Health Plan Required Documents 2016

BLUE CROSS BLUE SHIELD APPLICATION AND POLICY CHANGE FORM REQUIRED DOCUMENTS FOR
NEW EMPLOYEES
OR
CURRENT EMPLOYEES MAKING CHANGES
CURRENT INSURANCE COSTS AS OF 1-1-2016
$28.14 PER MONTH EMPLOYEE ONLY
SINGLE COVERAGE - $12.99 PER PAY FOR EMPLOYEES ON 26 PAYS
$16.88 PER PAY FOR EMPLOYEES ON 20 PAYS
$86.27 PER MONTH EMPLOYEE + 1 OR MORE
FAMILY COVERAGE - $39.82PER PAY FOR EMPLOYEES ON 26 PAYS
$51.76 PER PAY FOR EMPLOYEES ON 20 PAYS
1. Employees electing single coverage
No documentation is required
2. Spouse - To verify the eligibility of your legal spouse, you must submit a COPY of..
Legal Marriage Certificate
AND
Your Most Recent Federal Tax Return. Send the first two pages of your most recent 1040 federal
income tax return, showing filing status as well as your and your spouse’s signatures and
the filing date. If you file separately, please send the first two pages of your spouse’s most
recent 1040 federal income tax return. Please black out any personal financial information
such as income and account numbers. Do not send any tax return schedules OR W-2’s.
E-filers can send in their printed e-filed copy indicating it was filed electronically with a PIN, or
the Form 8453 U.S. Individual Income Tax Transmittal for an IRS e-file Return, along with
the tax return if a PIN was not used (in lieu of signatures).
OR
Legal Separation OR Divorce Decree. If dropping spouse from your plan, a copy of the Legal
Separation or Divorce Decree showing such date must be provided.
3. Civil Union Partner – To verify the eligibility of your civil union partner, you must submit a COPY of..
Civil Union Certificate
AND
Supporting Financial Documentation. You must provide evidence of a current, mutual financial
obligation shared between the employee and civil union partner. Examples:
Your most recent joint Illinois state income tax return,
OR
TWO of the following documents: current mortgage statement, current lease, current
property tax assessment for real property, auto loan, homeowners/renters or auto insurance
policy, brokerage or investment account. Please black out any personal financial
information such as income and account numbers.
4. Biological Child (under age 19) – To verify the eligibility of a biological child, you must submit a COPY
of..
Birth Certificate or birth registration card
OR
For children 6 months of age or younger: Documentation on hospital letterhead indicating the
birth date of the child or children under 6 months, as well as the parents’ names.
5. Biological Child (age 19 to 26th birthday) – To verify the eligibility of a biological child from age 19 to
their 26th birthday, you must submit a COPY of..
Birth Certificate or birth registration card
6. Adopted Child Documents – To verify the eligibility of an adopted child or a child placed with you for
adoption, you must submit a COPY of the following documents. The documents you submit will depend
on the current stage of the adoption:
Official court/agency placement papers for a child placed with you for adoption (initial stage)
OR
Official Court Adoption Agreement for Adopted Child (mid-stage)
OR
Birth Certificate (final stage)
7. Stepchild Documents – To verify the eligibility of your stepchild, you must submit a COPY of..
Child’s Birth Certificate or birth registration card showing the child’s parent is the employee’s
spouse.
AND
Marriage Certificate showing legal marriage between the employee and the child’s parent.
AND
Your Most Recent Federal Tax Return. Send the first two pages of your most recent 1040 federal
income tax return, showing filing status as well as your and your spouse’s signatures and the filing
date. If you file separately, please send the first two pages of your spouse’s most recent 1040
federal income tax return as well. Please black out any personal financial information, such as
income and account numbers. Do not send any tax return schedules OR W-2’s. E-filers can send in
their printed e-filed copy indicating it was filed electronically with a PIN, or the Form 8453 U.S.
Individual Income Tax Transmittal for an IRS e-file Return, along with the tax return if a PIN was not
used (in lieu of signatures).
8. Other Child Documents (Grandchild, Niece/Nephew, Brother/Sister, Other) – To verify the eligibility
of a grandchild, niece/nephew, brother/sister, or any other type of child for whom you are the legal
guardian, you must submit a COPY of..
Court papers demonstrating legal guardianship, including the person or persons named as the
legal guardian.
9. Child of Civil Union Partner Documents – To verify the eligibility of a child of your civil union partner,
you must submit a COPY of..
Child’s Birth Certificate or birth registration card showing the child’s parent in the employee’s civil
Union partner.
AND
Civil Union Certificate showing a civil union between the employee and the child’s parent.
AND
Supporting Financial Documentation. You must provide evidence of a current, mutual financial
Obligation shared between the employee and civil union partner. Examples:
Your most recent joint Illinois state income tax return,
OR
TWO of the following documents: current mortgage statement, current lease, current
property tax assessment for real property, auto loan, homeowners/renters or auto insurance
policy, brokerage or investment account. Please black out any personal financial
information such as income and account numbers.
10. Court-Ordered Medical Coverage – If you do not have custody of a child, but you do have a written
court order that requires your employer to provide medical coverage for this child, you must submit a
COPY of..
Qualified Medical Child Support Order (QMCSO)
OR
National Medical Support Notice (NMSN)
OR
Divorce Decree
11. Disabled Child, 26 Years and Older – To verify the continuing eligibility of your disabled child over
the age of 26, you must submit a COPY of..
Physician’s current determination letter. Please submit the most recent, current physician’s
determination letter OR Social Security Disability determination letter. Letters must be dated
within the past 18 months.
Employee will be given insurance coverage upon submission of their
insurance form. Dependents will be added upon receipt of necessary
documents.
If you fail to submit the required documentation, your dependent(s)
will not be included in the plan.