CONNECTICUT CARPENTERS HEALTH FUND
2011
COVERAGE OF ELIGIBLE ADULT CHILDREN
UNDER THE PATIENT PROTECTION AND AFFORDABLE CARE ACT OF 2010
I. Background: In our notice of October 2010, we reported that a new federal law requiring coverage of participants' adult children would apply to the Health Fund beginning April 1, 2011. Because our annual eligibility cycle begins on March 1, 2011, the Health Fund Trustees have decided to comply one month earlier than required. This notice and election form is designed to permit you to enroll, re-enroll, or continue enrollment of any "adult child" who is age 19 or older but younger than age 26 as of March 1, 2011 (or, if later, the 1st of the month after the date you sign this form). You do not need to complete this form to continue coverage for any of your dependent children who are younger than age 19.
In order for the Fund to provide coverage to such adult child on and after March 1, 2011, we need additional information from you so that the Fund and our service providers (Anthem for medical, Prescription Solutions for prescriptions, and Delta Dental for dental) can properly process your adult child's eligibility and claims.
II. Instructions: For each adult child of yours who is between the ages of 19 and 25, you should:
→ Complete section A to provide the information and documentation the Fund needs to add or maintain the adult child on your coverage, and
→ Complete section B to inform the Fund if, as of the later of March 1, 2011 or the date you sign this form, the adult child will be eligible to enroll in (or have coverage through) an employer-sponsored health plan offered by the employer of the child or the child's spouse, and
→ Complete section C to acknowledge that there are serious penalties if you make a false statement on this form.
NOTE: If you are covered under the Fund under a self-pay plan, the Fund may charge an additional amount to provide coverage to such adult child(ren). Please contact the Fund Office for further information and costs.
If you have more than one adult child you wish to cover, a separate form, along with the requested documentation, must be completed for each child. Feel free to make copies of the attached form. There is no need to submit a form for any child younger than 19.
If you have any questions about this Notice, the form, or any other issue, contact the Fund Office by telephone at 203-281-5511 (or toll-free in Connecticut at 1-800-922-6026) extension 641 OR by fax at 203.288.3235. You may also write to the Fund Office using the following address: Deborah L. Palmieri, Health Fund Administrator, 10 Broadway, Hamden, CT 06518.
*in fact, we continue coverage through the last day of the month in which your child reaches age 26.
FORM --- COVERAGE OF AN ADULT CHILD YOUNGER THAN AGE 26
Section A --- Information about participant Carpenter or other person and Child/Child's Spouse:
*Participant name:
*Participant address:
* Participant Identification Number:
* Name of Adult Child:
* Adult Child's address:
* Adult Child's date of birth:
* Adult Child's Social Security Number:
* Adult Child's Employer/address (if applicable):
* If Adult Child is married, please give name of spouse and the name and address of the spouse's employer: Spouse's name: ______________________________________
Spouse's Employer/address:
* Adult Child's relationship to participant (check box and include requested info with form. We don't need the info if your child has been covered by the Fund at any time in the past 3 years.):
□ natural child (please include copy of child's birth certificate)
□ step child (please call Fund Office for documents required to add your step child)
□ legally adopted child, child placed for adoption with you, or foster child (please call Fund Office for documents required to add your legally adopted child)
Section B --- Certification as to certain other health coverage for adult child:
In order for the Fund to provide coverage on and after March 1, 2011, but before April 1, 2014, a child who is younger than age 26 must not be eligible to enroll in a health plan sponsored by his or her employer or, if married, his or her spouse's employer. Please complete the following certification:
I, _________________________________ [print participant's name], hereby certify to the best of my knowledge and belief, that my adult child named in Section A, above, [check one] will→□ / will not→□ be eligible to enroll in, or have coverage through, an employer-sponsored health plan maintained by either the child's employer or, if married, the child's spouse's employer, as of the later of: (i) March 1, 2011, or (ii) the date I sign this form in section C below. If coverage may or will be available to my child through a health plan sponsored by an employer, please note the health plan's name here: _____________________________________________________.
IMPORTANT REMINDERS: If this form states that your adult child will not be eligible to enroll in a health plan sponsored by an employer and that fact changes at any time after this form is completed (meaning the adult child becomes eligible to enroll in, or enrolls in, employer-sponsored health coverage of the child or child's spouse), the Fund must be notified immediately. Also, keep in mind that your child's coverage cannot continue unless you have Fund coverage.
Section C --- Acknowledgment: I acknowledge that this form is being submitted to the Connecticut Carpenters Health Fund for the purpose of determining my adult child's eligibility under the Fund's rules. If I make a false statement on this form or fail to provide updated information promptly, I know that (a) I will be responsible for repaying (directly or via offset against benefits otherwise due for me or my family) any benefits the Fund pays in reliance on my false or uncorrected statement, and (b) the Fund may terminate coverage for me and my family.
By: __________________________________________________ Dated: ___________________
Print Name: __________________________________________