Adding Dependents to Your Coverage

To add dependents to your Health Plan coverage, the dependents must meet the Health Plan’s definition of eligible dependents, and you must pay the applicable premium.

Under earned coverage, there is no premium to maintain participant-only coverage. The premium to add dependents to your Health Plan earned coverage is as follows:

• $390 semi-annually or $780 per year for one dependent
• $600 semi-annually or $1,200 per year for two or more dependents

If you are on COBRA or self-pay coverage, please refer to the premium schedule identified in your open enrollment letter or contact the Health Plan’s Eligibility Department at (877) 866-2200, ext. 502.

Eligible Dependents

The following are eligible dependents:

• your lawful spouse
• your children under age 26 (until the end of the month they turn age 26)
• your disabled children age 26 and older

Required Documentation for Enrolling Dependents

• Dependent Enrollment FormThis form must be submitted to the Health Plan when enrolling new dependents under your coverage and when re-enrolling dependents after a break in coverage.
• Documents Verifying Eligible Dependent StatusTo verify dependent eligibility for coverage, you must send the Health Plan office the appropriate documentation as described below:
  

  Spouse	A copy of your certified marriage certificate. When the certified marriage certificate is not yet available, you may send an uncertified copy as temporary documentation, but you must submit a copy of the certified marriage certificate within six months of your date of marriage. If you have been married for more than one year, you will also need to submit one of the following documents that is not older than six months, showing your spouse’s name, your own name and a current address: A copy of the front page of your most recent filed federal tax return; or A copy of a joint household bill, such as gas, water, or electric; or A copy of a joint bank/credit account statement; or A copy of your joint mortgage/lease; or A copy of your joint insurance policy. The financial information on the forms above can be redacted.
  Divorce	A copy of the final divorce decree or judgment of dissolution of marriage. In order for your ex-spouse to be eligible for COBRA coverage due to loss of dependent status, the Health Plan must be notified within 60 days from the date of divorce.
  Birth	A copy of the child’s certified birth certificate. When the certified birth certificate is not yet available, you may send an uncertified copy as temporary documentation, but you must submit a copy of the certified birth certificate within six months of your child’s birth.
  Adoption/Guardianship	A copy of the adoption or guardianship documents.
  Physical or Mental Disability	Proof that you are providing at least half of the dependent’s support. For children age 18 and over, you must also remit documentation on an annual basis supporting a current Social Security disability award on behalf of the child.

For more information covering dependents, refer to the March 2020 Health Plan Summary Plan Description beginning on page 25.