Mid-Year Qualifying Events

Faculty, administrative professional and other non-classified staff

"*" indicates required fields

When you experience a life event – such as birth or adoption of a child, marriage, or loss of other coverage – you can make changes to your benefits within 30 days of the event. Changes must be consistent with the event and type of coverage. If you miss the 30 day deadline, your next chance to make a change is during the open enrollment period.

With the exception of birth and adoption, the effective date of a change is the first of the month following the life event date or notification to HR, whichever is later. Additional information can be found on the HR website.

You will be required to make elections in the online enrollment system and submit documentation that substantiates the requested change.

Human Resources will follow-up with you directly when an enrollment window has been opened. (Your enrollment window will not be available until the effective date occurs).

Employee Information

Name*

First Last

CSU ID*

Phone

Mid-Year Event

Changes can be made to your benefits within 30 days of an event. If you miss the 30 day deadline, your next chance to make a change is during the open enrollment period. Changes must be consistent with the event and type of coverage. With the exception of birth and adoption, the effective date of a change is the first of the month following the life event date or notification to HR, whichever is later.

Effective Date of Change

MM slash DD slash YYYY

Indicate the date of the life event (e.g. dependent's date of birth, marriage date, date other coverage began, etc). Life event must be within 30 days of today's date.

Applicable Dependents*

Myself/Employee

Spouse/Common Law Spouse

Domestic or Civil Union Partner

Dependent Child(ren)

Spouse or Partner's Name

Name of Child 1

Child 2

Child 3

Child 4

Mid-Year Qualifying Event Type

Birth or Adoption

Marriage

Gain other coverage

Lose other coverage

Divorce or Dissolution of Domestic/Civil Union Partnership

Gain of Medicare or Medicaid

Loss of Medicaid coverage

Indicate the mid-year qualifying event type (for either the employee or eligible dependents)

Birth or Adoption*

1) If your child does not have a Social Security Number, please email MyHR@colostate.edu to obtain a temporary SSN.

2) Add the child to your Personal Information in Employee Self-Service.

3) Add the child to your benefit plans online in CSU Benefits.

4a) For birth, upload a certified copy of the newborn's birth certificate to our HR Secure OneDrive.

4b) For adoption, upload a copy of the placement for adoption paperwork to our HR Secure OneDrive.

5) Change benefit plans online in CSU Benefits.

Follow the above steps to add a new child to your benefit plans.

Marriage*

1a) Add your spouse to your Personal Information in Employee Self-Service.

1b) If applicable, add dependent children.

2) Add dependents to your benefit plans online in CSU Benefits.

3) Upload a filed, certified copy of your marriage certificate to our HR Secure OneDrive.

4) Change benefit plans online in CSU Benefits.

Follow the above steps to add a new spouse or other eligible dependents to your benefit plans.

Gain other coverage*

1) Upload a letter on company letterhead to our HR Secure OneDrive.

1a) Documentation should indicate who has gained coverage, what type of coverage and on what effective date.

2) Wait for an email from Human Resources when an enrollment window has been opened in ESS.

3) Change benefit plans online under CSU Benefits in Employee Self-Service.

3a) If you want HR to drop coverages on your behalf, please confirm which dependents and from what plans in "Comments".

Follow the above steps to remove a spouse or other eligible dependents from your benefit plans.

Lose Other Coverage*

1) Upload a letter on company letterhead to our HR Secure OneDrive.

1a) Documentation must indicate who is losing coverage, the types of coverage and the date the coverage was lost.

2) If applicable, add dependents to your benefit plans online in CSU Benefits.

3) Wait for an email from Human Resources when an enrollment window has been opened in ESS.

4) Change benefit plans online under CSU Benefits in Employee Self-Service.

Follow the above steps to add a spouse/partner or other eligible dependents to your benefit plans.

Gain of Medicare/Medicaid Coverage*

1) For Medicare, upload the Medicare card to our HR Secure OneDrive.

2) For Medicaid, upload a letter on official letterhead indicating the loss of other coverage to our HR Secure OneDrive.

1a, 2a) Documentation must indicate who is gaining coverage and the effective date the coverage was lost.

3) Wait for an email from Human Resources when an election window has been opened in ESS.

4) Change benefit plans online under CSU Benefits in Employee Self-Service.

If you or your dependent has gained Medicare or Medicaid in the last 60 days, follow the above steps to remove them from your benefit plans (medical only for Medicare, unless gain of dental is documented).

Loss of Medicaid Coverage*

1) Upload their Medicare cars or a Medicaid letter on official letterhead indicating the loss of other coverage to our HR Secure OneDrive.

1a) Documentation must indicate who is gaining coverage and the effective date the coverage was lost.

3) Wait for an email from Human Resources when an election window has been opened in ESS.

4) Change benefit plans online under CSU Benefits in Employee Self-Service.

Divorce / Dissolution of Domestic Partnership*

1) Remove your former spouse/partner from your Personal Information in Employee-Self Service.

2a) For divorce, upload a filed copy of your divorce decree to our HR Secure OneDrive.

2b) For dissolution of a partnership, upload a filed copy of the dissolution form to our HR Secure OneDrive.

3) Wait for an email from Human Resources when an enrollment window has been opened in ESS.

4) Change benefit plans online under CSU Benefits in Employee Self-Service.

4a) If you want HR to drop coverages on your behalf, please confirm which dependents in "Comments".

Follow the above steps to remove a former spouse/partner or other dependents from your benefit plans.

Former Spouse/Partner Contact Information

Provide your former spouse's mailing address, so we can send paperwork regarding coverage continuation under COBRA.

Comments

Acknowldgements

I understand:*

Completing this notification form does not confirm enrollment or approval of the change.

I am required to make elections in the online enrollment system and submit documentation that substantiates the requested change.

Documentation to substantiate the change is due within 30 days of the mid-year change

If I do not submit documentation or make elections in the online system timely, my request will be canceled.

I confirm I am within 30 days of my mid-year qualifying event.

Signature*

By typing your name, you are agreeing to the acknowledgments above and are giving your consent for the requested change.