Health Insurance Change Form
Fill out the Health Insurance Change Form (pdf)
This form may be used to change health insurance elections in the event of the following changes:
- Marriage or divorce
- Birth or adoption of a dependent
- Gain or loss of legal custody of a dependent.
- Changing from part-time to full-time or from full-time to part-time employment by your spouse or dependent that affects cost, benefit level, or benefit coverage for you, your spouse, and/or your dependents. Changing from a benefits eligible position to a benefits ineligible position by you, your spouse or a dependent. Termination or commencement of employment (including retirement) of you, your spouse or a dependent which affects benefits coverage for you, your spouse and/or your dependents (you may change your medical plan at the time of retirement). Any employment status changes that affect eligibility.
- Significant changes in the health insurance coverage of you, your spouse or dependent. Change of Network Status of a physician is not a qualifying event. You may make a mid-year change due to an Open Enrollment change made by a spouse or dependent on their health plan.
- If you, your spouse, or dependent are called to active military duty and/or gain or lose eligibility for military insurance.
- Loss of COBRA eligibility (for other than non-payment of premium) from a previous employer for you, your spouse, or dependent.
- Death of your spouse or dependent.
- Your dependent child turns age 26 (coverage will end for your dependent the last day of the month of their birthday). If the birth date is on the first day of the month, the coverage ending date for your dependent will be the last day of the preceding month.
- If you, your spouse or dependent gain or lose government-sponsored medical card coverage. Terminating coverage is not allowable if you become covered under programs like SCHIP (State Children’s Health Insurance Program) because these programs are not supposed to replace existing insurance. This may apply to other government card coverage.
- If you, your spouse, or dependent lose Medicare eligibility, or become eligible for Medicare, and elect Medicare coverage as primary.
- Dependent children identified under a Medical Withholding Order (K.S.A. 23-4,105) or Qualified Medical Child Support Order (the SEHP has the authority to add these dependent children without the consent of the employee).
- Court Order requiring adding or dropping coverage for a dependent child.
- Dependent children losing eligibility/coverage under another group health insurance plan.
- Children that change from non-dependent to dependent status during the Plan Year under SEHP guidelines can only be added back on to your coverage at Open Enrollment.
- Dependent spouse or children who move to the U.S.