Exhibit_D_-_Dependent_Eligibility_Affidavit.pdf

Brevard County Board of County Commissioners, Dependent Eligibility Affidavit, Revised 09/2022

BOARD OF COUNTY COMMISSIONERS

FLORIDA’S SPACE COAST

OFFICE OF HUMAN RESOURCES, 2625 Judge Fran Jamieson Way, Building B, Viera, FL 32940 General Phone: (321) 633-2031 / FAX: (321) 633-2036 Risk Management: (321) 633-2037 / FAX: (321) 637-5364 Employee Benefits: (321) 633-2103 Records: (321) 633-2030

Dependent Eligibility Requirements

Brevard County’s Group Health Plan includes specific eligibility requirements for a Covered Employee to enroll and continue coverage for their Dependents under the plan. Eligible Dependents under the plan include Spouses and Children. The following summarizes the Dependent Eligibility requirements for Spouses, Surviving Spouses, and Overage Dependent Children in order to be covered under the plan. Additional eligibility information can be found in the plan’s Summary Plan Description.

Spouse: The Covered Employee's legal spouse is defined as one who meets all requirements of a legal marriage.

Former spouses ARE NOT legal spouses and are not eligible to participate under the plan except to the extent continuation of coverage may be available under COBRA. Upon divorce the Covered Employee MUST notify the Employee Benefits Office within 30 days to remove the spouse from the Brevard County Group Health Plan. This eligibility rule applies even if a divorce decree stipulates the Covered Employee is required to provide health insurance coverage to a former spouse.

Spouses who decline enrollment in primary health plan coverage available through their own employer will be subject to a monthly Spousal Surcharge as set forth by the Brevard County Board of County Commissioners.

Surviving Spouse: If a Covered Retiree or a Covered Employee who is fully vested in the Florida Retirement

System dies, the eligible dependents covered at the time of death may remain members of the health insurance plan as long as they continue to meet the eligibility criteria. If a surviving spouse remarries, they cease to meet the definition of an eligible dependent under this plan and will no longer be able to participate. A surviving Spouse must notify the Employee Benefits Department immediately upon remarriage and will cease to be eligible for coverage effective on the date of marriage.

Overage Dependents: A state mandate requires the County to extend healthcare coverage to dependents between the ages of 26-30 under certain conditions. This law allows employees to cover their “overage dependents” under the County’s Group Health Plan provided ALL of the following Eligibility Rules are met:

1. The dependent is unmarried and has no dependents of his or her own

2. The dependent is a Florida resident OR is a full or part-time student AND

3. The dependent does not have health insurance available to them through their employer or through another group health plan (i.e. Medicare or Medicaid).

Overage Dependents (Continued):

If a Covered Employee provides health insurance coverage to an overage dependent under IRS rules the fair market value of the coverage is considered imputed income, and must be reported as taxable income on the employee’s paycheck. This is not actual income, but it is included in the employee’s gross income in order to assess tax withholdings.

In addition to paying imputed income, the employee will be required to pay a monthly Overage Dependent Surcharge as set forth by the Brevard County Board of County Commissioners for each overage dependent who is covered under their medical insurance plan.

Documentation Required:

The Covered Employee is required to complete the attached Dependent Eligibility Affidavit every year during the annual open enrollment process in order for his or her Dependents to be covered under the County’s Group Health Plan. If requested by the Employee Benefits Department, the employee must a l s o submit their marriage certificate, divorce decree, covered dependent’s birth certificate and, if the overage dependent resides outside the state of Florida, the employee must also submit proof the dependent is attending school. Such documentation includes but is not limited to an enrollment status letter or certified copy of their transcript from the college/university they are currently attending.

Falsification of information or failure to notify the County of a change in your legal marital status or the status of your overage dependent that would result in that individual not meeting the eligibility requirements outlined above will result in, at a minimum, the removal of the spouse/dependent retroactively to the date of the change in eligibility status. In addition, any medical costs incurred by the County’s Group Health Plan for an ineligible person will be reversed by the County and will become the responsibility of the ineligible member. Willful provision of false information is considered insurance fraud may result in disciplinary action against the employee up to and including termination.

Change of Dependent Eligibility Status

Should the status of a covered spouse or overage dependent child c hange such that the eligibility rules set forth above are no longer met, the employee MUST notify the Employee Benefits Office within 30 days to remove the dependent from the Brevard County Group Health Plan, or to have the Spousal and/or Overage Dependent Surcharge adjusted accordingly.

BOARD OF COUNTY COMMISSIONERS

This form must be completed each annual open enrollment period if any of the highlighted Dependent Types below are enrolled in Brevard County’s Board of County Commissioners Group Health Plan:

Employee’s Last Name (Print) First Name: Middle Initial:

Employee ID#:

Dependent Type (You may select more than one)

□ Spouse (complete Section 1)

□ Surviving Spouse (complete Section 2)

□ Overage Dependent - Age 26 to 30 (complete Section 3)

Based on your selection above, please provide responses to all questions for each Dependent Type chosen in the applicable section below:

Section 1: Spouse

Employee Name (Print) Employee SS#:

Spouse Name (Print) Spouse SS#:

1. Are you legally married? (Note: former spouses are not your legal spouse and are not eligible to participate)

□ YES □ NO

2. If YES, do you agree to provide your marriage license upon request?

3. I understand that upon divorce I must notify the Employee Benefits Office within 30 days to remove my former spouse from the Brevard County Group Health Plan.

4. Please choose one of the following options that describes the status of your spouse:

□ My spouse is not actively working or works for Brevard County or other public entity participating in the Brevard County Group Health Plan. If the spouse is not currently working and the employee elects to cover the spouse under the County’s Group Health Plan, or the spouse works for Brevard County Government or participating entity, then no additional surcharge will apply.

□ My spouse is working and has elected coverage through their employer as primary coverage and is enrolling in the Brevard County Group Health Plan as secondary coverage. If the spouse is enrolled under their employer's medical plan as primary coverage and the County’s Group Health Plan as secondary coverage, then no additional surcharge will apply.

□ My spouse is working and has declined coverage through their employer and is enrolling in the Brevard County Group Health Plan as primary coverage. If the spouse declines coverage through their employer and elects coverage under the County’s Group Health Plan, the employee will be charged the designated contribution plus the additional surcharge.

□ My spouse is working and does not have medical coverage available through their employer and is enrolling in the Brevard County Group Health Plan as primary coverage. If the spouse does not have coverage available through their employer and the employee elects to cover the spouse under the County’s Group Health Plan, then no additional surcharge will apply.

Dependent Eligibility Affidavit

The following section must be completed by the Spouse’s employer

Name of Employer (Print) Employer’s Address:

1. Does your Company offer medical benefits to employees?

2. Is the above-named individual enrolled in your Company’s medical benefit program?

3. Is the above-named individual eligible for benefits?

4. If answered YES, please provide the following information:

Name of Insurance Plan

Group # of Insurance Plan

Effective Date of Coverage

5. Will the above-named individual be eligible to enroll in the medical plan in the future?

□ YES, if so, when? ______________ □ NO

6. Contact Info:

Name of Person Completing Form (Print)

Job Title

Phone Number

Signature of person completing form on behalf of the employer Date

Verification of Self-Employment:

If spouse is self-employed please provide the following:

Name of Company

Address

Phone Number

1. Are medical benefits offered to any employees of this organization?

2. If answered YES, please answer #3 above (Section 2).

3. Do you own this company?

Section 2: Surviving Spouse

Surviving Spouse’s Last Name (Print) First Name:

1. Are you remarried?

2. If answered YES, please provide the Date of Marriage:

3. I understand that if I remarry I must notify the Employee Benefits Office within 30 days of my remarriage to be removed from the Brevard County Group Health Plan.

Section 3: Overage Dependent

Dependent’s Last Name (Print) First Name:

1. Please list your dependent’s Date of Birth:

2. Is this dependent your child?

□ YES □ NO (please explain)

3. Is this dependent married?

□ YES □ NO

4. Does this dependent have children of their own?

□ YES □ NO

5. Does this dependent live in the State of Florida?

□ YES □ NO

*If the answer is NO, is this dependent a full or part-time student?

□ YES □ NO

6. Does this dependent have available to them other medical insurance either through their employer or through other means?

□ YES (please explain) □ NO

7. I have read and understood the eligibility requirements included in this packet for Overage Dependents. If my dependent becomes ineligible then I must notify the Employee Benefits Office within 30 days.

Month Day Year

Month Day Year

III. Attestation

By signing below, I represent and warrant that all information provided is accurate, current and complete to the best of my knowledge. I understand that falsification of information regarding my dependent’s available coverage will result in, at a minimum, the removal of the spouse/dependent retroactively to the date of the change in eligibility status. In addition, any medical costs incurred by the County’s Group Health Plan for an ineligible person will be reversed by the County and will become the responsibility of the ineligible member. Willful provision of false information is considered insurance fraud and may result in disciplinary action against the employee up to and including termination of employment.

I also understand that if the status of eligibility for medical coverage for any dependent changes, it is my responsibility to notify the Brevard County Benefits Department within 30 days of the change. If the Dependent is to be discontinued due to a change, there will be no premium or Surcharge refund if the Brevard County Benefits Department is not notified within 30 days of the change. The refund will not exceed the effective date of the event.

Employee’s Signature Date