| | Dependent Coverage, as the name suggests is coverage for your dependents. Please complete 'Section E,' if you have any dependents for whom you would want coverage. |
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 | Name (Column 1) - Enter Dependent's Name (Last, First, Middle), one in each row. |
| Gender (Column 2) - Use the check box to check appropriate Gender for the dependent.. |
| Birth Date (Column 3) - Enter the Birth Date of the Dependent (MM/DD/YYYY format). |
| Dep. Nation ID/SSN (Column 4)- Enter SSN of the dependent, required for all dependents 12 months or older. |
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'Relationship (Column 5) - Check 'Sp' for Spouse, 'D' or 'S' for natural or adopted daughter or son and 'O' for other than natural or adopted child. |
| Health (Column 6) - Check Enroll against each dependent's name, if you have opted for health coverage. For Full-Time Employee Health Premiums,click here. For Part Time Employee & Grad Student Premium,click
here |
| Dental (Column 7) - Check Enroll against each dependent's name, if you have opted for dental coverage. For Dental Premiums summary, click here. |
| Dependent Life (Column 8) - Check Enroll against each dependent's name, if you have opted for dependent life coverage. For Dependent Lifel Premiums summary, click here. |
| Dependent(s) Previously covered under National ID/SSN - If you are currently being covered as a dependent in medical plan of the Group Benefits Plan administered by the Employees Retirement System of Texas, please write the Social Security Number of the person that is covering you. |
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| Information of Dependent Coverage |
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| | Eligibility of Your Dependents For Coverage |
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| | Your spouse and children who meet certain conditions may be covered as dependents in the health plan in which you are enrolled. During your initial period of eligibility, you may choose a plan that provides both you and your eligible dependents with health, dental and other coverage. You must enroll yourself in a health care plan in order to have health coverage for your dependents. Your dependents must be enrolled in the same health plan as you; however, they do not need to choose the same primary care physician (PCP) that you have selected. The same enrollment requirements apply to dental care. |
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| | Eligibility of Your Spouse |
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| During your initial period of eligibility, you may enroll the person to whom you are legally married, including a common-law spouse, in the health and dental plans in which you are enrolled, dependent term life and voluntary AD&D (Employee Only, Employee and Family). |
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| In the event of divorce, your former spouse is no longer eligible for coverage as your dependent. When your divorce is final, you must notify your benefits coordinator immediately. You may make coverage changes due to this Qualifying Life Event, and you must do so within 30 days of your divorce. Your ex-spouse may be eligible to continue health and dental coverage under the provisions of the Consolidated Omnibus Budget Reconciliation Act (COBRA), if you notify your benefits coordinator within 60 days of your divorce. |
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| No person is eligible to be enrolled in coverage as your spouse while you are legally married to another person. For example, you may not have a common-law spouse enrolled as your spouse in a health plan, and then marry another person and have them enrolled as your spouse, until you have obtained a legal divorce from the common-law spouse and dropped him or her from coverage. |
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| | Your Children as Dependents |
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| During your initial period of eligibility, you may enroll your unmarried children under 25 years of age who are one of the following: |
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| | | - | Your natural child. | | - | Your adopted child (including a child living with you during the period of probation). | | - | Your stepchild whose primary residence is with you. | | - | Your foster child whose primary residence is with you, provided the child is not covered by another governmental health program. | | - | A child for whom you are the legal guardian and whose primary place of residence is with you. | | - | A child for whom you must provide medical support as required by a valid medical support order. | | - | Your grandchild who is your dependent for federal income tax purposes. | | - | A child with whom you have established a parent-child relationship, whose primary residence is with you, for whom you provide the necessary care and support and whose natural parent, if older than 21 years of age, does not reside in the same household. |
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When your child loses eligibility as your dependent as defined previously,
you must notify your benefits coordinator immediately. The plan will not
cover medical expenses incurred after your dependent loses eligibility. You
may make certain changes in coverage consistent with this QLE, but those changes must be made within 30 days of the event. Your child may be eligible to continue health and dental coverage under the provisions of COBRA, if you notify your benefits coordinator within 60 days of your dependent’s loss of eligibility. |
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| Your unmarried, mentally or physically incapacitated child may be eligible to continue coverage as your dependent after age 25 when all five of the following conditions are true: |
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| | | - | Your child was enrolled as a GBP participant on his/her 25th birthday. | | - | Your child's coverage has not lapsed. | | - | The condition of physical or mental incapacitation began prior to your child reaching age 25. | | - | You submit satisfactory certification of your child's condition within 30 days from your child's 25th birthday. | | - | You agree to submit periodic re-certification of your child's condition and dependency when requested. |
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| Mental or physical incapacitation includes any medically determined mental or physical condition which prevents your child from engaging in self-sustaining employment. Your mentally or physically incapacitated child will lose eligibility for coverage if any one of the following events occurs: |
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| | | - | You fail to pay premiums for coverage. | | - | Your child marries. | | - | Your child is determined to be employable and self-sustaining. | | - | You drop your child from all coverage. | | - | You agree to submit periodic re-certification of your child's condition and dependency when requested. |
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| In the event one of these conditions occurs, your child will no longer be eligible for coverage as your dependent even in the event of any change in your child’s condition. Upon losing eligibility, your child may be eligible to continue health and dental coverage under the provisions of COBRA, provided you notify your benefits coordinator within 60 days of your dependent’s loss of eligibility. |
