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DEPENDENT ELIGIBILITY CERTIFICATION AND VALIDATION (Ivy Tech Community College)

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I/2576733.7

DEPENDENT ELIGIBILITY CERTIFICATION AND VALIDATION

Ivy Tech is committed to providing its employees and their families with a very comprehensive and affordable

alth, dental, and vision insurance program. This commitment can only be honored if we responsibly manage

our costs through thoughtful plan designs and participation (enrollment). Our health, dental, and vision

insurance plan designs are the subject of intense discussions each year as we are confronted with the task of

balancing the required premiums with the desired benefits that are provided. The other cost, i.e. participation

or enrollment, is managed by assuring that all employees and their eligible dependents are afforded the

opportunity to participate in our plans.

Ivy Tech has a “Working Spouse Rule,” which requires the working spouses of our employees who have

affordable health and/or dental insurance available at their place of employment to enroll in their employer's

coverage in order to be eligible for secondary coverage under Ivy Tech's health and/or dental coverage. This

increasingly common eligibility rule is one way Ivy Tech has addressed the challenge of rising health care

costs without excluding eligible dependents who may not have their own affordable health care options.

Another way Ivy Tech manages our health, dental and vision insurance costs is to confirm that each dependent

that is covered by the Ivy Tech benefit plans is actually eligible. As with the Working Spouse Rule, the process

for confirming the eligibility of dependents is a common practice by most employers in the private and service

sectors.

In order to confirm the eligibility of your dependents under Ivy Tech’s benefit plans, please follow

these steps:

1. Review the eligibility language associated with our benefit plans (page 2).

2. Once you understand our eligibility language, review the documentation requirements (page 3).

3. In order for you to cover the dependents shown on the Dependent Confirmation Documentation

Remittance Form (page 4), you must gather the necessary documentation as listed and you must

provide what is requested for all covered dependents. Please provide us with copies and

maintain the originals for your files.

4. We realize the sensitivity of the documents we are asking you to provide. To avoid any potential

concerns you may have, please black-out all personal information, including income and social

security numbers, which is not required to verify your dependents.

5. If you are covering a spouse, please complete and return the New Hire or Newly Eligible Questionnaire

for Health and Dental Coverage of a Spouse (pages 5 & 6). Page 7 must be completed if your spouse

is employed or retired and is eligible for health and/or dental coverage through such employer or

former employer.

6. If you have questions about this dependent eligibility confirmation procedure or if you experience

problems gathering your information, contact your Regional Human Resources Department.

I/2576733.7 Page 2 of 7

ELIGIBILITY LANGUAGE FOR IVY TECH HEALTH, DENTAL AND VISION PLANS

To enroll an individual as a Dependent in the Ivy Tech Community College Health and Dental Care Plan ("Health and Dental Plan")

and the Ivy Tech Community College Vision Plan ("Vision Plan"), the individual must be listed on the enrollment form completed

by the Covered Employee (including an LTD Participant) or Retiree, meet all dependent eligibility criteria established by Ivy Tech,

and fall within one of the following categories:

• The Covered Employee's or Retiree's spouse. For this purpose, "spouse" means a person who whom the Covered Employee's

or Retiree's is legally married to under federal tax law, unless:

o the Covered Employee or Retiree and his or her spouse are divorced or legally separated under a decree of

divorce or separate maintenance, or

o the spouse is not a citizen, resident or national of the United States, or

o the Covered Employee or Retiree and his or her spouse file separate returns, the Covered Employee or Retiree

maintains a household which is the principal place of abode for a child (with respect to whom the Covered

Employee or Retiree is entitled to a deduction) for more than ½ the calendar year, the Covered Employee or

Retiree furnishes more than ½ of the cost of maintaining that household, and the spouse was not a member of

that household during the last 6 months of the year.

• The Covered Employee's or Retiree's child until the end of the month in which the child attains age 26. For this purpose,

"child" means the natural child, stepchild, legally adopted child or child who has been placed for adoption, or eligible foster

child. An "eligible foster child" is a child who is placed with the Covered Employee or Retiree by an authorized placement

agency or by judgment, decree, or other order of a court of competent jurisdiction. For purposes of the Vision Plan only,

the child must be unmarried or a full-time student for coverage to extend until the end of the month the child attains age 26.

• The Covered Employee's or Retiree's child, as defined above, past the limiting age if the child:

o is enrolled as a Dependent prior to reaching the limiting age,

o is claimed as a tax dependent on the Covered Employee's or Retiree's federal tax return, and

o is "permanently and totally disabled," meaning that such child is unable to engage in any substantial gainful

activity by reason of a medically-determinable physical or mental impairment which can be expected to result in

death, or has lasted or can be expected to last for a continuous period of not less than 12 months.

The Covered Employee or Retiree must submit proof of incapacity to Ivy Tech within 120 days after the Dependent would

otherwise lose eligibility under the plan. Subsequent proof of continued incapacity may be required by Ivy Tech. You must

notify the Administrator and/or Ivy Tech if the Dependent’s status changes and he or she is no longer eligible for continued

coverage.

The Plan may require the Covered Employee to submit proof of continued eligibility for any enrolled child. Your failure to provide

this information could result in termination of a child’s coverage.

Working Spouse Rule

The Working Spouse Rule requires employed spouses of Covered Employees or Retirees to enroll in their employer’s group health

plan and/or dental plan in order for them to be eligible to enroll in or remain on the Health and Dental Plan for secondary coverage.

The Working Spouse Rule will not apply with respect to any dental plan offered by Ivy Tech or any other employer that does not

coordinate benefits with other employer-sponsored dental coverage. Health and dental coverage are separately electable under

the Health and Dental Plan and this Working Spouse Rule will apply to each independently. The coordination of benefits provisions

under the Health and Dental Plan will continue to apply.

IMPORTANT: Your spouse may remain on the Health and Dental Plan for primary coverage as a Dependent if he or she meets

one of the following criteria:

1. He or she is currently unemployed and has no comprehensive group health and/or dental coverage (other than COBRA);

2. He or she is retired, is not currently employed, and is not eligible for coverage as a retiree under any employer-sponsored

comprehensive group health and/or dental plan, respectively;

3. He or she is employed or self-employed, but is not eligible for any employer-sponsored comprehensive group health

and/or dental plan, respectively;

4. He or she is employed or retired, but the employer or former employer does not provide comprehensive group health

and/or dental coverage, as applicable; or

5. He or she is employed or retired, but the employer or former employer does not pay at least 50% of the premium expense

for the spouse's employee/retiree only coverage under the employer-sponsored comprehensive group health and/or

dental plan, as applicable.

A Covered Employee's spouse is considered to be "eligible for" other coverage even if a pre-existing condition clause is applicable

or the spouse received a cash opt-out payment for not electing such coverage.

If you and your spouse are both benefits-eligible employees at Ivy Tech, you must each enroll as an employee under the Health

and Dental Plan and decide which parent will cover any Dependent children.

I/2576733.7 Page 3 of 7

REQUIRED DOCUMENTATION

R DEPENDENT COVERAGE

For Your Spouse

Submit the following:

• Copy of marriage certificate (not license)

• Copy of most recent federal tax return (SUBMIT FRONT PAGE AND SIGNATURE PAGE

ONLY)

AND

• Signed and dated Remittance Form (page 4)

AND

• Signed and dated Working Spouse Questionnaire (pages 5 and 6)

For Your Children (ALL Children) Under Age 26

Submit the following:

• Copy of birth certificate

• For adopted children, a copy of the amended birth certificate naming the you as the

parent or adoption papers

AND

• Signed and dated Remittance Form (page 4)

For Your Child Who Is an Eligible Foster Child

Also submit:

• Copy of judgment, decree, or order from court, or other documentation from authorized

placement agency, confirming placement of child with you

For Your Child Who Is Totally and Permanently Disabled

Also submit all of the following that apply:

• Physician letter with a Statement of Total and Permanent Disability, completed and

signed by the dependent’s physician (stamped signature not acceptable)

• Copy of most recent federal tax return (SUBMIT FRONT PAGE AND SIGNATURE PAGE

ONLY)

• Copy of SSI award if eligible

PLEASE DO NOT SENT ORIGINAL DOCUMENTS. They will not be returned to you.

NEED ASSISTANCE? Contact your Regional Human Resources Department.

PLEASE SEND COPIES, NOT ORIGINAL DOCUMENTS.

They will not be returned to you. Black-out financial

information and Social Security numbers on all documents.

Your information will be kept confidential.

I/2576733.7 Page 4 of 7

IVY TECH COMMUNITY COLLEGE OF INDIANA

DEP

ENDENT CONFIRMATION DOCUMENTATION REMITTANCE FORM

RETURN THIS PAGE WITH YOUR REQUIRED DOCUMENTATION

Please complete and return this remittance form to your Regional Human Resources Department along

with copies of the required documentation for each dependent that you have enrolled in the Ivy Tech

Community College Health and Dental Plan ("Health and Dental Plan") and/or Ivy Tech Community College

Vision Plan ("Vision Plan").

Employee Name: ___________________________________________________________________

Email Address:

Covered Dependent(s):

Name Relationship Date of Birth

In executing this form, I certify that the above information pertaining to my dependents is accurate and

truthful. I understand that all benefits will be revoked and I may be charged with any associated claims

costs if it is determined that I have intentionally misrepresented my dependents' information and such

misrepresentation impacts my dependents' eligibility under the Health and Dental Plan or Vision Plan.

If you have enrolled a spouse under the Health and Dental Plan, please complete pages 5 & 6.

_______________________________________________________________________________________________________________________________________

Employee Signature Date

In executing this form, I certify that I have reviewed the required documentation for dependent eligibility

and that it satisfies Ivy Tech’s dependent eligibility confirmation requirements.

______________________________________________________________________________________________________________________________________

Human Resources Signature Date

DUE DATE: Return completed form to your Regional Human R

esources Department within 31 days of employment or eligibility

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I/2576733.7 Page 5 of 7

IVY TECH COMMUNITY COLLEGE OF INDIANA

NEW

HIRE OR NEWLY ELIGIBLE QUESTIONNAIRE FOR

HEALTH AND DENTAL COVERAGE OF A SPOUSE (WORKING SPOUSE RULE)

Under the Working Spouse Rule, your employed spouse is not eligible for coverage under the Ivy Tech Community

College Health and Dental Care Plan ("Health and Dental Plan") unless your spouse enrolls in his or her employer’s

comprehensive employer-sponsored group health plan and/or dental plan, as applicable (for at least “employee

only” coverage), if available. Spouses who enroll in their employer's group health plan and/or dental plan are eligible

for secondary coverage under the Health and Dental Plan. Details of this Working Spouse Rule are set forth in the

Health and Dental Plan document. This Working Spouse Rule is not applicable to COBRA, and the Health and

Dental Plan's coordination of benefits rules still apply.

Complete this questionnaire if:

A. You wish to enroll your spouse for primary health or dental coverage under the Health and Dental Plan.

B. Your spouse is enrolled in his or her employer's or former employer's group health plan and/or dental plan

or is covered as a retiree through an employer-sponsored health plan and/or dental plan, and you are

electing secondary spousal coverage under the Health and Dental Plan.

Employee/Retiree/LTD Participant Name:__________________________________________________ C#____________________

Spo

use’s Name:____________________________________________________________ SSN#______-______-______ (optional)

Name of Spouse’s Employer:___________________________________________________________

A. No Health Coverage is Available

If you answer "Yes" to all of the statements below related to health coverage, your spouse will not be eligible for

health coverage under the Health and Dental Plan.

Your spouse is or was employed by an employer other than Ivy Tech.

Due to that employment or former employment, your spouse is eligible for a comprehensive

group health plan coverage (other than COBRA), for which the employer pays at least 50% of

the premium cost for employee/retiree only coverage.

1. YES NO

2. YES NO

3. YES NO

Your spouse did not elect coverage under such health plan.

B. No Dental Coverage is Available

If you answer "Yes" to all of the statements below related to dental coverage, your spouse will not be eligible for

dental coverage under the Health and Dental Plan:

Your spouse is or was employed by an employer other than Ivy Tech.

Due to that employment or former employment, your spouse is eligible for a comprehensive

group dental plan coverage (other than COBRA), for which the employer pays at least 50%

of the premium cost for employee/retiree only coverage.

1. YES NO

2. YES NO

3. YES NO

Your spouse did not elect coverage under such dental plan.

C. Health and Dental Coverage Will Be Available as Secondary Coverage

If you answer "Yes" to statements 1 and 2 above with respect to either health coverage under Section A or dental

coverage under Section B, and, with regard to statement 3 in each Section, your spouse did in fact elect coverage

under such health plan or dental plan, then health and/or dental coverage, as applicable, will be available as

secondary coverage under the Health and Dental Plan.

D. Health Coverage Will Be Available as Primary Coverage

If you answer "Yes" to any one of the questions below, your spouse will be eligible for primary health coverage

under the Health and Dental Plan:

1. YES NO

Your spouse is currently unemployed and has no comprehensive group health coverage

(other than COBRA).

I/2576733.7 Page 6 of 7

Your

spouse is retired, is not currently employed, and is not eligible for any employer-

sponsored comprehensive group health coverage.

Your spouse is employed or self-employed, but is not eligible for any employer-sponsored

comprehensive group health coverage.

Your spouse is employed or is retired, but your spouse's current or former employer does

not provide comprehensive group health coverage.

2. YES NO

3. YES NO

4. YES NO

5. YES NO

Your spouse is employed or retired, but your spouse's current or former employer does not

pay at least 50% of the premium cost for employee/retiree only coverage under the employer-

sponsored comprehensive group health coverage.

E. Dental Coverage Will Be Available as Primary Coverage

If you answer "Yes" to any one of the statements below, your spouse will be eligible for primary health coverage

under the Health and Dental Plan:

Your spouse is currently unemployed and has no comprehensive group dental coverage

(other than COBRA).

Your spouse is retired, is not currently employed, and is not eligible for any employer-

sponsored comprehensive group dental coverage.

Your spouse is employed or self-employed, but is not eligible for any employer-sponsored

comprehensive group dental coverage.

Your spouse is employed or is retired, but your spouse's current or former employer does

not provide comprehensive group dental coverage.

1. YES

2. YES

3. YES

4. YES

5. YES NO

Your spouse is employed or retired, but your spouse's current or former employer does not

pay at least 50% of the premium cost for employee/retiree only coverage under the

employer-sponsored comprehensive group dental coverage.

In all instances, please sign below and return this form to your Regional Human Resources Department.

However, if your spouse is employed or retired and is eligible for health and/or dental coverage through such

employer or former employer, then page 7 of this form must be completed by a representative of your spouse's

employer or former employer and be returned to your Regional Human Resources Department before claims for

your spouse will be considered for payment.

Employee Acknowledgment

If my spouse’s employment or retirement status changes in the future, I understand that I am responsible for

completing a new enrollment form and the Questionnaire for Health and Dental Coverage of a Spouse within 31

days of the employment status change. In addition, by my spouse’s signature below, authorization is given to his

or her employer to release the required dependent information indicated on Page 7 of this form. I understand that

failure to notify Ivy Tech of my spouse’s employment or retirement change or falsifying his or her employment or

retirement status is fraud and could result in financial penalty, loss of coverage and/or possible termination of

employment.

______________________________________________________ __________________ _______________________

Employee/Retiree/LTD Participant Signature Date Daytime Contact Phone

______________________________________________________ __________________ _______________________

Spouse Signature Date Daytime Contact Phone

DUE DATE: Return completed form to your Regional Human Resources Department within 31 days of employment or eligibility

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I/2576733.7 Page 7 of 7

IVY TECH COMMUNITY COLLEGE OF INDIANA

PLOYER/FORMER EMPLOYER OF SPOUSE (WORKING SPOUSE RULE)

Name of Ivy Tech Employee: ________________________________________________________ C#: ________________________

Name of Spouse: _________________________________________________________________

TO BE COMPLETED BY EMPLOYER OR FORMER EMPLOYER OF SPOUSE

Spouses of Ivy Tech employees, retirees, or LTD Participants are not eligible for coverage under the Ivy Tech

Community College Health and Dental Care Plan ("Ivy Tech Health and Dental Plan") unless the spouse enrolls in

his or her own employer’s or former employer's comprehensive group health and/or dental plan, as applicable (with

at least “employee only” coverage), where such coverage is available. Please complete the section below in order

to determine whether your employee’s health and dental claims will be considered as “primary” or "secondary"

under the Coordination of Benefits (COB) provision of the Ivy Tech Health and Dental Plan.

PLEASE CHECK THE APPROPRIATE BOX BELOW:

1. Yes____ No____ Is your employee or retiree currently enrolled or will he/she be enrolled in your

employer-sponsored comprehensive group health coverage ?

2. Yes____ No____ Is your employee or retiree currently enrolled or will he/she be enrolled in your

employer-sponsored comprehensive group dental coverage ?

If you answered "Yes" to both questions 1 and 2, then your plan will be primary and the Ivy Tech Health

and Dental Plan will be secondary. Please skip the remaining questions and sign this form at the bottom.

If you answered "No" to either question 1 or 2, please complete the remaining questions and sign this form

at the bottom.

3. Yes ____ No ____ Does your employee or retiree have access to employer-sponsored comprehensive

group health coverage through employment or retirement with your company, for which the company pays

at least 50% of the “employee (or retiree) only” premium?

4. Yes ____ No ____ Does your employee have access to employer-sponsored comprehensive group dental

coverage through employment or retirement with your company, for which the company pays at least 50%

of the “employee (or retiree) only” premium?

If you answer “Yes” to question 3 or 4 above regarding group health coverage and/or group dental coverage, then

your employee or retiree must be enrolled for primary coverage under your company's employer-sponsored health

plan or dental plan, as applicable (on at least “employee (or retiree) only” basis) in order to enroll as or remain an

eligible dependent under the Ivy Tech Health and Dental Plan for secondary coverage.

If you answer “No” to question 3 or 4 above regarding group health coverage and/or group dental coverage, then

your employee or retiree remains eligible for primary health or dental coverage, as applicable, under the Ivy Tech

Health and Dental Plan.

If eligible but not enrolled, what is the earliest date that your employee or retiree will be allowed to join your

employer-sponsored comprehensive group health plan? __________________________________. Your

employer-sponsored comprehensive group dental plan? ____________________________________.

__________________________________________________________________ _________________________________

Name of Employer Date

__________________________________________________________________ _________________________________

Employer Representative Signature Phone Number

__________________________________________________________________

Printed Name of Employer Representative

__________________________________________________________________

Title of Employer Representative

DUE DATE: Return completed form to your Regional Human Resources Department within 31 days of employment or eligibility

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