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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 below in the Question: When does health coverage terminate for my dependents?

Dependent Eligibility

1. Who is eligible as a dependent if I select family coverage?

  • Your spouse
  • Your children who include:
    • Your natural children.
    • Stepchildren.
    • Adopted children and pre-adoption placements. Coverage will be effective on the date that a court makes a final order granting adoption by the subscriber or on the date the child is placed in the custody of the subscriber, whichever occurs first. These dates are defined by Wis. Stat. § 632.896. If the adoption of a child is not finalized, the insurer may terminate coverage of the child when the adoptive placement ends.
    • Legal wards that become your permanent ward before age 19. Coverage will be effective on the date that a court awards permanent guardianship to you (the subscriber or your spouse).
    • Your grandchildren born to your insured dependent children may be covered until the end of the month in which your insured dependent (your grandchild's parent) turns age 18. Your child's eligibility as a dependent is unaffected by the birth of the grandchild.

Dependents and subscribers 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. If the dependent is to be newly covered by a subscriber that has individual coverage, the contract may be converted to a family contract. The effective date will be the first of the month following receipt of the application. The health plan(s) will be notified.

Children may be covered until the end of the month in which they turn age 26, but his/her spouse and their dependents are not eligible. Upon losing eligibility, they may be eligible for COBRA continuation. See COBRA/Continuation of Health Coverage FAQs Question: Who is eligible for continuation?

NOTE: Coverage may continue beyond turning age 26 when the children:

  • Have a disability of long standing duration, are unmarried, are dependent on you or the other parent for at least 50% of support and maintenance, and are incapable of self-support; or
  • Are full-time students and were called to federal active duty when they were under the age of 27 years and while they were attending, on a full-time basis, an institution of higher education. Note: The adult child must apply to an institution of higher education as a full-time student within 12 months from the date the adult child fulfilled his or her active duty obligation.

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:

  • You may each elect individual coverage with your current health plan(s).
  • If your spouse is also an eligible state employee or retiree, one of you may select family coverage that will cover all of your eligible dependents. 
    Note: Dependents and subscribers 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. If the dependent(s) is to be newly covered by a subscriber that has individual coverage, the contract may be converted to a family contract. The effective date will be the first of the month following receipt of the application. The health plan(s) will be notified.
  • If both spouses are each enrolled for individual coverage and premiums are being deducted on a pre-tax basis, family coverage may only be elected effective at the beginning of the calendar year or when the employees have gained a dependent that necessitates family coverage.
  • If premiums for family coverage are being deducted on a pre-tax basis, coverage may only be changed to individual coverage effective at the beginning of the calendar year or when the last dependent becomes ineligible for coverage or becomes eligible for and is enrolled in other group coverage.
  • If premiums are being deducted on a post-tax basis, one of the individual contracts may be changed to a family plan at any time without restriction and the other individual contract will be canceled. Family coverage must include all eligible dependents with the exception of adult child dependents (19 and older) who have other group health insurance coverage. Family coverage will be effective at the beginning of the month following receipt of an electronic or paper application, or a later date specified on the application.
  • If premiums are being deducted post-tax, one family policy can be split into two individual plans with the same carrier effective on the beginning of the month following receipt of an electronic or paper application, or a later date specified on the application from both spouses.

(See Benefits and Services FAQs Question: How do I pay my portion of the premium?)

Some things to note:

  1. State and Retirees only: If you and your spouse each have individual coverage, no dependents are covered, and if one of you should die, that individual's state sick leave credits will not be available for use by the surviving dependents. Under a family plan, sick leave credits are preserved for the surviving dependents regardless of who should die first.
  2. If you or your spouse have family coverage deducted on a pre-tax basis and want to change the named subscriber for the family coverage to the other spouse, coverage may only be changed to the other spouse:
    • effective at the beginning of the calendar year;
    • when the subscriber carrying the coverage terminates employment or goes on an unpaid leave of absence; or
    • the premium contribution increases because of reduced work hours.
    For subscribers whose premiums are being deducted on a post-tax basis, coverage can be changed at any time. Coverage will be effective at the beginning of the month following receipt of an electronic or paper application, or a later date specified on the application.
  3. If at the time of marriage, the employees and/or retirees each have family coverage or one has family coverage and the other has individual coverage, coverage must be changed to one of the options listed above within 30 days of marriage to be effective as of the date of marriage. Failure to comply with this requirement may result in denial of claims for eligible dependents. Note: Change from individual to family coverage due to marriage is effective on the date of marriage if an electronic or paper application is received by your employer (or for retirees and COBRA continuants, by the Department of Employee Trust Funds (ETF)) within 30 days of the marriage.

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. Medical documentation requirements vary by plan. If you change health plans, the new plan is required to verify their disabled status. Timely responses to the plan are needed to retain uninterrupted coverage for your dependent. 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 (or ETF for retirees and COBRA continuants) to initiate the disability review process by the health plan. Your dependent will be offered COBRA continuation coverage*.

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 coverage*. 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 FAQs.

*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:

  • The date eligibility for coverage ends for the subscriber
  • The end of the month in which:
    • The child turns age 26.
    • Coverage for the grandchild ends when your child (parent of grandchild) ceases to be an eligible dependent or turns 18, whichever occurs first. The grandchild is then eligible for COBRA continuation coverage.
    • Coverage for a spouse and stepchildren under your health plan terminates when there is an entry of judgment of divorce.
    • The child was covered per Wis. Stats. 632.885 (2) (b) and ceases to be a full-time student.
    • The child becomes insured as an employee of a state agency, or an employer who participates in the State of Wisconsin or Wisconsin Public Employers Group Health Insurance Program.
    • You terminate coverage for your adult dependent (19 or older) within 30 days of their combined eligibility for and enrollment in another group health insurance program. Termination will be effective the first of the month following receipt of an electronic or paper application. You may also terminate coverage for your adult dependent during the annual open enrollment period to be effective January 1 of the following year.

Note: If 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.

See the COBRA/Continuation of Health Coverage FAQs for information on continuing coverage after eligibility terminates.

Family Status Changes

6. 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 COBRA 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.

  • Change of name, address, telephone number, Social Security number, etc.
  • Obtaining or losing other health insurance coverage, including any part of Medicare.
  • Addition of a dependent (within 60 days of birth, adoption, or date legal guardianship is granted).
  • Loss of dependent's eligibility, including Medicare eligibility.
  • Marriage.
  • Divorce.
  • Death (Contact ETF if dependent is your named survivor).
  • State and Retirees only: Eligibility/Enrollment for Medicare.

7. Who do I notify when a dependent loses eligibility for coverage?

You have the responsibility to inform your employer (ETF for retirees and COBRA 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 an individual plan does not create a continuation opportunity.

If your last dependent is losing eligibility, you must file an application to change to individual 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 and COBRA continuants) within 30 days of the following events, coverage becomes effective on the date of the following events:

  • Marriage.
  • You or any of your eligible dependents involuntarily lose eligibility for other medical coverage or lose the employer contribution for the other coverage. The expiration of COBRA permits you to enroll, but COBRA termination due to non-payment of premium is considered voluntary cancellation and will not permit you to enroll.
  • An unmarried parent whose only eligible child becomes disabled and thus is again an eligible dependent. Coverage will be effective the date eligibility was regained.

If an application is received (by your benefits/payroll/personnel office for active employees, or ETF for retirees and COBRA continuants) within 60 days of the following events, coverage becomes effective on the date of the following events:

  • Birth or adoption of a child or placement for adoption (timely application prevents claim payment delays).
  • Legal guardianship is granted.
  • A single father declaring paternity. Children born outside of marriage become dependents of the father on the date of the court order declaring paternity, on the date the acknowledgment of paternity is filed with the Department of Health Services (or equivalent if the birth was outside of the state of Wisconsin) or on the date of birth with a birth certificate listing the father's name. The effective date of coverage will be the birth date if a statement of paternity is filed within 60 days of the birth. If filed more than 60 days after the birth, coverage will be effective on the first of the month following receipt of application.

If an application is received (by your benefits/payroll/personnel office for active employees, or ETF for retirees and COBRA continuants), upon order of a federal court under a National Medical Support Notice, coverage will be effective on either:

  • The first of the month following receipt of application by the employer; or
  • The date specified on the Medical Support Notice.

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?

Note: Family coverage must include all eligible dependents with the exception of adult child dependents (19 and older) who have other group health insurance coverage. 

Marriage 
You can change from individual to family coverage to include your spouse (and stepchildren if applicable) effective on the date of your marriage, without restriction, provided your electronic or paper application is received within 30 days after your 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 if applicable) 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 Events Guide and Question above: 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 under the new 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 already have family coverage, you need to submit a timely electronic or paper application to add the new dependent. Coverage is effective from the date of birth, adoption, when legal guardianship is granted, or when a dependent becomes eligible and otherwise satisfies the dependency requirements. Be prepared to submit documentation of guardianship, paternity, or other information as requested by your employer. For more information see the Life Change Events and Documentation Requirements page.

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 
A subscriber may cover his or her dependent child, effective on the date of the child's birth or adoption, by submitting a timely electronic or paper application to change from individual to family coverage.

Children born outside of marriage become dependents of the father on either the date of the court order declaring paternity, 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 the date of birth if the birth certificate lists 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 (for example, a divorcee) may cover the child under her health plan effective on the date of birth by submitting an application changing from individual 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
This can occur when a parent has been ordered to insure his/her eligible child(ren) who is not currently covered. You will need to submit an electronic or paper application to your benefits/payroll/personnel office (retirees and COBRA continuants will notify ETF) with coverage becoming effective on either:

  • The first of the month following receipt of application by the employer, or
  • The date specified on the National Medical Support Notice.

Divorce 
Your ex-spouse (and stepchildren) can remain covered under your family plan only until the end of the month in which the marriage is terminated by divorce or annulment, or to the end of the month in which the Continuation-Conversion Notice (ET-2311) is provided to the divorced spouse (as long as family premium continued to be paid), whichever is later (In Wisconsin, a legal separation is unlike divorce in that it does not affect coverage under the State of Wisconsin Group Health Insurance Program). Divorce is effective on the date of entry of judgment of divorce. This date is usually when the judge signs the divorce papers and the clerk of courts date stamps them.

You should notify your payroll office prior to the divorce hearing date and once the entry of judgment of divorce has occurred. You will need to contact the clerk of courts to learn the date of entry of judgment of divorce. If you fail to provide timely notice of divorce, you may be responsible for premiums or claims paid in error which covered your ineligible ex-spouse and stepchildren. Following divorce, your ex-spouse and stepchildren are eligible to continue coverage under a separate contract with the group plan under COBRA for up to 36 additional months. Conversion coverage would then be available. You can keep your dependent children and adopted stepchildren on your family plan for as long as they are eligible (See COBRA/Continuation of Health Coverage FAQs for further information).

To change from family to individual coverage or to remove ineligible dependents from a family contract active employees must file an electronic or paper health application with your benefits/payroll/personnel office. Retirees and COBRA continuants must file with ETF.

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 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.

  • The participant who is the subscriber of the insurance coverage at the time of the divorce must submit an electronic or paper health application to remove the ex-spouse from his or her coverage and may also elect to change to individual coverage.
  • The participant insured as a dependent under his or her ex-spouse's insurance must submit a health application to establish coverage in his or her own name. The ex-spouse must continue coverage with the same health plan unless he or she moves (e.g., from the county). The electronic or paper application must be received by the employee's benefits/payroll/personnel office (or ETF, for retirees and COBRA continuants) within 30 days of the date of the divorce.
  • Only one participant may cover any eligible dependent children (not including former stepchildren) under a family contract. Coverage of the same dependents by both parents is not permitted.

Note for Active Employees: Failure to apply in a timely manner will limit enrollment to the next annual open enrollment period for coverage effective the following January 1.

Note for Retirees and COBRA Continuants: Failure to apply in a timely manner will delay the effective date of coverage.

Medicare Eligibility: Please refer to the Medicare Information FAQs 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 at group rates for life under the State of Wisconsin Group Health Insurance Program. The dependent children may continue coverage until eligibility ceases if they:

  • Were enrolled at the time of death,
  • Were previously insured and regain eligibility, or
  • Are a child of the employee and born after the death of the employee.

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. Any unused sick leave credits are forfeited. 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 COBRA/Continuation of Health Coverage FAQs 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 or individual to family coverage is not allowable unless there is an IRS qualified family status change such as divorce, marriage, birth, or adoption. Additionally, if all covered family members become eligible for and enroll in another group health plan (group plans do not include Medicare or individual Medicare supplement policies), then you would also be allowed to change from family to individual coverage. 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 any time. 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 COBRA 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 COBRA 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 a switch to 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?