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Individual coverage covers only you. Family coverage covers those described below. All eligible, listed dependents are covered under a family contract. A subscriber cannot choose to exclude any other eligible dependent from family coverage except as described in the question: When does health coverage terminate for my dependents? Show
Dependent Eligibility1. Who is eligible as a dependent if I select family coverage?
Note: Coverage may continue beyond turning age 26 when children:
2. What are my coverage options if my spouse is also a state or participating Wisconsin Public Employer (WPE) employee or state retiree?You have the following options:
(See Question: How do I pay my portion of the premium?) Some things to note:
3. What if I have an adult child who is, or who becomes, physically or mentally disabled?If your unmarried child has a physical or mental disability that is expected to be of long-continued or indefinite duration and is incapable of self-support, he or she may be eligible to be covered under your health insurance through the state program. You must work with your health plan to determine if your child meets the disabled dependent eligibility criteria. If disabled dependent status is approved by the health plan, you will be contacted annually to verify the adult dependent's continued eligibility. If your child loses eligibility for coverage due to age or loss of student status, but you are now indicating that the child meets the disabled dependent definition, eligibility as a disabled dependent must be established before coverage can be continued. If you are providing at least 50% support you must file an electronic or paper application with your employer to initiate the disability review process by the health plan. Your dependent will be offered COBRA continuation*. If your disabled dependent child, who has been covered due to disability, is determined by the health plan to no longer meet their disability criteria, the health plan will notify you in writing of their decision. They will inform you of the effective date of cancellation, usually the first of the month following notification, and your dependent will be offered COBRA continuation*. If you would like to appeal the health plan's decision, you must first complete the health plan's grievance procedure. If the health plan continues to deny disabled dependent status for your child, you may appeal the health plan's grievance decision to ETF by filing an ETF Insurance Complaint Form (ET-2405). Note: If you are changing health plans, see also the Changing Health Plans section. *Electing COBRA continuation coverage should be considered while his or her eligibility is being verified. If it is determined that the individual is not eligible as a disabled dependent, there will not be another opportunity to elect COBRA. If it is later determined that the child was eligible for coverage as a disabled dependent, coverage will be retroactive to the date they were last covered, and premiums paid for COBRA continuation coverage will be refunded. 4. What if I don't have custody of my children?Even though custody of your children may have been transferred to the other parent, you may still insure the children if the other dependency requirements are met. Note: Dependents may only be covered once under both the State of Wisconsin Group Health Insurance Program and the Wisconsin Public Employers Group Insurance Program. In the event it is determined that a dependent is covered by two separate subscribers, the subscribers will be notified and will have 30 days to determine which subscriber will remove coverage of the dependent and submit an application to remove the dependent. The effective date will be the first of the month following receipt of the application. The health plan(s) will be notified. 5. When does health coverage terminate for my dependents?Coverage for dependent children who are not physically or mentally disabled terminates on the earliest of the following dates:
See Continuation of Health Coverage for information on continuing coverage after eligibility terminates. Family Status Changes6. Which changes need to be reported?You need to file an electronic or paper application as notification for the following changes to your benefits/payroll/personnel office within 30 days of the change. Retirees and continuants will need to contact ETF. Additional information may be required. Failure to report changes on time may result in loss of benefits or delay payment of claims.
7. Who do I notify when a dependent loses eligibility for coverage?You have the responsibility to inform your employer (ETF, for retirees and continuants) of any dependents losing eligibility for coverage under the State of Wisconsin Group Health Insurance Program. Under federal law, if notification is not made within 60 days of the later of (1) the event that caused the loss of coverage, or (2) the end of the period of coverage, the right to continuation coverage is lost. A voluntary change in coverage from a family plan to a individual plan does not create a continuation opportunity. If your last dependent is losing eligibility, you must file an application to change to single coverage. 8. If I do not change from individual to family coverage during the annual open enrollment period, will I have other opportunities to do so?There are other limited opportunities for coverage to be changed from individual to family coverage without restrictions as described below: If an electronic or paper application is received by your benefits/payroll/personnel office for active employees (or ETF for retirees/continuants) within 30 days of the following events, coverage becomes effective on the date of the following event:
If an application is received by your benefits/payroll/personnel office for active employees or ETF for retirees/continuants, within 60 days of the following events, coverage becomes effective on the date of the following event:
If an application is received by your benefits/payroll/personnel office for active employees or ETF for retirees/continuants, upon order of a federal court under a National Medical Support Notice, coverage will be effective on either:
Note: This can occur when a parent has been ordered to insure one or more children who are not currently covered. 9. What action do I need to take for the following personal events (marriage, birth, etc.)? What restrictions apply?Marriage If you were enrolled in family coverage before your marriage, you need to complete an electronic or paper application as soon as possible to report your change in marital status, add your new spouse (and stepchildren) to the coverage and, if applicable, change your name. In most cases, coverage for the newly added dependent(s) will be effective as of the date of marriage. (See the Life Event Guide and Question: What are my coverage options if my spouse is also a state of Wisconsin or participating Wisconsin Public Employer (WPE) employee or state retiree?) Note: You may also change health plans when adding a dependent due to marriage. The subscriber will need to file an application within 30 days of the marriage with coverage with the new health plan effective on the first day of the month on or following receipt of the application. Birth/Adoption/Legal Guardianship/Dependent Becoming Eligible If you have individual coverage, you can change to family coverage with your current health plan by submitting an application within 30 days of the date a dependent becomes eligible, or within 60 days of birth, adoption or the date legal guardianship is granted. Note: You may also change health plans if you, the subscriber file an application within 30 days of a birth or adoption with coverage effective on the first day of the month on or following receipt of the electronic or paper application. Single Mother or Father Establishing Paternity Children born outside of marriage become dependents of the father on the date of the court order declaring paternity or on the date the "Voluntary Paternity Acknowledgment" (form DPH 5024) is filed with the Department of Health Services (or equivalent if the birth was outside the state of Wisconsin) or on date of birth with a birth certificate listing the father's name. The effective date of coverage will be the date of birth if a statement of paternity is filed within 60 days of the birth. If more than 60 days after the birth, coverage is effective on the first of the month following receipt of the electronic or paper application. A single mother may cover the child under her health plan effective with the birth by submitting an application changing from single to family coverage, along with a birth certificate, adoption order, or other documentation indicating guardianship over the child. Upon Order of a Federal Court Under a National Medical Support Notice
Divorce You must file an electronic or paper health application with your employer to change from family to individual coverage or to remove ineligible dependents from a family contract. When both parties in the divorce are state or university employees or retirees, and each party is eligible for state health insurance in his or her own right and is insured under the state health plan at the time of the divorce, each retains the right to continue state health insurance coverage regardless of the divorce.
Note for Active Employees: Failure to apply in a timely manner will limit enrollment to the annual open enrollment period for coverage effective January 1. Note for Retirees and Continuants: Failure to apply in a timely manner will delay the effective date of coverage. Medicare Eligibility: Please refer to the Medicare information in this FAQ for details regarding Medicare eligibility and enrollment requirements. Death (Surviving Dependents): If an active or retired employee with family coverage dies, the surviving insured dependents shall have the right to continue coverage for life under the State of Wisconsin Group Health Insurance Program at group rates. The dependent children may continue coverage until eligibility ceases if they:
Health insurance coverage will automatically continue for your covered surviving dependents. Continued coverage will be effective on the first of the month after your date of death. Surviving dependents may voluntarily terminate coverage by providing written notification to ETF, and it will terminate on the last day of the month in which their written request is received by ETF. Note: Survivors may not add persons to the policy who were not insured at the time of death unless the survivor is also a state employee and eligible for the insurance in his or her own right. If family coverage was in force at the time of death, any unused sick leave credits in the deceased employee's account are available to the surviving dependents for premium payments. If sick leave credits are escrowed, the surviving dependents may continue to escrow the credits or may apply to convert the credits to pay health insurance premiums. Note: If individual coverage was in force at the time of death, the monthly premiums collected for coverage months following the date of death will be refunded. No partial month's premium is refunded for the month of coverage in which the death occurred. Surviving dependents are not eligible for coverage. Grad only: If family coverage was in force at the time of death, the covered surviving dependents are then eligible for COBRA Continuation. (See Question: Who is eligible for continuation?). 10. When can I change from family to individual coverage, or individual to family coverage?If your employee premiums are deducted on a pre-tax basis under Internal Revenue Code Section 125 rules, switching from family to individual coverage is not allowable unless there is an IRS qualified family status change such as divorce, marriage, birth or adoption. For example, all covered family members lose eligibility for health coverage or become eligible for and enroll in another group plan. (Group plans do not include Medicare or individual Medicare supplement policies.) If any covered dependents remain eligible for coverage, a change from family to individual coverage is allowed only during the annual open enrollment period. If your employee premiums are deducted on a post-tax basis or you are a retiree, you may change from family to individual coverage at anytime. The change will be effective on the first day of the month on or following receipt of your electronic or paper application by your benefits/payroll/personnel office (ETF for retirees and continuants). Switching from family to individual coverage when you still have eligible dependents is deemed a voluntary cancellation of coverage for all covered dependents and is not considered a "qualifying event" for continuation coverage. State only: If you have individual coverage and you should die, your sick leave credits will not be available for use by your surviving dependents. Changing from individual to family coverage, regardless of whether your premiums are deducted on a pre- or post-tax basis, is only allowed during the annual open enrollment period, or when you or an eligible dependent has a qualifying event that allows for family coverage. See Question: If I do not change from individual to family coverage during the annual open enrollment period, will I have other opportunities to do so? How long can a child stay on their parents insurance in Wisconsin?Effective January 1, 2010, Wisconsin law requires health insurers to provide coverage for an adult child of the insured. The child must be: Over 17 but less than 27 years of age.
Can spouse cancel health insurance before divorce in PA?It is more common than you might think for vindictive spouses to try to cease their spouse's health insurance coverage as soon as you serve them with divorce papers. But, under Pennsylvania law, your spouse is not legally able to kick you off of their insurance policy until the date your divorce decree is entered.
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