HSTA VB Retiree – Qualifying Events

The following common qualifying events allow enrollment changes for Retirees. To learn more about a specific event, click on the + located on the left of the event.

Acquisition of Coverage

EVENT DESCRIPTION: Retiree or dependent gets coverage from another plan and wishes to cancel EUTF or HSTA VB plans

WHEN EC-2/EC-2H MUST BE SUBMITTED TO EUTF: Within 30 days from effective date of acquiring coverage elsewhere

DOCUMENTATION REQUIRED TO BE ATTACHED TO EC-2/EC-2H: Letter from carrier or employer detailing type of coverages enrolled in (i.e., medical, drug, dental, vision), effective date of coverage, and names of covered insured and/or dependents

EFFECTIVE DATE (All plans except UnitedHealthcare’s Medicare Advantage Plan): End of pay period in which retiree acquires coverage from a non-EUTF plan, except when the retiree acquires coverage from the non-EUTF plan on the first or 16th of the month, in which case coverage ends at the end of the prior pay period

EFFECTIVE DATE (UnitedHealthcare’s Medicare Advantage Plan): End of pay period in which retiree acquires coverage from a non-EUTF plan, except when the retiree acquires coverage from the non-EUTF plan on the first or 16th of the month, in which case coverage ends at the end of the prior pay period

CAN I CHANGE PLANS?: N/A

Birth

EVENT DESCRIPTION: Retiree wishes to add newborn to plans

WHEN EC-2/EC-2H MUST BE SUBMITTED TO EUTF: Within 180 days from date of birth

DOCUMENTATION REQUIRED: Birth certificate only if child has a different last name from employee. Social Security Number within 180 days of date of birth.

EFFECTIVE DATE (All plans except UnitedHealthcare’s Medicare Advantage Plan): Retiree can choose: birth date, beginning of the next pay period after birth date, or beginning of 2nd pay period after birth date

EFFECTIVE DATE (UnitedHealthcare’s Medicare Advantage Plan): No plan changes allowed if already enrolled. May enroll in plans if not already enrolled or may add dependents if already enrolled.

CAN I CHANGE PLANS?: N/A

Cancellation due to failure to comply with Rules

WHEN EC-2/EC-2H MUST BE SUBMITTED TO EUTF: N/A

DOCUMENTATION REQUIRED TO BE ATTACHED TO EC-2/EC-2H: Proof of compliance documentation provided to EUTF

EFFECTIVE DATE (All plans except UnitedHealthcare’s Medicare Advantage Plan): The date set forth in a notice to the retiree of his/her failure to comply with the Rules

EFFECTIVE DATE (UnitedHealthcare’s Medicare Advantage Plan): The date set forth in a notice to the retiree of his/her failure to comply with the Rules

CAN I CHANGE PLANS?: N/A

Death

WHEN EC-2/EC-2H MUST BE SUBMITTED TO EUTF: As soon as reasonably practical

DOCUMENTATION REQUIRED TO BE ATTACHED TO EC-2/EC-2H: Death certificate or copy of obituary as soon as available

EFFECTIVE DATE (All plans except UnitedHealthcare’s Medicare Advantage Plan): Date of death or last day of pay period in which death occurs for dependents

EFFECTIVE DATE (UnitedHealthcare’s Medicare Advantage Plan): Date of death

CAN I CHANGE PLANS?: N/A

Divorce

EVENT DESCRIPTION: Retiree must terminate spouse or civil union partner’s coverage

WHEN EC-2/EC-2H MUST BE SUBMITTED TO EUTF: Within 30 days of date of divorce. If EC-2/EC-2H is filed more than 30 days after date of divorce, retiree is responsible for claims incurred after the date of divorce

DOCUMENTATION REQUIRED TO BE ATTACHED TO EC-2/EC-2H: Pages 1 and 2 of divorce decree, along with signature page. If children are involved, those pages that outline health benefits for children

EFFECTIVE DATE (All plans except UnitedHealthcare’s Medicare Advantage Plan): First day of the first pay period following the divorce

EFFECTIVE DATE (UnitedHealthcare’s Medicare Advantage Plan): First day of the first pay period following the divorce

CAN I CHANGE PLANS?: No

Failure to Enroll in Medicare Part B

EVENT DESCRIPTION: Retirees and their dependents who are eligible to enroll in Medicare Part B must enroll

WHEN EC-2/EC-2H MUST BE SUBMITTED TO EUTF: N/A

DOCUMENTATION REQUIRED TO BE ATTACHED TO EC-2/EC-2H: N/A

EFFECTIVE DATE (All plans except UnitedHealthcare’s Medicare Advantage Plan): Cancellation in the medical and prescription drug plan is effective the date the retiree or dependent first became eligible to enroll in Medicare Part B

EFFECTIVE DATE (UnitedHealthcare’s Medicare Advantage Plan): Cancellation in the medical and prescription drug plan is effective the date the retiree or dependent first became eligible to enroll in Medicare Part B

CAN I CHANGE PLANS?: N/A

Failure to Pay

EVENT DESCRIPTION: Retiree owes a shortage, but does not pay shortage by due date – enrollment will be cancelled

WHEN EC-2/EC-2H MUST BE SUBMITTED TO EUTF: N/A

DOCUMENTATION REQUIRED TO BE ATTACHED TO EC-2/EC-2H: None

EFFECTIVE DATE (All plans except UnitedHealthcare’s Medicare Advantage Plan): If enrollment is cancelled, retiree may only re-enroll during the next open enrollment period

EFFECTIVE DATE (UnitedHealthcare’s Medicare Advantage Plan): If enrollment is cancelled, retiree may only re-enroll during the next open enrollment period

CAN I CHANGE PLANS?: No

Geographic Relocation

EVENT DESCRIPTION: Retiree enrolled in Kaiser and moves to an area where Kaiser is not available

WHEN EC-2/EC-2H MUST BE SUBMITTED TO EUTF: Within 30 days from the date of relocation

DOCUMENTATION REQUIRED TO BE ATTACHED TO EC-2/EC-2H: None

EFFECTIVE DATE (All plans except UnitedHealthcare’s Medicare Advantage Plan): The date of the retiree’s relocation.

EFFECTIVE DATE (UnitedHealthcare’s Medicare Advantage Plan): The date of the relocation.

CAN I CHANGE PLANS?: Yes

Ineligible Student

EVENT DESCRIPTION: Dependent child is no longer a full-time student and is age 19 through 23

WHEN EC-2/EC-2H MUST BE SUBMITTED TO EUTF: As soon as the dependent child is no longer enrolled as a full-time student

DOCUMENTATION REQUIRED TO BE ATTACHED TO EC-2/EC-2H: None

EFFECTIVE DATE (All plans except UnitedHealthcare’s Medicare Advantage Plan): First day of the pay period following the date the child was no longer enrolled as a full-time student

EFFECTIVE DATE (UnitedHealthcare’s Medicare Advantage Plan): N/A

CAN I CHANGE PLANS?: No

Legal Separation

EVENT DESCRIPTION: Retiree must terminate spouse’s or civil union partner’s EUTF or HSTA VB coverage

WHEN EC-2/EC-2H MUST BE SUBMITTED TO EUTF: Within 30 days of date of legal separation. If EC-2/EC-2H is filed more than 30 days after date of legal separation, retiree is responsible for claims incurred after the date of legal separation

DOCUMENTATION REQUIRED TO BE ATTACHED TO EC-2/EC-2H: Court document establishing legal separation, including any pages regarding health benefits to children

EFFECTIVE DATE (All plans except UnitedHealthcare’s Medicare Advantage Plan): First day of the pay period following the legal separation

EFFECTIVE DATE (UnitedHealthcare’s Medicare Advantage Plan): First day of the pay period following the legal separation

CAN I CHANGE PLANS?: No

Loss of Coverage

EVENT DESCRIPTION: Retiree and/or dependent lost coverage from a non-EUTF plan, wishes to enroll in EUTF or HSTA VB plans, and for dependents the retiree is currently enrolled in an EUTF or HSTA VB plan

WHEN EC-2/EC-2H MUST BE SUBMITTED TO EUTF: Within 30 days from loss of other coverage

DOCUMENTATION REQUIRED TO BE ATTACHED TO EC-2/EC-2H: Loss of coverage letter from previous employer/ carrier detailing type of coverages lost (i.e., medical, drug, dental, vision), date of loss of coverage, and names of any covered dependents.

Copy of dependent’s Medicare Part B card, if eligible to enroll

EFFECTIVE DATE (All plans except UnitedHealthcare’s Medicare Advantage Plan): Day following loss of coverage from other plan

EFFECTIVE DATE (UnitedHealthcare’s Medicare Advantage Plan): First of the month following the Signature date on the EC-2 Enrollment Form. Dependent must be enrolled in Medicare Parts A and B

CAN I CHANGE PLANS?: No

Marriage

WHEN EC-2/EC-2H MUST BE SUBMITTED TO EUTF: Within 30 days from date of marriage

DOCUMENTATION REQUIRED TO BE ATTACHED TO EC-2/EC-2H: Marriage Certificate within 60 days from date of marriage.

Copy of Spouse’s Medicare Part B card, if eligible to enroll

EFFECTIVE DATE (All plans except UnitedHealthcare’s Medicare Advantage Plan): The date of marriage, the first day of the first pay period after the date of marriage, or the first day of the 2 nd pay period after the date of marriage

EFFECTIVE DATE (UnitedHealthcare’s Medicare Advantage Plan): First of the month following the signature date on the EC-2 Enrollment form

New spouse must be enrolled in Medicare Parts A & B at time of enrollment

CAN I CHANGE PLANS?: No

New Civil Union Partner

EVENT DESCRIPTION: Retiree wishes to enroll new civil union partner in EUTF or HSTA VB plans

WHEN EC-2/EC-2H MUST BE SUBMITTED TO EUTF: Within 30 days from date of civil union

DOCUMENTATION REQUIRED TO BE ATTACHED TO EC-2/EC-2H: Civil Union certification (on- line proof accepted), Affidavit of Dependency. Copy of Partner’s Medicare Part A & B card, if eligible to enroll

EFFECTIVE DATE (All plans except UnitedHealthcare’s Medicare Advantage Plan): The date of the civil union, or the first day of the first pay period after the date of the Civil Union, or the first day of the 2nd pay period after the date of the Civil Union

EFFECTIVE DATE (UnitedHealthcare’s Medicare Advantage Plan): First of the month following the Signature date on the EC-2 Enrollment form. New civil union partner must be enrolled in Medicare Parts A & B at time of enrollment

CAN I CHANGE PLANS?: No

New Domestic Partner

EVENT DESCRIPTION: Retiree wishes to enroll new domestic partner in EUTF or HSTA VB plans

WHEN EC-2/EC-2H MUST BE SUBMITTED TO EUTF: Within 30 days from date of notarized signature (event date is considered date of notarization)

DOCUMENTATION REQUIRED TO BE ATTACHED TO EC-2/EC-2H: Notarized Declaration of Domestic Partnership and Affidavit of Dependency (notarized if IRS qualified) with EC-2/EC-2H (forms available on the EUTF website).

Copy of Partner’s Medicare Part B card, if eligible to enroll

EFFECTIVE DATE (All plans except UnitedHealthcare’s Medicare Advantage Plan): The date the notary signs the Declaration of Domestic Partnership, the first day of the first pay period after the notary signs, or the first day of the 2nd pay period after the notary signs

EFFECTIVE DATE (UnitedHealthcare’s Medicare Advantage Plan): First of the month following the Signature date on the EC-2 Enrollment form. New domestic partner must be enrolled in Medicare Parts A & B at time of enrollment

CAN I CHANGE PLANS?: No

Newly Eligible Student

EVENT DESCRIPTION: Retiree wishes to enroll child because child became full-time student and is age 19 through 23

WHEN EC-2/EC-2H MUST BE SUBMITTED TO EUTF: Within 30 days from school start date

DOCUMENTATION REQUIRED TO BE ATTACHED TO EC-2/EC-2H: Student certification from an accredited college on school letterhead with registrar’s signature confirming full time status. Transcripts not acceptable

EFFECTIVE DATE (All plans except UnitedHealthcare’s Medicare Advantage Plan): Date child becomes full-time student, the first day of the first pay period after becoming a full-time student, or the first day of the 2nd pay period after becoming a full-time student

EFFECTIVE DATE (UnitedHealthcare’s Medicare Advantage Plan): Students are not eligible unless enrolled in Medicare Parts A & B

If enrolled in Parts A & B, effective date of coverage is the first of the month following the signature date on the EC-2 Enrollment Form

CAN I CHANGE PLANS?: No

Surviving Spouse/Domestic Partner Remarries or Enters Into Another Domestic Partnership

EVENT DESCRIPTION: Surviving spouse or domestic partner will be cancelled from EUTF’s or HSTA VB’s plans

WHEN EC-2/EC-2H MUST BE SUBMITTED TO EUTF: Within 30 days from the remarriage or the new domestic partnership

DOCUMENTATION REQUIRED TO BE ATTACHED TO EC-2/EC-2H: None

EFFECTIVE DATE (All plans except UnitedHealthcare’s Medicare Advantage Plan): The first day of the pay period following the remarriage or new partnership

EFFECTIVE DATE (UnitedHealthcare’s Medicare Advantage Plan): The first day of the pay period following the remarriage or new partnership

CAN I CHANGE PLANS?: N/A

Termination of Domestic Partnership

EVENT DESCRIPTION: Retiree must terminate domestic partner from EUTF or HSTA VB plans

WHEN EC-2/EC-2H MUST BE SUBMITTED TO EUTF: Within 30 days of termination of domestic partnership. If EC-2/EC-2H is filed more than 30 days after date of termination of domestic partnership, retiree is responsible for claims incurred after the date of termination of domestic partnership

DOCUMENTATION REQUIRED TO BE ATTACHED TO EC-2/EC-2H: Declaration of Termination of Domestic Partnership with EC-2/EC-2H (forms are available on the EUTF website)

EFFECTIVE DATE (All plans except UnitedHealthcare’s Medicare Advantage Plan): First day of the pay period following the date of the termination of the domestic partnership

EFFECTIVE DATE (UnitedHealthcare’s Medicare Advantage Plan): First day of the pay period following the date of the termination of the domestic partnership

CAN I CHANGE PLANS?: No