Get Affidavit For Dependent Continuation Of Health Care Coverage ... - Franciscan

Wants to be Removed An eligible child may be removed from a Self Plus One or a Self and Family enrollment if a request is submitted to the enrollee's agency for approval. The child's request must include a notarized statement from the child. A child's removal is considered a cancellation.

When your child reaches age 26, they are no longer an eligible family member on your FEHB plan. Your child's coverage will continue at no cost for 31 days starting from the date the child turns 26 years old.

The request must include proof that the child is no longer a dependent (by providing the enrollee's most recent tax return or a signed affidavit attesting that the child is no longer a dependent under the IRS definition of dependent) and a Health Benefits Election Form (Standard Form (SF) 2809).

The Plan's Working Spouse Rule states that, if your spouse is working for an employer who offers a health plan, the Plan requires them to enroll in that employer-sponsored coverage to be eligible for Plan coverage. Your spouse must confirm whether they have access to and are enrolled in their employer's health plan.

Family Member Type: Spouse The request must include a Health Benefits Election Form (Standard Form (SF) 2809) and a notarized statement signed by both the enrollee and the spouse. A draft statement is attached. A spouse's removal is considered a cancellation.

You're also responsible for submitting transactions during Open Enrollment for employees on a leave of absence who want to change plans or add/delete dependents. Employees who do not change plans or add/delete dependents during Open Enrollment may do so within 60 days from the date they return to regular pay status.