Health Care & Benefits Division


For each applicable Dependent enrolled, the plan member shall submit the following information. If a dependent is enrolled due to a mid-year change qualifying event, additional verification may be required.


For a spouse:

  1. Copy of the marriage certificate, or
  2. Copy of the front page of the most recent tax-return showing the tax filing status as “Married Filing Jointly”. (Any financial information may be blacked out.)


For a domestic partner:

  1. Declaration of Domestic Partner Relationship and Affidavit of Shared Residence Form
  2. A copy of mutually-granted powers of attorney or health care powers of attorney; or
  3. A copy of mutual designations of primary beneficiary in will, life insurance policies or retirement plans.


For Dependent children:

  1. A copy of the Dependent child’s birth certificate, adoption order or pre-adoption papers, or
  2. A copy of a court-ordered parenting plan, custody agreement or guardianship order.


For stepchildren:

  1. Required documentation listed above for domestic partner or spouse, if individual is not enrolled; and
  2. A copy of the stepchild’s birth certificate, adoption order or pre-adoption papers; or
  3. A copy of a court-ordered parenting plan, custody agreement or guardianship order.


For grandchildren:

  1. A copy of the grandchild’s adoption order or pre-adoption papers; or
  2. A copy of a court-ordered custody agreement or legal guardianship.

For incapacitated children:

Incapacitated child(ren) must be enrolled on the State Plan before the age of 26 to be eligible for coverage after the age of 26. It is the plan members responsibility to provide the required documentation, listed below, to continue State Plan benefits for an incapacitated child(red) over the age of 26. 

  1. The incapacity commenced before the date the child’s Plan coverage would otherwise terminate.
  2. The child is dependent upon the eligible Participant or Retiree for support and maintenance within the current meaning of the COBRA disability continuation criteria. In other words, the Social Security Administration must have determined that the child is disabled and qualifies for disability benefits through either Old Age, Survivors and Disability Insurance (OASDI) or Supplemental Security Insurance (SSI) (documentation must be provided).
  3. Notification and proof of such incapacity must be submitted to the Plan Supervisor within thirty-one (31) days of the date the child’s coverage would otherwise terminate.
  4. Must submit the most recent tax return which indicates the disabled child is a qualified tax dependent of the Participant or Retiree.
  5. Re-Certification of the disability may be required annually by the Plan. 


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