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 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 parent

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/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, a copy of divorce decree from clerk of courts showing date of entry of divorce per the Terms and Conditions 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).

Divorce (family to individual) Yes

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

In addition, a copy of divorce decree from clerk of courts showing date of entry of divorce per the Terms and Conditions 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).

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

COBRA notice is acceptable if the coverage end date, covered individuals and health plan are indicated. If loss of employer premium contributions, letter from employer indicating they no longer contribute toward their employee’s premium.

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.)
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 re-enroll Yes Sick Leave Re-enrollment Application (ET-4317) and additional documentation listed on the sick leave re-enrollment application.

 

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