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.
Documentation requirements are the same for supplemental dental, vision, and the accident plan regardless of active/retiree status or pre-tax/post-tax status.
| Reason for Change or Enrollment | Documentation Required | Type of Documentation (Actives give to employers, retirees to ETF) |
|---|---|---|
| Adoption | Yes | Certified court document establishing the date of placement for adoption (typically a Certificate of adoption or Adoption decree) or International adoption papers from the country of adoption in the case of the child being adopted from outside the US |
| Annulment | Yes | Annulment court order, not a church annulment |
| Birth | Yes | Birth certificate |
| Cancel coverage or remove adult dependent due to enrollment in other health or supplemental insurance coverage | Yes | Documentation indicating the effective date of the other coverage such as a copy of a medical or supplemental ID card or a letter from the plan. Must be received within 30 days of enrollment in other coverage. Does not apply to health insurance change for retirees or post-tax deductions |
| Change of residence | Yes | Notify employer (retirees send application, letter, or email with effective date of change) |
| Custody transfer | Yes | Court order specifying custody change. For example, may be transfer to reflect gaining or changing custody, or a dependent's move out of area to another parent |
| Death | Yes | Original death certificate |
| Dependent who is disabled, age 26+, and 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 COBRA Continuation-Conversion Notice (ET-2311), provided by the employer (or ETF for retirees) and Certified 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/Change form (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 COBRA Continuation-Conversion Notice (ET-2311), provided by the employer (or ETF for retirees) and Certified 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/Change form (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 or supplemental benefit ID card or letter from plan indicating effective date of other coverage. Must be received within 30 days of enrollment in other coverage. Does not apply to health insurance change for 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 |
| 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 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
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 | Yes | Marriage certificate |
| Medicare-eligible and enrolled | Yes | Copy of 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) |
| 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 |
| State retiree reenroll | Yes | Sick Leave Re-enrollment Application (ET-4317) and additional documentation listed on the sick leave reenrollment application |