter
Insurance Card w/ Effective Date
Monthly Bill
Divorce Decree
