Fillable Form Ib03 - State Employee'S Membership Status Change (Page 2 of 2) in pdf

State Employees’ Health Insurance Plan

Eligible Dependent

The term "dependent" includes the following individuals, subject to appropriate documentation (Social Security

number, marriage certificate, birth certificate, court decree, etc.):

1. Your spouse (excludes divorced or common-law spouse).

2. A child under age 26, only if the child is:

a. your son or daughter,

b. a child legally adopted by you or your spouse ,

c. your stepchild,

d. your grandchild, niece, or nephew for whom the court has granted custody to you or your spouse.

3. An incapacitated dependent over age 25 will be considered for coverage provided dependent:

a. is unmarried,

b. is permanently mentally or physically disabled or incapacitated,

c. is so incapacitated as to be incapable of self-sustaining employment,

d. is dependent on you for 50% or more support,

e. is otherwise eligible for coverage as a dependent except for age,

the condition must have occurred prior to the dependent’s 26th birthday, and

is not eligible for any other group health insurance benefits.

Neither a reduction in work capacity nor inability to find employment is, of itself, evidence of eligibility. If a mentally or

physically disabled dependent is working, despite his disability, the extent of his earning capacity will be evaluated.

To apply, contact the SEIB to obtain an Incapacitated Dependent Certification Form. Final approval of incapacitation

will be determined by Medical Review. Proof of disability must be provided to the SEIB within 60 days from the date

the child would cease to be covered because of age.

Exception: There are two situations under which it may be possible to add an incapacitated dependent who meets the

eligibility requirements except for age:

1. When a new employee requests coverage for an incapacitated dependent within 60 days of employment; or

2. When an employee’s incapacitated dependent is covered under a spouse’s employer group health insurance for

at least 18 consecutive months and:

a. the employee’s spouse loses the other coverage because:

•

spouse’s employer ceases operations, or

•

spouse’s loss of eligibility due to termination of employment or reduction of hours of employment, or

•

spouse’s employer stopped contribution to coverage,

b. a change form is submitted to the SEIB within 30 days of the incapacitated dependent’s loss of other

coverage, and

c. Medical Review approved incapacitation status.

The above requirements must be met as a minimum threshold in order to be considered for incapacitation status. The

SEIB shall make the final decision as to whether an application for incapacitated status will be accepted. NOTE: The

SEIB reserves the right to periodically re-certify incapacitation.

In the event of the death of an active employee, who carried family coverage, the eligible dependents may continue

coverage by making the appropriate premium payment to the SEIB. The SEIB must be notified within 90 days of the

death.

Exclusion: You may not cover your spouse or other dependents if they are independently covered as a State

employee.

STATE EMPLOYEES’ INSURANCE BOARD

POST OFFICE BOX 304900

MONTGOMERY, ALABAMA 36130-4900

334-263-8341 / 1-866-836-9737 / FAX: 334-263-8541

Form Ib03 - State Employee'S Membership Status Change Page 2

Related Articles

Related forms

Related Categories