(5 of 5)
Family Coverage
Eligibility Requirements
721 South Parker, Suite 200, Orange, CA 92868
800
558-8003 www.calchoice.com
•
CC 0500D 9/2020 Eff. 1/1/2021
License # 0B42994 - CaliforniaChoice Benefit Administrators
Inc.
Who can be covered?
If all required documentation is received
before the 16th day of the month of
marriage, premiums are charged for the
full month and coverage begins on the date
of marriage.
If all required documentation is received on
or after the 16th day of the month of
marriage, coverage begins on the 1st of
the month following
the date of receipt.
Effective dates Requirements that MUST be met
■ New spouse must be legally married to the employee
■ New stepchild must also meet the dependent children requirements listed below
New Spouse/
New Stepchild
Birth/Adoption/
Legal Guardianship/
Eligible Dependent
Child
If birth/date of placement occurred
before the 16th of the month, coverage
begins on the first day of the month of the
date of birth/placement.
If birth/date of placement occurred on the
16th or after, child is automatically covered
at no cost under Subscriber between date
of birth/placement and the first of the
following
month. Coverage for the
dependent begins on the first of the month
following the birth/date of placement.
MEDICAL, CHIRO, VISION and SMILESAVER DENTAL Dependent eligibility:
■ Born to, a stepchild or legal ward of, adopted by, or have an established
parent-child relationship with the eligible employee, employee spouse or
domestic partner
■ Under age 26 (unless disabled, disability diagnosed prior to age 26)
AMERITAS DENTAL Dependent eligibility:
■ Born to, a stepchild or legal ward of, adopted by, or have an established
parent-child relationship with the eligible employee, employee spouse or
domestic partner
■ Financially dependent upon the employee per IRS guidelines
■ Unmarried or not involved in a domestic partnership
■ Under age 26 (unless disabled, disability diagnosed prior to age 26)
Disabled Dependents:
Dependents who are incapable of self-support
because of continuous mental or physical disability that existed before the age
limit are eligible for coverage until the incapacity ends. Documentation of
disability will be requested. Once the child reaches the age limit for coverage,
verification of eligibility will occur annually at the child’s birthday.
Dependents must meet all requirements listed in order to be
eligible for enrollment
Both have filed a duly executed Declaration of Domestic Partnership with the
Secretary of State and will provide copies to CaliforniaChoice within 60 days
of its issue.
gree to notify CaliforniaChoice immediately upon termination of domestic
partnership.
Children of Domestic Partner must also meet the dependent children
requirements listed above
■
■
Domestic Partner/
Child of Domestic
Partner
During Initial Enrollment or Group’s Annual
Renewal:
Coverage begins on group’s effective date.
Involuntary Loss of Other Coverage:
Domestic Partner can be added outside of
Renewal only if he/she loses other
coverage involuntarily. Coverage is
effective the first of following month.
Mid-Year Addition:
Mid-year additions of a
domestic partner will require a
state-stamped copy of the Declaration of
Domestic Partnership from the California
Secretary of State within 60 days of
issuance. If domestic partners have filed a
Declaration of Domestic Partnership and
have not yet received a copy from the state,
a signed Affidavit of Domestic Partnership
will be accepted. Domestic Partners agree
to provide a copy of the Declaration of
Domestic Partnership within 60 days of
issuance. If all required documentation is
received before the 16th day of the month in
which the domestic partnership was
established, premiums are charged for the
full month and coverage begins on the date
of the event. If all required documentation is
received on or after the 16th day of the
month in which the domestic partnership
was established, coverage begins on the
1st of the month following
the date of
receipt.
Employee and Domestic Partner must meet all requirements
listed in order to be eligible for enrollment
®
For a Domestic Partner to qualify, Employee and Domestic Partner must:
Employee and Domestic Partner must meet all requirements
listed in order to be eligible for enrollment
12322