New Employee & Life Event Enrollments Dependent Eligibility Verification Southern Methodist University performs dependent eligibility verification for all dependents enrolled in the SMU Health and Wellness Plan, i.e., the Medical options currently administered by BlueCross BlueShield of Texas (BCBSTX). We understand this process requires both time and effort on your part. Section 125 of the Internal Revenue Code enables SMU to deduct premiums for your health coverage on a pre-tax basis and requires that certain rules and restrictions regarding eligible dependents be observed. Insuring ineligible dependents is a violation of Section Code 125, as well as University policy. IMPORTANT: New benefits-eligible employees and employees who experience a qualified Life Event (e.g., marriage, birth or adoption, etc.) may add eligible dependents to their SMU medical coverage within 31 days of their date of hire date or Life Event date. In addition, you are required to provide proof of eligibility for all enrolled dependents within 60 days of your hire date or Life Event date. Information regarding dependent eligibility criteria, documentation requirements for different dependent types (e.g., spouse, children), and how to submit required documents, are attached. SMU HR will review your submitted documentation and notify you of the eligibility determination. If we cannot successfully verify your dependent(s) within 60 days of your hire date or the date of a qualified Life Event, your dependent(s) will be removed from the Plan. SMU reserves the right to request verification of dependent status at any time and will pursue any fraudulent activity, which may result in disciplinary action, including repayment of claims paid for ineligible dependents dating back to original enrollment and, in extreme cases, termination of employment. A dependent whose eligibility is terminated due to lack of insufficient documentation will NOT be eligible for COBRA coverage.

SMU appreciates your assistance in ensuring compliance with IRS and SMU dependent eligibility requirements.

HOW DO I CERTIFY MY DEPENDENTS? STEP 1: Review the list of the dependents you have enrolled and match each of them to a dependent type listed on the attached document. STEP 2: For each dependent type, you will find the eligibility requirements and a list of document options required to verify that particular dependent type. STEP 3: When submitting your documents, please note the following: Do NOT submit original documents. SEND COPIES ONLY!!! Black out social security numbers appearing on any documents submitted. Only send the first page of your 2008 or 2009 Federal Tax Return that shows your dependents. State Tax Returns are NOT accepted in lieu of Federal Tax Returns. Black out all monetary amounts appearing on Federal Tax Returns: e.g., earnings listed on your 1040. Documents proving joint ownership include: Mortgage Statements, Credit Card Statements, Bank Statements, and Residential Leasing Agreements listing both parties’ names as co-owners. The joint ownership may be established prior to the current year; however, the statement provided must be issued within the last six months. Proof of Marriage must be a government-issued marriage license or marriage certificate (not a church-issued certificate), including the date of your marriage. Birth Certificates must be government-issued birth certificates listing parent names (not hospital-issued certificates or wallet-sized certificates). Current Proof of Enrollment as a full time student must be for the current semester.

STEP 4: Once you have matched your dependents to the appropriate types, make a copy of all necessary documents and forward the copies to SMU Human Resources. You may mail, fax, or e-mail the documents – Attention: Helen Regan – as follows: U.S. Mail: Southern Methodist University, Department of Human Resources, 6116 N. Central Expressway, Suite 200, Dallas, TX 75206 SMU Campus Mail: Human Resources, Expressway Tower, Box 232 Secure Fax: 214-768-2043 E-Mail: Scan and e-mail your documents to [email protected].

ID

LS

Dependent Type

Legal Spouse

Age

N/A

Eligibility Requirements

•

The covered employee's husband or wife under Federal Law

Document Options for Verifying Eligibility:

• Government Issued Marriage Certificate and 2008 or 2009 Federal Tax Return OR • Government Issued Marriage Certificate and Proof of Joint Ownership Issued Within Last 6 Months OR • Government Issued Marriage Certificate Only (if married in the past 12 months) DP

Domestic Partner

Age 18 and over

A Domestic Partner is defined as a person of the same sex who:

• •

shares your residence; has resided with you for no less than one year;

• •

is no less than 18 years of age;

•

provides a notarized affidavit of Domestic

is not a blood relative or any closer than would prohibit legal marriage;and Partnership signed by both parties

Document Options for Verifying Eligibility:

• Notarized Affidavit of Domestic Partnership and Proof of Joint Ownership Issued Within Last 6 Months CLS

Common Law Spouse

N/A

Only allowable in the following states, according the criteria listed below:

• • • • • • • •

Alabama Colorado Georgia (if created before 1/1/97) Idaho (if created before 1/1/96) Iowa Kansas Montana New Hampshire (for inheritance purposes only)

• •

Ohio (if created before 10/10/91) Oklahoma (possibly only if created before 11/1/98)

• • • • • •

Pennsylvania (if created before 1/1/05) Rhode Island South Carolina Texas Utah Washington, D.C.

Document Options for Verifying Eligibility:

• Affidavit of Common Law Marriage and Proof of Joint Ownership Issued Within Last 6 Months

ID

BC

Dependent Type

Biological Child

Age

Eligibility Requirements

Age 18 and under

•

Must be unmarried

Age 19-24

• • •

Must be unmarried

Document Options for Verifying Eligibility:

• Government Issued Birth Certificate BS

Biological Student

Must be enrolled as a full-time student Must be financially supported by the employee and spouse

Document Options for Verifying Eligibility:

• Government Issued Birth Certificate, Spring 2010 Proof of Enrollment, and 2008 or 2009 Federal Tax Return DBC

Disabled Biological Child

Age 19 and over

• • •

Must be unmarried Must be medically certified as disabled Must be financially supported by the employee and spouse

Document Options for Verifying Eligibility:

• Government Issued Birth Certificate, and 2008 or 2009 Federal Tax Return SC

Step-Child

Age 18 and under

•

Must be unmarried

Document Options for Verifying Eligibility:

• Government Issued Birth Certificate, Government Issued Marriage Certificate, and 2008 or 2009 Federal Tax Return (proving ongoing parental relationship) OR • Government Issued Birth Certificate, Affidavit of Common Law Marriage, and Proof of Joint Ownership Issued Within the Last 6 Months (proving ongoing parental relationship) OR • Government Issued Birth Certificate, Government Issued Marriage Certificate, and Proof of Joint Ownership Issued Within Last 6 Months (proving ongoing parental relationship) OR • Notarized Affidavit of Domestic Partnership, Government Issued Birth Certificate, and Proof of Joint Ownership Issued Within Last 6 Months (proving ongoing parental relationship) SS

Step-Child Student

Age 19-24

• • •

Must be unmarried Must be enrolled as a full-time student Must be financially supported by the employee and spouse

Document Options for Verifying Eligibility:

• Government Issued Birth Certificate, Government Issued Marriage Certificate, 2008 or 2009 Federal Tax Return, and Spring 2010 Proof of Enrollment OR • Government Issued Birth Certificate, Affidavit of Common Law Marriage, Proof of Joint Ownership Issued Within Last 6 Months, Spring 2010 Proof of Enrollment, and 2008 or 2009 Federal Tax Return OR • Government Issued Birth Certificate, Notarized Affidavit of Domestic Partnership, Spring 2010 Proof of Enrollment, Proof of Joint Ownership Issued Within Last 6 Months, and 2008 or 2009 Federal Tax Return OR • Government Issued Marriage Certificate, Proof of Joint Ownership Issued Within Last 6 Months, 2008 or 2009 Federal Tax Return and Spring 2010 Proof of Enrollment

ID

DS

Dependent Type

Disabled Step-Child

Age

Age 19 and over

Eligibility Requirements

• • •

Must be unmarried Must be medically certified as disabled Must be financially supported by the employee and spouse

Document Options for Verifying Eligibility:

• Government Issued Birth Certificate, Government Issued Marriage Certificate, and 2008 or 2009 Federal Tax Return OR • Government Issued Birth Certificate, Affidavit of Common Law Marriage, 2008 or 2009 Federal Tax Return, Proof of Joint Ownership Issued Within Last 6 Months OR • Government Issued Birth Certificate, Notarized Affidavit of Domestic Partnership, 2008 or 2009 Federal Tax Return, and Proof of Joint Ownership Issued Within Last 6 Months OR • Government Issued Birth Certificate, Government Issued Proof of Marriage, Proof of Joint Ownership Issued Within Last 6 Months, and 2008 or 2009 Federal Tax Return AC

Adopted Child

Age 18 and under

•

Must be unmarried

• • •

Must be unmarried

Document Options for Verifying Eligibility:

• Adoption Placement Agreement and Petition for Adoption OR • Adoption Certificate Only AS

Adopted Child Student

Age 19-24

Must be enrolled as a full-time student Must be financially supported by the employee and spouse

Document Options for Verifying Eligibility:

• Adoption Certificate, Spring 2010 Proof of Enrollment, and 2008 or 2009 Federal Tax Return DAC

Disabled Adopted Child

Age 19 and over

• • •

Must be unmarried Must be medically certified as disabled Must be financially supported by the employee and spouse

Document Options for Verifying Eligibility:

• Adoption Certificate and 2008 or 2009 Federal Tax Return LW

Legal Ward

Age 18 and under

• •

Must be unmarried Must be financially supported by the employee and spouse

Document Options for Verifying Eligibility:

• Government Issued Birth Certificate, 2008 or 2009 Federal Tax Return, and Court Ordered Document of Legal Custody OR • Government Issued Birth Certificate and Court Ordered Document of Legal Custody (if custody was obtained in the past 12 months)

ID

LWS

Dependent Type

Legal Ward Student

Age

Age 19-24

Eligibility Requirements

• • •

Must be unmarried Must be enrolled as a full-time student Must be financially supported by the employee and spouse

Document Options for Verifying Eligibility:

• Government Issued Birth Certificate, 2008 or 2009 Federal Tax Return, Spring 2010 Proof of Enrollment, and Court Ordered Documentation of Legal Custody DW

Disabled Legal Ward

Age 19 and over

• • •

Must be unmarried Must be medically certified as disabled Must be financially supported by the employee and spouse

Document Options for Verifying Eligibility:

• Government Issued Birth Certificate, 2008 or 2009 Federal Tax Return, and Court Ordered Document of Legal Custody GC

Grandchild

Age 18 and under

• •

Must be unmarried Must be financially supported by the employee and spouse

Document Options for Verifying Eligibility:

• Dependent Government Issued Birth Certificate, Parent Government Issued Birth Certificate, and 2008 or 2009 Federal Tax Return GS

Grandchild Student

Age 19-24

• • •

Must be unmarried Must be enrolled as a full-time student Must be financially supported by the employee and spouse

Document Options for Verifying Eligibility:

• Dependent Government Issued Birth Certificate, Parent Government Issued Birth Certificate, 2008 or 2009 Federal Tax Return, and Spring 2010 Proof of Enrollment DG

Disabled Grandchild

Age 19 and over

• • •

Must be unmarried Must be medically certified as disabled Must be financially supported by the employee and spouse

Document Options for Verifying Eligibility:

• Dependent Government Issued Birth Certificate, Parent Government Issued Birth Certificate, and 2008 or 2009 Federal Tax Return QM

Qualified Medical Support Order

Age 18 and under

•

Document Options for Verifying Eligibility:

• Qualified Medical Child Support Order (ordered for the employee or spouse)

Qualified Medical Child Support Order

ID

Dependent Type

QMS

Qualified Medical Support Order Student

Age

Age 19-24

Eligibility Requirements

• •

Qualified Medical Child Support Order Must be enrolled as a full-time student

Document Options for Verifying Eligibility:

• Qualified Medical Child Support Order (ordered for the employee or spouse) and Spring 2010 Proof of Enrollment The above benefit descriptions describe the plan(s) generally, and in summary form only. In the event of a conflict between what is stated in this document and the governing plan document(s), the plan document(s) will control.