PE-628 Spouse Eligibility Verification Form

Dependent Change Form
Directions: Use this form if you currently have family coverage and want to add an additional dependent, or drop a
dependent and still maintain coverage for your other dependent(s). If you want to add or drop family coverage, complete
a Basic Application. If you are making a clinic change, contact the plan directly. If your change involves legal
documentation (such as an adoption or a divorce), include a copy of the legal document with this form. For other eligibility
rules, please reference the Dependent Eligibility section on the back of this form. Completely fill out this form and return
it to: MMB, Employee Insurance Division, 658 Cedar Street, St. Paul, MN 55155 or fax this form to: 651-296-5445. For
questions, call 651-355-0100.
Name
Employee/COBRA ID Number
(Last, First, Middle Initial)
Work Phone
Home Phone
Current Health Plan
Current Dental Plan
Effective Date of Change
Reason for Change
General: to add or drop a dependent, please complete this section and, if applicable also complete a section below:
Add/
Drop
Name and Address
Check if address is same as employee,
otherwise list address below
Relationship to
employee
Sex
Date of
Birth
SSN
Health Clinic
Number*
*A search for your health clinic’s number can be found at: http://www.doer.state.mn.us/insdir/provider_directory.aspx
Spousal Eligibility: to add or drop your spouse, please provide the following information:
Marital Status
Yes
No
Yes
No
Yes
Yes
No
No
Married
Divorced
Do you have common dependent children?
Yes
1. Is your spouse employed full-time by an employer with 100 or more employees?
2. Is your spouse eligible to receive health insurance from his/her employer?
3.
4.
No
Has your spouse chosen to receive from his/her employer:
a) cash instead of health insurance, or
b) credit towards the purchase of some other employee benefit instead of health insurance, or
c) cash and a health insurance plan with a deductible of $750 or more instead of a plan with a smaller
deductible? (This includes a high deductible health plan.)
Does your spouse receive insurance benefits as an employee of the State of Minnesota or another
organization participating in the State Employee Group Insurance Program (SEGIP)?
Your spouse is NOT eligible for coverage as a dependent on your health insurance if:
(a) you answered “yes” to questions, 1, 2, and 3 OR (b) you answered “yes” to question 4.
NOTE: If you have an MDEA (FSA) your spouse is may not be eligible for an health savings account (HSA). If your spouse has a high
deductible health plan, that plan may prohibit your spouse from certain SEGIP coverage. Please contact your spouse’s employer to
understand these eligibility rules.
I have read the above statements relating to my spouse’s eligibility for health insurance and certify that:
My spouse is eligible
PE-00628-07 (10/08)
My spouse is not eligible
Dependent Over 19: to add or drop a dependent over age 19, please provide the following additional information:
Name of Dependent
Name of School
Date Student First Enrolled: Month
Is Student Full-time
Yes
No
Child’s Marriage Status
Single
Married
Child is Disabled
Yes
No
Year
Date Student Expects to Graduate
Divorced
Last Date Attended
Date of Marriage or Divorce
Your health plan will verify student eligibility on an on-going basis. Failure to reply to their inquiry will result in the student’s
termination of coverage. Members are required to notify SEGIP if your dependent has a change in status.
Complete one copy of this section for each dependent over age 19 you are requesting to enroll.
Medicare Enrolled: if you or your dependent is enrolled in Medicare, please provide the following information:
Name of Medicare enrolled member
Does the covered member have Medicare Hospital Coverage (Part A)?
Yes
No
If yes, effective date
Medicare #
Does the covered member have Medicare Hospital Coverage (Part B)?
Yes
No
If yes, effective date
Medicare #
Reason for Medicare coverage
Age
Disability
End stage renal disease
If there is a change in my dependent’s eligibility for insurance, I understand that it is my responsibility to notify the Employee
Insurance Division in writing of such a change. By using this form to add dependents, I verify that my dependents are eligible for
coverage according to the dependent eligibility rules. Insurance claims incurred by ineligible dependents will be denied.
Employee’s Signature
Date
Dependent Eligibility
Spouse. The spouse of an eligible employee may be covered unless he/she is legally separated from the employee. The other spouse
eligibility rules are detailed in the “Spousal Eligibility” section above.
Children and Grandchildren. An eligible employee’s unmarried dependent children and unmarried dependent grandchildren through
age 18 or through age 24 if he/she is a full-time student at an accredited educational institution. A disabled child may be covered
regardless of age or marital status if the child if he/she meets the qualifications listed below.
“Dependent child” includes an employee’s biological child, child legally adopted by or placed for adoption with the employee, foster
child, and step-child. To be considered a dependent child, a step-child or foster child must maintain residence with the employee and be
dependent upon the employee for his/her principal support and maintenance. To be considered a dependent child, a foster child must be
placed by the court in the custody of the employee. You must complete a Foster Child Verification form to verify eligibility. The form
can be obtained by calling SEGIP at 651.355.0110.
“Dependent grandchild” includes an employee’s grandchild placed in the legal custody of the employee, grandchild legally adopted by
the employee or placed for adoption with the employee, or grandchild who is the dependent child of the employee’s unmarried
dependent child. Grandchildren placed in the employee’s legal custody and those who are the dependent child of the employee’s
unmarried dependent child must be dependent upon the employee for the principal support and maintenance and live with the employee.
“Disabled dependent,” is a child or grandchild, regardless of age or marital status, who is incapable of self-sustaining employment by
reason of mental or physical disability and is chiefly dependent on the employee for support. The disabled dependent is eligible for
coverage as long as he/she continues to be disabled and dependent, unless coverage terminates under the contract. The disability status is
determined by the member’s health plan.
Dependent Coverage Restrictions. If both spouses work for the State or another organization participating in SEGIP, either spouse, but
not both, may cover their eligible dependent children or grandchildren. This restriction also applies to two divorced, legally separated, or
unmarried employees who share legal responsibility for their eligible dependent children. If both spouses work for the State or another
organization participating in SEGIP, neither spouse may be covered by the other as a dependent by the other unless one is not eligible
for a full employer contribution as defined in the contracts.
PE-00628-07 (10/08)
Ex-Spouse Policy
When an employee divorces his/her spouse state law requires that the ex-spouse be allowed to continue as a SEGIP member. To be
eligible the ex-spouse must be on the employee’s family policy at the time of the divorce (a spouse may not be removed from the plan in
anticipation of a divorce). If the employee has claimed no dependents other than the ex-spouse at the time of the divorce, or when all
children in common lose their eligibility, the employee may cancel family coverage and the ex-spouse will remain in SEGIP as a paying
member. The ex-spouse continues to be covered even if the employee remarries; an employee may cover both the current and ex-spouse.
Newly hired employees and newly insurance eligible employees may not cover an ex-spouse. The ex-spouse will lose eligibility if either
of the following occur:
1. The ex-spouse acquires other group health insurance that has no pre-existing condition exclusion.
2. The ex-spouse requests to be taken off the employee’s policy.
Minnesota Management & Budget
NOTICE OF COLLECTION OF PRIVATE DATA
Minnesota Management & Budget administers the State Employee Group Insurance Program (SEGIP). This notice
explains why we may request information (data) about you, your dependents and beneficiaries, how we will use it, who will
see it, and your obligation to provide that information.
What information will we use?
We will use the information you provide us at this time, as well as information you have previously provided us about
yourself, your dependent(s), and/or your beneficiary. If you provide any information about yourself or your dependent or
beneficiary that is not necessary, we will not use it for any purpose.
SEMA4, the information system used to administer employee benefits, contains required information fields that may not be
necessary for us to process your request. We do not need the gender or marital status for your beneficiary designation, so
you may enter “unknown” in these fields. We only need your dependent’s date of death to process a death benefit claim or
to discontinue the dependent’s coverage due to his or her death. Student status and disability status are needed only to
determine eligibility for insurance continuation for your dependent. We only need your dependent’s social security number
to offer insurance continuation or process a death benefit.
Why we ask you for this information?
We ask for this information to process your request to add or change coverage for yourself, your dependent or a beneficiary.
The requested information helps us to determine eligibility, to identify you and your dependents and beneficiaries, and to
contact you or your dependents and beneficiaries. We use the information so that we can successfully administer SEGIP,
including analyzing unidentifiable aggregate data to develop new programs and ensure current programs are effectively and
efficiently meeting member needs. We may ask for information about you that we have already collected, including all or
part of your social security number, in order to ensure we are matching you to the correct change request or other insurance
benefit transaction.
Do you have to answer the questions we ask?
You are not legally required to provide any of the information requested.
What will happen if you do not answer the questions we ask?
If you do not answer these questions, the insurance benefit transaction you requested for you or your dependent or other
insurance benefit transaction may be delayed or denied.
Who else may see this information about you and your dependents and beneficiaries?
We may give information about you and your dependents and beneficiaries to the insurance carrier you have chosen,
SEGIP’s representatives, vendors, and actuary, the Legislative Auditor, the Department of Health, any law enforcement
agency or other agency with the legal authority to the information, and anyone authorized by a court order. In addition, the
parents of a minor may see information on the minor unless there is a law, court order, or other legally binding instrument
that blocks the parent from that information. We can use or relates this information only as stated in this notice unless you
give your written consent to authorize release of the information to another person/entity, or if Congress or the Minnesota
Legislature passes a law allowing or requiring us to release the information or to use it for another purpose.
PE-00628-07 (10/08)
Minnesota Management & Budget
NOTICE OF COLLECTION OF PRIVATE DATA
We ask for this information to process your request to add or change coverage for yourself, your dependent or beneficiary.
The requested information helps us to determine eligibility, identify you and your dependents and beneficiaries, and contact
you or your dependents and beneficiaries. We use the information so that we can successfully administer SEGIP, including
using unidentifiable, aggregate data to develop new programs and ensure current programs effectively and efficiently meet
member needs. We can use or release this information only as stated in this notice unless you give us your written
permission to release the information or to use it for another purpose.
You are not legally required to provide us any of this information and you may refuse to provide the information. However, if
you do not provide us the requested information, the insurance transaction you requested for you or your dependent or
other insurance benefit transaction may be delayed or denied.
We may give information about you and your dependents and beneficiaries to the insurance carrier you have chosen,
SEGIP’s representatives, vendors, and actuary, the Legislative Auditor, the Department of Health, any law enforcement
agency or other agency with the legal authority to the information, and anyone authorized by a court order. In addition, the
parents of a minor may see information on the minor unless there is a law, court order, or other legally binding instrument
that blocks the parent from that information. This information may also be used or released if Congress or the Minnesota
Legislature passes a law allowing or requiring us to release the information or to use it for another purpose.
PE-00628-07 (10/08)