Non-Monroe
County
Municipal
School
District
Program
Required
Dependent
Eligibility
Document
Checklist
Contract
Tier
Single
No
documents
required
2
Person,
Employee
&
Spouse
Documents
required
Family
No
Spouse,
Employee
&
Children,
Family
Documents
required
Please
request
and
review
these
documents
and
return
the
documents
to
the
employee
upon
checklist
completion.
Spouse
I
Common
Law
D
A
copy
of
your
marriage
certificate/civil
union
certificate
or
completed
Affidavit
of
Common
Law
Marriage
AND
D
One
form
of
documentation
dated
within
the
last
6
months
establishing
current
marital
status,
such
as
a
joint
household
bill,
joint
bank
/
credit
card
account,
joint
mortgage
or
lease,
or
front
page
of
your
jointly
filed
federal
tax
return
Children
I
Grandchildren
D
A
copy
of
the
child’s
birth
certificate,
(or
hospital
certificate
for
newborn
child)
naming
you
or
your
spouse
as
the
child’s
parent,
or
appropriate
court
order
/
adoption
decree
naming
you
or
your
spouse
as
the
child’s
legal
guardian
AND
E
lf
applicable,
a
copy
of
a
divorce
decree
granting
full
or
joint
custody
(names
of
all
parties
must
be
included)
OR
If
applicable,
a
copy
of
a
courtissued
Qualified
Medical
Child
Support
Order
(QMCSO)
or
other
court
order
where
you
are
required
to
provide
healthcare
(names
of
all
parties
must
be
included)
Children
Eligible
for
Dental
with
the
Age
19/23
Student
Rider
(This
section
to
be
completed
only
for
dependent
children
age
19/23)
D
A
copy
of
the
child’s
birth
certificate,
naming
you
or
your
spouse
(or
domestic
partner,
if
applicable)
as
the
child’s
parent,
or
appropriate
court
order
/
adoption
decree
naming
you,
your
spouse,
or
domestic
partner
as
the
child’s
legal
guardian
AND
D
A
copy
of
the
Spring
2011
college
or
university
school
schedule
or
enrollment
verification
statement
that
confirms
the
dependent’s
status
as
a
full
time
student
(Full
time
status
is
typically
12
hours
or
more
as
an
undergraduate,
and
9
hours
or
more
as
a
graduate
student).
The
student’s
name,
enrollment
dates,
credit
hours
and/or
status,
and
the
name
of
the
educational
institution
must
be
included
Disabled
Dependents
D
A
copy
of
the
child’s
birth
certificate,
naming
you
or
your
spouse
as
the
child’s
parent,
or
appropriate
court
order
/
adoption
decree
naming
you
or
your
spouse
as
the
child’s
legal
guardian
AND
D
The
Excellus
handicap
dependent
application
form
AND
E
lf
applicable,
a
copy
of
a
divorce
decree
granting
full
or
joint
custody
(names
of
all
parties
must
be
included)
OR
If
applicable,
a
copy
of
a
court-issued
Qualified
Medical
Child
Support
Order
(QMCSO)
or
other
court
order
where
you
are
required
to
provide
healthcare
(names
of
all
parties
must
be
included)
Affidavit/Signature
Employee
Name
(print)
Employee
Signature
Date
District
Rep
Name
(print)
District
Rep
Signature
Date
Revised
4/1/2011
NDP
&
DNTL
19/23
-
HCR
Non-Monroe
County
Municipal
School
District
Program
Required
Dependent
Eligibility
Verification
As
part
of
the
commitment
to
control
healthcare
costs,
the
Non-Monroe
County
Municipal
School
District
Program
(NMCMSOP)
is
taking
steps
to
ensure
that
only
eligible
dependents
are
covered
under
our
health
and/or
dental
plans.
To
ensure
that
each
dependent
enrolled
in
the
plans
is
accurately
listed
and
eligible
for
coverage,
documents
are
required
to
enroll
a
newly
eligible
employee
or
add
a
new
dependent
to
an
existing
NMCMSDP
plan.
The
definition
of
eligible
dependents
is
below.
Definition
of
Eligible
Dependents
Definition
of
Eligible
Dependents
-
Medical
Plans
Eligible
Spouse
Your
legal
spouse
or
civil
union
partner
as
evidenced
by
a
marriage
or
civil
union
certificate;
if
you
married
under
a
recognized
common
law
arrangement
in
a
state
that
has
recognized
this
relationship,
you
may
complete
an
Affidavit
of
Common
Law
Marriage
in
lieu
of
a
marriage
certificate
Eligible
Domestic
Partner
(if
applicable)
Your
qualifying
same
or
opposite
sex
domestic
partner
as
established
by
plan
guidelines.
Is
at
least
18
years
old,
not
related
to
the
employee
by
blood
or
a
degree
of
closeness
that
would
prohibit
marriage
in
the
law
of
the
state
in
which
the
couple
resides,
and
not
married
to
or
in
a
domestic
partnership
with
any
other
person;
is
capable
of
consenting
to
a
domestic
partnership;
shares
a
common
residence
and
financial
responsibility
with
an
employee.
Eligible
Children
/
Disabled
Dependents
Your
child
younger
than
age
26;
coverage
may
be
extended
to
a
child
of
any
age
who
is
incapable
of
self-sustaining
employment
because
of
mental
illness
and/or
physical,
mental
or
developmental
disability.
A
child
is
defined
as
your
natural
child;
stepchild;
adopted
child
or
child
placed
with
you
for
adoption;
child
for
whom
you
are
the
court
appointed
legal
guardian;
or
child
for
whom
you
are
required
to
provide
health
insurance
and/or
support
by
means
of
a
legal
order.
Eligibility
for
dependent
child
coverage
is
based
only
in
terms
of
the
relationship
between
a
child
and
participant,
and
coverage
may
not
be
denied
or
restricted
based
on
factors
such
as:
financial
dependency,
residency,
student
status,
employment
status,
eligibility
of
other
coverage
or
marital
status.
An
employee’s
grandchild
for
whom
the
employee
has
legally
adopted
or
accepted
legal
guardianship
of
or
for
whom
the
employee
is
legally
required
to
provide
health
insurance
is
also
an
eligible
dependent.
Healthcare
reform
does
not
require
that
the
spouse
of
a
child
be
covered,
nor
does
it
require
that
the
dependent
child
of
a
child
(grandchild)
be
covered.
For
Blue
Million
Policies
Blue
Million
plans
also
allow
as
eligible
dependents
a
foster
child
who
resides
with
and
is
chiefly
dependent
upon
you
for
support;
a
foreign
exchange
student
who
is
chiefly
dependent
upon
you
for
support.
Definition
of
Eligible
Dependents
-
Dental
Plans
Eligibility
definitions
for
eligible
spouse,
domestic
partner
and
children
from
age
0-
18
are
the
same
as
the
medical
plans
above.
Children
age
19-23
must
meet
one
additional
eligibility
criteria.
If
the
dental
plan
is
offered
with
dependent
students
eligible
from
the
age
of
19-23,
the
child
must
be
enrolled
as
a
full-time
student
at
an
accredited
college.
Revised
4/1/2011
NDP
&
DNTL
19/23
-
11CR