HEALTH PLAN ELIGIBILITY REQUIREMENTS
For All Medical & Dental Plans

Open Enrollment

Each year the County holds an open enrollment period during which employees and retirees may switch medical, vision & dental coverage, enroll (if coverage was initially waived or subsequently dropped) and add dependents.

Important note: If dental coverage is voluntarily terminated by a retiree, it cannot be reinstated or added at a later date –even during an annual open enrollment period.

To switch plans, your enrollment materials must be submitted to the County’s Human Resources Department before the close of the open enrollment period (that date will be announced each year). Your coverage under the new plan selection or any changes to your coverage will take effect on July 1.

If you are adding or dropping dependents, obtain the appropriate change form and submit it to the Human Resources-Employee Benefits Division within the enrollment period.

Eligible Employees and Retirees

You are eligible to enroll in a County Medical or Dental Plan if:

•	you are a regular, full-time or permanent part-time employee of the County, or
•	you are a qualified retiree who is currently receiving a retirement allowance from the County, and
•	you may not enroll in medical or dental coverage only; to be eligible for dental coverage you must enroll in a medical plan offered by the County and to be eligible for medical coverage, you must enroll in a County dental plan.

 

Eligible Dependents

Eligible employees and retirees who enroll in the the County's medical and dental plans may also enroll their eligible dependents in the Plan. Eligible dependents include:

•	the employee’s or retiree’s lawful spouse as defined by applicable law, or, a person that is a sole spousal equivalent and is 18 years old or older, is mentally competent to contract, resides with the employee or retiree and intends to do so indefinitely, is jointly responsible with the employee or retiree for their common welfare and financial obligations, is unmarried and is not related to the employee or retiree by blood to a degree of closeness as to bar marriage in the state of residence, and has not filed a Statement of Termination of Domestic Partnership within the last 6 months. The employee or retiree must also be unmarried for the sole spousal equivalent to be eligible for membership in the Dental Plan,
•	the employee’s or retiree’s natural children, stepchildren, foster children, children who, before reaching the age of 18, are either adopted by the employee or retiree or placed in the employee’s or retiree’s home for adoption, and children for whom the employee or retiree is legal guardian. A dependent child must be unmarried and rely on the employee or retiree for primary support and maintenance. Dependent children must be under the age of 19, or 23 if they remain dependent upon the employee or retiree for at least 50% of their support,
•	any child named in a qualified medical child support order for which an eligible employee or retiree is required to provide health coverage.

Eligible dependents do not include any person on active duty in the Armed Forces of the United States or any person covered as an employee or retiree under the Dental Plan. If a dependent may claim dependent status by reason of a relationship to more than one eligible employee or retiree, the dependent can only be enrolled as a dependent of one of the eligible employees or retirees.

Important note: You are required to submit to your County medical insurance carrier on an annual basis a completed Certification of Dependents Status form for dependent children between 19 and 23 years of age.

Waiver of Coverage

Eligible employees may waive health insurance coverage by completing and submitting to the County’s Human Resources Department a Waiver of Medical/Dental Coverage form. Dental coverage for employees cannot be waived without waiving medical coverage.

Enrollment Requirements

New Hires: Eligible employees who want coverage under the County's medical and dental plans must enroll by completing the applicable enrollment form and submitting it to the Human Resources-Employee Benefits Division prior to the start of coverage. Coverage starts at the beginning of the month that immediately follows the employee's first pay period of employment in a regular position. Part-time employees must be employed a minimum of fifty percent (50%) of full-time in order to be eligible for insurance benefits.

Retirees: Retirees must enroll by completing the applicable enrollment form and submitting it when they complete and return the County’s Application for Retirement form.

Dependents: If an eligible employee or retiree wants their eligible dependents covered under their medical and dental Plan at the same time their initial coverage begins, the eligible dependents must be listed on the initial enrollment form. If an eligible employee or retiree acquires eligible dependents after his initial enrollment, the dependent(s) must be enrolled within 31 days of the date they are acquired. A newborn dependent child is automatically covered from birth for 31 days. In order for coverage to be continued beyond the first 31 days, a completed enrollment form must be submitted to the County’s Human Resources Department within 31 days following birth.

Late enrollment: If enrollment does not take place as provided above, the eligible employee or retiree may enroll himself and/or his eligible dependents on their medical / dental coverage only during the County’s annual open enrollment period, except as provided below under “special enrollment.”

Special enrollment: If an eligible employee or retiree does not enroll himself and/or eligible dependents in a County medical and dental Plan because he or they were covered under another group health plan or had other health insurance coverage at the time enrollment in the medical and dental plans was declined, the eligible employee or retiree may enroll himself and/or his eligible dependents in these plans if the following conditions are met:

•	The individual’s other group health plan or health insurance coverage was terminated due to the loss of eligibility for coverage or the employer ceased making contributions for the coverage, and
•	The individual requests coverage under the medical and dental plan by submitting a completed enrollment form to the County’s Human Resources Department not later than 30 days after coverage is lost under the other plan.
If the preceding conditions are met, coverage under the plan selected will begin as follows:
•	For active employees - coverage begins on the first day of the month following the date the other coverage ends.
•	For retirees - coverage begins on the first day of the month following the date the other coverage ends.

When Coverage Begins

If enrollment takes place during the County’s annual open enrollment period, coverage begins on July 1. If enrollment is delayed because of other health coverage, refer to “Special enrollment” above for the date coverage begins.

Following are the dates coverage begins when enrollment takes place when a person is first entitled to enroll.

New Hires: When enrollment requirements are met, coverage begins on the first day of the month following the end of the first pay period regular employment begins.

New Retirees: When the enrollment requirements are met, coverage beings on the date of retirement or, if coverage has been extended under COBRA, on the date that coverage ends.

Dependents: When enrollment requirements are met, coverage for eligible dependents begins on the date the eligible employee’s or retiree’s coverage begins or, if acquired after that date, the date the dependent becomes an eligible dependent.

When Coverage Ends

Unless a special extension applies as described below, coverage under the County's medical and dental plans will end on the earliest of the following dates:

•	for eligible employees and their eligible dependents only, the last day of the month following the date of the employee's separation or the date the employee otherwise ceases to meet the requirements of an eligible employee;
•	for retirees and their eligible dependents only, the last day of the month a retiree no longer qualifies for coverage because his retirement allowance from the County ceases;
•	for dependents only, on the last day of the month during which the dependent no longer qualifies as an eligible dependent;
•	the date of complete termination of the medical or dental plan or upon the effective date of an amendment to the medical or dental plan which excludes the covered person from such status;
•	for a covered person who changes his medical or dental plan selection to another plan provided by the County, on the date his new dental plan selection becomes effective;
•	the last day of the month following the date the county receives written authorization from the eligible employee or retiree to terminate his health coverage. Important note to retirees: if dental coverage is voluntarily terminated by a retiree, it can not be reinstated or added at a later date, even during an annual open enrollment period;
•	the last day of the month for which any required self-payment was made for this coverage if the next self-payment is not paid when due.

Special Extensions

Physical or Mentally Handicapped Child: If a dependent child is physically or mentally handicapped on the date coverage would otherwise end because of age, the child’s coverage will be continued for as long as the eligible employee or retiree is covered under the medical or dental plan provided the handicap continues and the child continues to qualify as an eligible dependent in all aspects except age. The County may require from time to time a physicians’ statement certifying the physical or mental handicap.

Leave of Absence: Eligible employees may continue coverage during a leave of absence provided they continue bi-weekly contributions as agreed upon with the County and they comply with the applicable provisions of the County’s Leave of Absence Policy.

Employees entering the Armed Forces of the United States: If an eligible employee goes into active military service (including periodic reserve training) for any of the Armed Forces of the United States for up to 31 days, medical and dental plan coverage may continue during the period of that leave, if such employee continues to pay his required contribution for coverage, if any. The County will continue its contribution for coverage during such military leave.

If an eligible employee goes into active military service for any of the Armed Forces of the United States for more than 31 days, medical and dental plan coverage may continue for up to 18 months or the period of such military leave, whichever is shortest, if such employee pays the full cost of the coverage during the military leave.

Whether or not an eligible employee elects to continue coverage, coverage will be reinstated on the first day he returns to active employment with the County if he is released under honorable conditions and he returns to work on whichever of the following dates is applicable:

•	on the first full business day following completion of his military service for a leave of 30 days or less,
•	within 14 days of completing his military service for a leave of 31 to 180 days,
•	within 90 days of completing his military service for a leave of more than 180 days.

When coverage under the medical and dental plans are reinstated, all provisions, limitations and exclusions of the plans will apply to the extent that they would have applied if he had not taken military leave and his coverage had been continuous under the Plan. The foregoing, however, does not apply to coverage for any illness or injury caused or aggravated by military service, as determined by the Veterans Administration.

Family, Medical or Personal Leave: If an eligible employee qualifies for an approved family, medical or personal leave, coverage under the medical and dental plans may continue for the duration of the leave if the eligible employee pays any required contributions towards the cost of coverage. County contribution towards the cost of employee coverage will continue for the first 18 months for an approved family or medical leave. For an approved personal leave, the County contribution towards the cost of employee coverage will continue for the first two pay periods.

Extension of Benefits for Self-Funded Dental Program: If a dentist certifies that a covered person is undergoing a course of treatment on the date coverage ends for any reason (other than the maximum benefit has been paid), Dental Plan benefits will be continued for covered expenses directly related to the completion of the course of treatment until the earliest of:

•	For orthodontia – the date the maximum benefits have been paid or the date the Dental Plan is terminated;
•	For other covered expenses - the date the maximum benefits have been paid; 90 days following the date the covered person’s coverage terminated, or the date the Dental Plan is terminated.

Prophylaxis and x-rays are not part of a course of treatment.

COBRA CONTINUATION COVERAGE

A federal law allows you and your eligible dependents to continue dental coverage along with your medical coverage at your own expense under certain circumstances when health coverage would otherwise end. Your COBRA rights are subject to change.

COBRA coverage is available if coverage would be lost under any of the following qualifying events:

•	termination of employment (for reasons other than gross misconduct) or a reduction in hours,
•	retirement,
•	employee’s or retiree’s death,
•	employee’s or retiree’s divorce or legal separation,
•	a dependent ceasing to qualify as an eligible dependent.

Notification Requirements

In the event of divorce, legal separation or a dependent ceasing to qualify as an eligible dependent, you or a family member must notify the County’s Human Resources Department-Benefits Division within 60 days after that event occurs. If notice is not received by the end of the 60-day period, the affected spouse or dependent will not be entitled to choose COBRA continuation coverage.