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QUALIFYING EVENT |
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DOCUMENTATION REQUIRED |
Death of spouse or ex-spouse |
Copy of death certification and written documentation from the employer on company letterhead providing names of covered participants and date coverage ends |
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Divorce |
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Copy of the signed divorce decree and written documentation from the employer on company letterhead providing names of covered participants, date coverage ends, and the reason why coverage ended
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Legal Separation |
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Copy of the agreed order of legal separation and written documentation from the employer on company letterhead providing names of covered participants
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Loss of Eligibility (does not include a loss due to failure to pay premiums or termination of coverage for cause) |
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Written documentation from the employer or the insurance company on company letterhead providing the names of covered participants, date coverage ends and the reason for the loss of eligibility
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Loss of Coverage due to Exhausting Lifetime Benefit Maximum |
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Written documentation from the insurance company on company letterhead providing names of covered participants, date coverage ended and stating that the lifetime maximum has been met
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Loss of TennCare (does not include a loss due to failure to pay premium) |
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Written documentation from TennCare on company letterhead stating that coverage has been or will be terminated
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Termination of Spouse’s or Ex-Spouses Employment (voluntary and non-voluntary) |
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Written documentation from the employer on company letterhead providing names of covered participants, date coverage ends and reason why coverage ended
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Employer Eliminated Contribution to Spouse’s, Ex-Spouse’s or Dependent’s Insurance Coverage (total contribution, not partial) |
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Written documentation from the employer on company letterhead providing names of covered participants, date contribution amount changed and date coverage ended
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Spouse’s or Ex-Spouse’s Work Hours Reduced Causing Loss of Eligibility for Insurance Coverage |
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Written documentation from the employer on company letterhead providing names of covered participants, date coverage ends and reason why coverage ended
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OR Employee Without Coverage or With Single Coverage |
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Acquires a New Dependent – Spouse (and adding other previously eligible dependents) |
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Copy of marriage certificate |
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Acquires a new dependent – Newborn (and adding other previously eligible dependents) |
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Copy of birth certificate for newborn |
