Healthy Advantage
Enrollment/Eligibility Guidelines
ENROLLMENT ACTIVITY
TYPE
DOCUMENT (S)
REQUIRED
DOCUMENTATION
INSTRUCTIONS
OPEN ENROLLMENT
Add Plan(s)
Add Dependents to Plan(s)
Term Self and/or Dependent(s)
from Medical Plan
Employee Election Form
Employee Election Form
Employee Election Form
Change from One Plan to Another
Employee Election Form
Proof of other Medical Insurance
Coverage (i.e., copy of ID card or
provide other insurance information)
NEW EMPLOYEE HIRE
Add Plan(s)
Add Dependent(s) to Plan(s)
Employee Election Form
Employee Election Form
QUALIFIED STATUS CHANGES
Addition of Spouse Coverage
Marriage
Marriage Certificate and enroll
Spouse on Employee Election
Form
Loss of Spouse’s Insurance
Coverage
Spouse’s HIPAA Certificate and
enroll Spouse on Employee
Election Form
Please forward a copy of your
Marriage License/Certificate to
Group Benefit Services. The
request to change benefits must be
made within 31 days after the date
of marriage.
Please forward a copy of the
HIPAA Certificate from your Other
Insurance Carrier to Group Benefit
Services. The request to change
benefits must be made within 31
days after the termination date of
your Other Insurance Coverage.
Termination of Spouse Coverage
Divorce/Annulment
Divorce/Annulment Decree and
terminate Spouse on Employee
Election Form
Enrollment in Other Insurance
Coverage
Proof of Other Coverage and
terminate your Spouse on
Employee Election Form.
Please forward a copy of the page
of your divorce decree that states
the date of divorce, and includes the
judge’s signature to Group Benefit
Services. The request to change
benefits must be made within 31
days after the date of divorce.
In order to provide proof of Other
Insurance coverage, complete the
Other Insurance Coverage
Information Section E for you
and/or your dependents and forward
to Group Benefit Services. The
request to change benefits must be
made within 31 days after the
termination date of your other
Insurance coverage.
Addition of Child/Dependent Coverage
Birth
Enroll child/dependent on
Employee Election Form
Adoption
Adoption/Court Records and
enroll child/dependent Employee
Election Form
Legal Guardianship/Custody
Granted
Court/Legal Records and
enroll child/dependent on
Employee Election Form
Court Order
QMCSO or NCMSO court order
and enroll child/dependent on
Employee Election Form
Step Children after New Marriage
Marriage Certificate and enroll
child/dependent on Employee
Election Form
Loss of Other Insurance Coverage
Dependent’s HIPAA Certificate
and enroll child/dependent on
Employee Election Form
Over 19 Dependent Becomes FullTime Student
Registrar Verification and enroll
child/dependent on Employee
Election Form
The request to add/enroll a newborn
must be forwarded to Group Benefit
Services within 31 days from the
date of birth.
Please forward a copy of the Legal
Adoption Documents to Group
Benefit Services. The request to
change benefits must be made
within 31 days after the Court Order
Issue date.
Please forward a copy of the Legal
Court Order to Group Benefit
Services. The request to change
benefits must be made within 31
days after the Court Order Issue
date.
Please forward a copy of the Legal
Court Order to Group Benefit
Services. The request to change
benefits must be made within 31
days after the Court Order Issue
date.
Please forward a copy of your
Marriage License/Certificate to
Group Benefit Services. The
request to change benefits must be
made within 31 days after the date
of marriage.
Please forward a copy of the
HIPAA Certificate from your Other
Insurance Carrier to Group Benefit
Services. The request to change
benefits must be made within 31
days after the termination date of
your Other Insurance Coverage.
Please forward student verification
confirming 12 or more credit hours
from an accredited college,
university, or trade school for any
dependent over the age of 19 to
Group Benefit Services. The
request to change benefits must be
made within 31 dates after the
enrollment date.
Termination of Child/Dependent Coverage
Loss of Custody
Court/Legal Document and
terminate child/dependent on
Employee Election Form
Forward a copy of the Legal Court
Order document to Group Benefit
Services. The request to change
benefits must be made within 31
days after the Court Order Issue
date.
Death
Death Certificate and terminate
child/dependent on Employee
Election Form
Child Over the Age of 25
Terminate child on the Employee
Election Form
Terminate child on the Employee
Election Form
Physician’s Records and terminate
child on the Employee Election
Form
Child Over 19 & Not Full Time
Student
No Longer Considered Disabled
Court Order Expired
Court/Legal Document and
terminate child on Employee
Election Form
Enrolled in Other Insurance
Coverage
Proof of Other Coverage.
Must complete COB Section on
Employee Election Form to
terminate a child/dependent.
Please forward a copy of the Death
Certificate to Group Benefit
Services. The request to change
benefits must be made within 31
days after death.
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N/A
Please forward a copy of the
Physician’s Records confirming “no
longer disabled status” to Group
Benefit Services. The request to
change benefits must be made
within 31 days after the status
change.
Please forward a copy of the Legal
Court Ordered document to Group
Benefit Services. The request to
change benefits must be made
within 31 days after the Court Order
expiration date.
In order to provide proof of Other
Insurance coverage, please
complete the Other Insurance
Information Section E for you
and/or your dependents. The
request to change benefits must be
made within 31 days after the
termination date of your Other
Insurance Coverage.
EMPLOYEE CHANGES
Enrolled in Other Insurance
Coverage (Terminate this plan)
Proof of Other Coverage.
Must complete COB Section on
Employee Election Form to
terminate coverage under this
plan.
Loss of Other Insurance Coverage
(Add this plan)
Spouse’s HIPAA Certificate and
enroll Spouse on Employee
Election Form
Address Change
Change address on Employee
Election Form
Change Other Insurance Carrier
information on Employee Election
Form
Coordination of Benefits (COB)
Update
In order to provide proof of Other
Insurance coverage, please
complete the Other Insurance
Information Section E for you
and/or your dependents. The
request to change benefits must be
made within 31 days after the
effective date of your Other Ins.
Coverage.
Please forward a copy of the
HIPAA Certificate from your Other
Insurance Carrier to Group Benefit
Services. The request to change
benefits must be made within 31
days after the termination date of
your Other Insurance Coverage.
N/A
N/A