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Memorandum

Date:December 16, 2014

To:All Benefit Eligible Employees(Full & Part-time)

From:Human Resources Department

RE:DEPENDENT ELIGIBILITY REVIEW

In an effort to help manage overall plan costs which benefit all subscribers and ensure only eligible dependents are covered, the Oregon Educators Benefit Board (OEBB)will be conducting Dependent Eligibility Reviews over the next two to three years. OEBB will be requiring that the eligibility of each dependent identified in MyOEBB be verified and confirmed with appropriate documentation. DEPENDENTS INCLUDE: SPOUSE, DOMESTIC PARTNER, BIRTH CHILDREN, STEP CHILDREN, ADOPTED CHILDREN AND CHILDREN FOR WHICH LEGAL GUARDIANSHIP HAS BEEN ESTABLISHED.

In accordance with OEBB Rule OAR 111-080-0055,OEBB has authorized Districts to have a third party complete the DEV under certain circumstances. Our District has been authorized to and has retained the services of American Fidelity Assurance (AFA),the District Section 125 Provider. AFA will conduct a Dependent Eligibility Reviewon behalf of JeffersonCounty School District509-J beginning3/9/2015, and end on 3/17/2015. Employees will be required to provide certification that your dependent(s) is eligible for coverage.Not providing the appropriate documentation will result in removal of your dependent(s)from health care coverage.

The Process

  • Verification of Dependent(s)

Employees who cover dependent(s) will be required to provide documentation verifying theirdependent(s)eligibility. Each employee will be required byJefferson County School District to meetwith an American Fidelity Assurance (AFA) Benefit Counselor. Employees will be required to sign the Dependent Verification Review form. Employees’ personal documentation will be viewed, but will not be retained by the AFA Enrollment Benefit Counselor or District. All information is confidential.

  • Meeting with an American Fidelity AssuranceBenefit Counselor is required byJefferson CountySchool District 509-J.

Employees will meet with an AFA Benefit Counselor to show their documentation. AFA will be available to review eligibility documents from 8:00 a.m. through 4:00 p.m. at your work location. Your individual one-on-one appointmenttime should not take more than 30 minutes. A meeting schedule will be posted at your work location. During these one-on-one confidential sessions, you may be offered American Fidelity products. THERE IS NO OBLIGATION TO PURCHASE American Fidelity products.

All employees are required by Jefferson County School District 509-J to see an AFA Enrollment Counselor no later than3/17/2015to verify your dependent(s) status. Failure to provide proof of dependent eligibility will result in terminated coverage of your dependent(s)effective no later than4/30/2015and they will not be able to be added back onto coverage during a future enrollment period.

DEPENDENT VERIFICATION REVIEW

ELIGIBILITY GUIDELINES FOR DEPENDENT(S)

Please review carefully to determine your dependent(s) eligibility and the appropriate documents you will be required to bring to your meeting with AFA. The following documents will be required to prove eligibility of your spouse, domestic partner, and children. The District will not be able to provide you with any documents submitted in the past. You will need to submit one or more documents listed below for each covered dependent.

Spouse(A person who is married under the laws of the State of Oregon or under the laws of any other state or country. The definition of spouse does not include a formerspouse and a former spouse does not qualify as a dependent):

Marriage Certificate: Must contain

  • Name of the member
  • Name of the spouse
  • Date of marriage
  • Certifier’s signature and official seal;
  • State or County of issuance

AND:

  • U.S. 1040 Tax return Indicating Married (first page only) NOTE: To maintain confidentiality, please black out SSNs and financial information.
  • Must Contain:
  • Tax authority (federal)
  • From tax years 2013 or 2014
  • Name of the member
  • Name of the spouse
  • Married filing jointly, or married filing separately
  • If married filing separately, spouse’s name must appear on form

IF legally separated:

Separation Agreement: Must contain

  • Name of the member
  • Name of the spouse
  • Date of separation
  • Must be dated and signed by court

AND:

  • U.S. 1040 Tax return Indicating Married (first page only) NOTE: To maintain confidentiality, please black out SSNs and financial information.
  • Must Contain:
  • Tax authority (federal)
  • From tax years 2013 or 2014
  • Name of the member
  • Married filing Single

Domestic Partner by Certificate:

•State-Issued Certificate of Registered Domestic Partnership

PLUS ONE OF THE FOLLOWING (These documents must be dated 6 months prior to the date of review):

  • Oregon Income Tax Return Indicating Registered Domestic Partners: Must contain
  • Tax Authority (State)
  • From tax year 2013 or 2014
  • Name of the registered domestic partner
  • Filing jointly or separately

OR

  • U.S 1040 “AS If” Tax Return Indicating Married (first page only): Must contain
  • Tax Authority (Federal)
  • From tax years 2013 or 2014
  • Name of the member
  • Name of the spouse
  • Married filing jointly, or married filing separately

NOTE: To maintain confidentiality, please black out SSN and financial information; OR

If legally separated:

  • Separation Agreement: Must contain
  • Name of the member
  • Name of the registered domestic partner
  • Date of separation
  • Must be dated and signed by Court

AND

  • Oregon Income Tax Return
  • Tax authority (State)
  • From tax year 2013 or 2014
  • Name of the member
  • Filing status single

NOTE: To maintain confidentiality, please black out SSN and financial information

Domestic Partner by Affidavit:

  • OEBB Affidavit of Domestic Partnership: Must contain
  • Name of the member
  • Name of the domestic partner
  • Date
  • Signature of both partners

PLUS ONE OF THE FOLLOWING:

  • Current Proof of Joint Mortgage or Joint Tenancy on a Residential Lease: Must contain
  • Name of the member
  • Name of the domestic partner
  • Name of the mortgage company/landlord/rental company
  • Statement date from 6 months prior to the date of review; OR
  • Joint Bank Account or Joint Liabilities (credit cards, car lease): Must contain
  • Name of the member
  • Name of the domestic partner
  • Name of the bank or lending company
  • Statement date from 6 months prior to the date of review

NOTE: To maintain confidentiality, please black out SSN and financial information; OR

  • Auto Insurance or Utility Bill (electric, gas, phone, internet, cable, garbage, water): Must contain:
  • Name of the member
  • Name of the domestic partner
  • Name of the insurance or utility company
  • Bill date must be from 6 months prior to the date of review;

NOTE: Employee may also submit one document displaying both names, or may submit two documents, one in each name showing the same address and dated within the past 6 months; OR

  • Current State Issued Driver’s License or State Issued ID: Must submit
  • Driver’s license or State ID for member,

AND

  • Driver’s license or State ID for domestic partner

NOTE: Both forms of identification must show same address and must be issued on or before the start of the dependent eligibility review.

Biological Children or Step Children:

  • Government Issued Birth Certificate or Naturalization Certificate/Report of Birth Abroad: Must contain
  • Name of the member, spouse, or domestic partner
  • Name of the child
  • Date of birth;

NOTE: A marriage Certificate will also be required if the biological parent of the Step Child is not being covered on benefits, the dependent child is married, or if the dependent child’s last name is different than the subscriber’s.

A legally adopted child or a child legally placed for adoption

  • Birth Certificate or Naturalization Certificate/Report of Birth Abroad: Must contain
  • Name of the member, spouse, or domestic partner
  • Name of the child
  • Date of birth; OR
  • Adoption Paperwork: Must contain
  • Name of the member, spouse, or domestic partner
  • Name of the child

Court ordered and signed legal adoption documentation;

Legal Guardianship

  • Court Ordered and Signed Legal Guardianship: Must contain
  • Name of the member, spouse, or domestic partner
  • Name of the child

NOTE: If using Divorce Decree, Custody Agreement, or Qualified Medical Child Support Order (QMCSO):

Must contain:

  • Name of the member, spouse, domestic partner or legal guardian
  • Name of the child
  • Statement of responsibility for health coverage

Court ordered and signed legal guardianship documentation

Certified disabled dependent child age 26 or older: Criteria for the specified child relationship as stated above.

PLUS:

  • Letter From OEBB Medical Plan Carrier: Must contain
  • Name of the member, spouse, domestic partner, or legal guardian
  • Name of the child
  • Statement that medical evidence has been reviewed and the child meets the disability requirements for coverage on OEBB plans
  • Date and text indicating the approval is currently in effect

NOTE: DO NOT submit medical evidence.

The following websites can assist you with your documentation search:

DEPENDENT VERIFICATION REVIEW

FREQUENTLY ASKED QUESTIONS

  1. Can I meet with the District’s Human Resources instead of AFA Benefit Counselor?

No. The District’s HR staff cannot meet with you for this purpose nor provide you with any previous documents submitted in the past. You are required by Jefferson County School District509-J to complete your review with AFA Benefit Counselor.

  1. Can my spouse take my documentation for me to my appointment if I can’t make it?

No, the audit must be completed by the employee. The employee must show proof and sign the dependent verification review form.

  1. Who is requiring this review?
  2. The Oregon Educators Benefits Board (OEBB), which our district is a member, will be completing an eligibility verification of all employees’ and early retirees’ dependents at least once every 3 years. Under the OEBB rules, entities are allowed to use a third party vendor to perform the verification review. Jefferson County School District chose to use American Fidelity to perform the review for our employees. It is Jefferson County School District’s first dependent verification review.
  1. What if I don’t complete the Dependent Eligibility Review by due date?

If you do not complete review by due date, OEBB will terminate coverage of your dependents from the effective 4/30/2015and they will not be able to be added back onto coverage during a future enrollment period. If a dependent has been identified as “ineligible”, they will be terminated from all OEBB benefit plans no later than the last day of the month in which the determination was made.

  1. What if I can’t find my birth certificates?

You can either obtain a copy from the appropriate county office, or you can order copies on line. See below for web sites (order today as itcould take about 3 to 4 weeks):

or