Health Summary Plan Description

Dependent Eligibility

If you have paid the applicable premium, coverage for your eligible dependents begins on the later of:

  • The date your coverage begins; or
  • The date they become eligible dependents.

Eligible dependents include:

Your Legal Spouse

Your legal spouse is the person to whom you are legally married.

Your Same-Sex Domestic Partner

Effective July 1, 2011, the Plan provides coverage for same-sex couples on par with the benefits provided to legal spouses, subject to the following requirements:

  • If you live in a state that recognizes same-sex marriage, you and your same-sex partner must be married.
  • If you live in a state that does not recognize same-sex marriage but recognizes same-sex domestic partnerships or civil unions, you and your same-sex domestic partner must have your domestic partnership or civil union recognized by the state.
  • If you live in a state that does not provide legal recognition of same-sex marriage, civil unions or domestic partnerships, please contact the Plan Office for information on the documentation that must be provided to qualify for the same-sex domestic partnership program.
  • If you are married or have a registered same-sex domestic partnership or civil union in a state other than the state in which you reside, the Plan will also recognize that documentation.

If you are receiving benefits as a same-sex domestic partner and either (i) your state subsequently recognizes same-sex marriage, or (ii) you move to a state where same-sex marriage is recognized, the existing same-sex partnership recorded with the Plans will continue to be honored.

Depending on the tax status of your domestic partner, you may be responsible for federal and state withholding tax on the value of the coverage provided by the Plan to your domestic partner and children. Basically, the tax laws view the value of such health coverage as wages. There is no withholding if your domestic partner and children are your dependents for tax purposes. However, the Plan may request verification of this dependent status from the Internal Revenue Service. If your domestic partner is not your dependent, you must prepay the taxes to the Plan on a quarterly basis. The Plan Office can advise you of the rates and will remit the taxes on your behalf.

If your same-sex domestic partner was covered by the Health Plan prior to July 1, 2011 you are not subject to the new requirements outlined above. However your domestic partner will not be eligible for the Extended Spousal benefit unless you satisfy the new requirements.

Your Dependent Children

This includes your children who are younger than 26 years of age. The children must be your:

  • Natural children.
  • Stepchildren.
  • Foster children.
  • Legally adopted children.
  • Children for whom you or your spouse or same-sex domestic partner are the legal guardian.
  • Children of your same-sex domestic partner although, depending on their tax status, you may be responsible for pre-paying federal and state withholding tax on the value of their coverage.
  • Your permanently disabled dependent children. Older children who are physically or mentally disabled may be considered dependents if they were disabled prior to turning age 26 and you were eligible for benefits at the time they became disabled, regardless of whether or not you were enrolled in the Plan at that time. The Plan will require an annual certification of permanent disability status by the child's attending physician.

Dependents do not include parents or any other relatives not listed above.

Note: In the event of divorce, or dissolution of a same-sex civil union or domestic partnership, medical expenses incurred by your spouse, domestic partner or stepchild on or after the final divorce or dissolution date are not covered by the Plan. You will be billed for expenses paid by the Health Plan from the date of divorce or domestic partnership dissolution.

Enrolling and Verifying Qualified Dependents

You can make changes to your covered dependents during your Open Enrollment Period (see page 10). The Plan requires documentation for the dependents you want covered as detailed in the chart to the right. In addition, you are responsible for notifying the Plan Office when you move, acquire new dependents, marry or divorce, or establish or terminate a same-sex civil union or domestic partnership. Plan records cannot be changed until the Plan Office receives a Dependent Enrollment Form and the appropriate documentation. There are deadlines in connection with some of these notices. For details contact the Plan Office or visit our website: www.sagph.org and click on "Life Events".

Enrollment of a dependent that does not meet the Plan's eligibility requirements will be treated as an intentional misrepresentation of a material fact, or fraud.

Enrolling and disenrolling dependents can affect the amount of your premium. Premium changes will be effective the 1st of the month in which the event occurred if enrolling a new dependent, and the 1st of the month following the month in which the event occurred if you are disenrolling a dependent.

Life Event Documentation Required by the Plan
Marriage A copy of the recorded marriage certificate.
Establishment of Same-Sex Domestic Partnership or Civil Union Download an enrollment packet from www.sagph.org or contact the Plan Office.
Divorce A copy of the recorded final divorce decree.
Dissolution of Same-Sex Domestic Partnership or Civil Union Certificate of dissolution.
Birth A copy of the recorded birth certificate.
Exception: The Plan will accept a copy of the birth certificate from the hospital to add your natural child who is younger than one year of age for a period not to exceed 120 days while you obtain a recorded copy.
Adoption A copy of the adoption papers issued by the court.
Guardianship A copy of the guardianship papers issued by the court.
Physically and/or Mentally Disabled Dependents A completed Total Disability application and a copy of the attending physician's history and physical report. An annual certification of disability status is also required.
Death A copy of the recorded death certificate.

Special Enrollment Opportunities

Special enrollment opportunities allow you to make changes to your dependent elections outside of the Open Enrollment Period. Please refer to page 11 for these rules.

Medical Child Support Orders

In order to pay benefits in accordance with a medical child support order, the Health Plan must determine that the order is a qualified medical child support order (QMCSO). A medical child support order is a court order that provides for medical child support or health benefit coverage with respect to your dependent child. You may obtain a copy of the Plan's procedures for determining whether or not an order is qualified by contacting the Plan Office. There is no charge to obtain the procedures.