Dependent Documentation Requirements

for State Employee Health Plan (SEHP)

Members


Appropriate Supporting Dependent Documentation
The following items are appropriate supporting documentation required to be uploaded via MAP, in English and legible with the Enrollment or Change Request when adding or removing other eligible individuals:

  1. Marriage License (for proof of spouse and stepchild eligibility)
  2. Birth certificate or hospital birth announcement for newborns and dependent children including full name of the parent(s).  (Birth registration cards are not acceptable proof for newborns and dependent children)
  3. Petition for adoption or placement agreement for dependent child
  4. Legal custody or guardianship document issued by the court including Judge’s signature and court date stamp
  5. Court order for dependents who are not natural or adopted children of the primary member including Judge’s signature and court date stamp
  6. Certificate of birth and Dependent Grandchild Affidavit for children born to a covered dependent (grandchild) and copy of current year’s filed Federal tax return for proof of financial dependency and residency.  Please see #8 for pages needed.
  7. An Application for Coverage of Permanent and Totally Disabled Dependent Child affidavit for covered dependent children aged 26 or older and copy of current year’s filed Federal tax return for proof of financial dependency and residency.  Please see #8 for pages needed.
  8. Copies of the current year’s filed Federal tax return (for proof of spouse eligibility only.)  Please note all income information may be whited out prior to uploading the document in MAP.  The pages needed from the current year’s filed Federal tax return depends on which Tax form was filed:
    • Form 1040—pages 1 & 2 containing the filer’s name, the employee and spouse’s signature, and a written signature date the employee and spouse each signed the form.
    • Form 1040A—pages 1 & 2 containing the filer’s name, the employee and spouse’s signature, and a written signature date the employee and spouse each signed the form.
    • Form 8879 (IRS e-file)—containing the date filed, the filer’s name, the employee and spouse’s signature, and a written signature date the employee and spouse each signed the form.
  9. Divorce decree (Only the first and last page of the court document are needed, but those pages must include the date stamp by the court and the signature of the judge)
  10. A copy of a military ID and privilege card with the expiration date is acceptable as proof of Tricare coverage and to document the end of Tricare coverage.
  11. For dependent loss of other group health coverage, a letter or certificate of other creditable coverage, listing the name of the member and all dependents that were covered under a previous employer’s insurance is required. The letter or certificate must identify the previous employer, and list the date in which coverage ended.