If you are eligible to enroll in or change plans due to a qualified life change event, you may be asked to provide documents (employees to your employer, retirees to the Department of Employee Trust Funds (ETF)) to confirm your eligibility. The table below outlines life change event documentation requirements for the State of Wisconsin Group Health Insurance Program. 

Reason for Change or Enrollment Documentation Required Type of Documentation (Actives give to employers, retirees to ETF)
Adoption Yes Recorded copy of court order granting adoption or letter of placement for adoption
Birth

Yes for single parents (including divorced)

Possible for married couples

Birth certificate required for single parent

ETF may request documentation for married couples per the Terms and Conditions on ETF’s group health insurance application (Actives ET-2301, or Retirees ET-2331)
Cancel coverage or remove adult dependent due to enrollment in other health insurance coverage when premium contributions are deducted pre-tax Yes Documentation indicating the effective date of the other coverage such as a copy of a medical ID card or a letter from the health plan. Must be received within 30 days of enrollment in other coverage. Does not apply to retirees or post-tax deductions
Change of address/telephone/email Yes Application, letter, or email with effective date of change
Custody transfer Yes Court order. For example, may be transfer to reflect gaining or changing custody
Death Yes Original death certificate
Dependent, disabled, age 26+, unmarried Yes Copy of letter from health plan approving disabled status

Divorce

(Family coverage remains in place when dependents other than spouse/stepchildren covered)

 Yes

Copy of Continuation-Conversion Notice (ET-2311), provided by the employer (or ETF for retirees)

In addition, ETF may request a copy of divorce decree from the clerk of courts showing the date of entry of divorce per the Terms and Conditions on ETF's group health insurance application (Actives ET-2301, or Retirees ET-2331). Further, ETF may request documentation from married couples per the Terms and Conditions on ETF’s group health insurance application
Divorce (family to individual) Yes

Copy of Continuation-Conversion Notice (ET-2311), provided by the employer (or ETF for retirees)

In addition, ETF may request a copy of divorce decree from the clerk of courts showing the date of entry of divorce per the Terms and Conditions on ETF's group health insurance application (Actives ET-2301, or Retirees ET-2331). Further, ETF may request documentation from married couples per the Terms and Conditions on ETF’s group health insurance application
Family to individual coverage because all dependents enrolled in other coverage  Yes Copy of medical ID card or letter from health plan indicating effective date of other coverage. Must be received within 30 days of enrollment in other coverage. Does not apply to retirees or post-tax deductions
Gain eligibility for other group medical coverage Yes

Copy of medical ID card with coverage effective date or letter from health plan indicating effective date of other coverage. Must be received within 30 days of enrollment in other coverage. Does not apply to post-tax deductions

Gaining Medicare Part A and/or B alone is not acceptable
Gender change Yes Copy of Address/Name/Gender form (ET-2815)
Job change where you gain a greater share of employer contribution toward your coverage Yes Your employer must validate that they are paying a larger percentage of your premium
Job change where you lose a significant share of employer contribution toward your coverage Yes Your employer must validate that they are paying a significantly lower percentage of your premium
Legal change of name (other than due to marriage or divorce) Yes Copy of court order
Legal ward Yes Court order (Letters of Guardianship) granting permanent guardianship of person
Loss of other coverage or loss of all employer contribution to premiums (applies to participant and dependents)  Yes

The following items on dated communication with letterhead from the previous insurer or former employer. Materials dated within 30 days before or after termination are acceptable

  1. Reason for the cancellation (that is voluntary, such as due to nonpayment of premium vs. involuntary, such as due to job loss),
  2. Who was covered (must list the name of the participant who is requesting this special, late enrollment),
  3. Name of health insurer,
  4. Subscriber name, and
  5. Date coverage was terminated

COBRA continuation notice is acceptable if the coverage end date, covered individuals, and health plan are indicated. For loss of employer premium contributions, a letter from the employer indicating they no longer contribute toward their employee’s premium is needed
Marriage If requested by ETF ETF may request original or certified copy of marriage certificate per the Terms and Conditions on ETF's group health insurance application (Employees ET-2301, or Retirees ET-2331)
Medicare-eligible and enrolled Yes Copy of Medicare card and Medicare Eligibility Statement (ET-4307) (Note: If you are on COBRA continuation and the subscriber or dependents become Medicare eligible after the COBRA effective date, subscriber or dependent is no longer eligible to continue on COBRA continuation)
Move No No documents required, but if changing your phone number or email address, notify your employer (or ETF for retirees)
National Medical Support Notice Yes Copy of National Medical Support Notice
Paternity Yes Court order declaring paternity, Voluntary Paternity Acknowledgement filed with DHS, or birth certificate
Social Security number change  Yes Copy of card or letter from Social Security Administration
State retiree reenroll Yes Sick Leave Reenrollment Application (ET-4317) and additional documentation listed on the sick leave reenrollment application