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City of Cocoa I Employee Benefit Highlights 12020-2021 Group Insurance Eligibilityibilit (Continued) Qualifying Events and Section 125 Please remember the following:In order to enroll or cover dependent(s)on the Section 125 of the Internal Revenue Code City's medical plan,the employee is required to provide documentation verifying the eligibility of such dependents to the Human Resources Division. Premiums for medical, dental, vision insurance, and/or certain supplemental policies and contributions to Flexible Spending Accounts (FSA) are deducted Dependent Relationship Documentation Required through a Cafeteria Plan established under Section 125 of the Internal Revenue Code and are pre-taxed to the extent permitted.Under Section 125,changes to • Official MarriageCertificate AND employee's pre-tax benefits can be made ONLY during the Open Enrollment periodSpouse ___ • SSNforACA purposes(Affordable Care Act) unless the employee or qualified dependent(s)experience(s)a Qualifying Event and • State issued birth certificate(s)OR legal the request to make a change is made within 30 days of the Qualifying Event guardianship court documents,listing the Child(ren)Under Age 26 employee or spouse as parent/legal guardian Under certain circumstances, employee may be allowed to make changes to AND benefit elections during the plan year,if the event affects the employee,spouse • SSNfor ACA purposes(Affordable Care Act) or dependent's coverage eligibility.An"eligible"Qualifying Event is determined by Section 125 of the Internal Revenue Code.Anyrequested changes must be • AND theappropriate de endent child q Step-Child(ren)UnderA e26 p g documentation listed above consistent with and due to the Qualifying Event. Child(ren)under Legal • AND court documents of the legal Examples of Qualifying Events: Guardianship or Custody Under Age 26 guardianship OR legal custody • Employee gets married or divorced Child(ren)adopted arinthe • AND court documents of the legal adoption • Birth of a child process of adoption Under showing relationship to and placement in • Employee gains legal custody or adopts a child Age 26 the employee's house OR adoption certificate • Employee's spouse and/or other dependent(s)die(s) g issued through the courts • Loss or gain of coverage due to employee, employee's spouse and/or I • ANDState issued Birth Certificate(s)of dependent(s)terminate or start of employment child(ren)stating child was borntoaninsured . An increase or decrease in employee's work hours causes eligibility or ineligibility Grandchild(ren)OR other dependent child ofemployee or spouse OR • A covered dependent no longer meets eligibility criteria for coverage children not related • Legal Guardianship/Custody/Document from • A child gains or loses coverage with an other parent or legal guardian the courts listing the employee or spouse as • Change of coverage under an employer's plan parent/legal guardian AND • Gain or loss of Medicare coverage • SSNfor ACA purposes(Affordable Care Act) • Losing or becoming eligible for coverage under a State Medicaid or CHIP Child(ren)Age 26-30 • AND Overage Dependent Affidavit signed by (including Florida Kid Care)program(60 day notification period) employee IMPORTANT All documentation must be either the original document or a notarized/ If employee experiences a Qualifying Event the Human Resources Division must be certified copy of original document.Please note the Human Resources Division contacted within 30 days of the Qualifying Event to make the appropriate changes will need to view the original documents and will make copies for employer to employee's coverage.Beyond 30 days,requests will be denied and employee may files. be responsible,both legally and financially,for any claim and/or expense incurred as a result of employee or dependent who continues to be enrolled but no longer meets Any person who knowingly and with intent to injure, defraud, or deceive eligibility requirements.If approved,changes are effective on the first of the month any insurer,files a statement of claim,or an application containing any false, following the Qualifying Event or date written request for change in coverage is incomplete,or misleading information iis guilty of a felony of a third degree. received by the Human Resources Division.Newborns are effective on the date of birth and marriage is effective on the date of occurrence.Cancellations will be processed at the end of the month.In the event of death,coverage terminates the date following the death.Employee may be required to furnish valid documentation supporting a change in status or"Qualifying Event" 12 4 02016,Gehring Group,Inc.,All Rights Reserved