State Group Health Insurance
<< Annual Benefit Enrollment Opportunities
<< State Group Health Insurance Enrollment Options
Special Enrollment for Current Participants
Enrollment Period: October 5-December 29, 2009
Application Deadline: Tuesday, December 29, 2009, 4:30 pm*
Changes Effective: January 1, 2010
How to add Eligible Adult Children under Age 27
1. Please review Benefit Eligibility for Adult Children up to Age 27, a detailed ETF question and answer document. Effective January 1, 2010, adult children are eligible for coverage up to the end of the month in which they turn the age of 27 as long as:
- They are not married, and
- They are not eligible for health insurance through their own employer for which the amount of their premium contribution is less than the additional premium amount you are required to pay to insure your adult child on your policy.
2. Review the Imputed Income and Health Insurance Benefits page.
3. If your adult child (age 19 and older) is currently insured with your health plan, you must complete the Adult Child Dependent Verification Form. Your health plan will mail the form to you during the week of October 26, 2009. Return the completed form to your health plan by December 1, 2009. Student status is no longer a requirement.
4. If your eligible adult child is not currently insured with your health plan, complete a new health insurance application. Specific instructions follow.
Application | Submit to your Payroll & Benefits Office
Health Insurance Application/Change Form, ET-2301
Use Adobe Reader to open and complete PDF forms.
MAC Users: Do not use "Preview", a PDF reader.
Section 1 - Applicant Information
- Complete all applicable fields.
- If applicable, for 'Marital or Domestic Partnership Status', check the appropriate box and enter your Spouse's/Domestic Partner's name, Social Security Number and Date of Birth.
- For 'I Want My Coverage To Be Effective', select 'It's Your Choice (January 1)'.
- For 'Coverage Desired', select 'Family'.
Section 2 - Reason for Application, Subsection A
- If you have had Single coverage, check the box 'Change to Family Coverage-43' - or - If you already have Family coverage, check the box 'Other' and enter "Adding Adult Child(ren)" in the text field.
Section 3 - Enrollment Information
- Complete all applicable fields.
- List your spouse/domestic partner and all eligible dependents. See the instructions above regarding the addition of a domestic partner and their eligible dependents to your health insurance coverage.
- For 'Tax Dep?' indicate Y (Yes) or N (No) if your dependent child is considered a “tax dependent” under federal law. Note: There may be tax consequences to you when you cover dependents (i.e., adult children) that are not dependent on you for at least 50% of their support.
Sections 4, 5, and 6
- Answer all questions (check boxes) and complete applicable fields.
Section 7 - Signature
Read the TERMS AND CONDITIONS.
- Check the first box, 'I apply for the insurance under the indicated health insurance contract made available to me through the State of Wisconsin and have read and agree to the TERMS AND CONDITIONS. A copy of this application is to be considered as valid as the original.'
- Sign and date the application, indicating agreement with the terms and conditions.
5. Submit your completed application to your benefits coordinator or your campus benefits office. Retain a copy of the application for your records.
- The application submission deadline is Tuesday, December 29, 2009, 4:30 pm*
- Coverage changes will be effective January 1, 2010.
*Note: Offices will be closed December 30, 2009, a mandatory furlough day for UW-Madison.
Eligibility for Adult Dependent Children Age 27 and Older
Adult dependent children 27 years or older that are not married are eligible for coverage when they are:
Disabled: incapable of self-support because of a physical or mental disability that is expected to be of long-continued or indefinite duration and dependent on either parent for at least 50% of their support and maintenance (see IRS Publication 501 for worksheet).
Returned from Military Duty: a full-time student who was previously called to federal active duty when under the age of 27 years and while attending an institution of higher education on a full-time basis.