Note: Voluntarily ending your health coverage or being terminated for not paying your premiums are not considered involuntary loss of coverage.

Date of event:
Enter the applicant's date first eligible for employee benefits.

Coverage start date will be the first of the month following 60 days after Date of event.

Enrollment Reason:
Birth of child

Coverage start date:
Coverage is effective retroactive to the date of birth

Period to request special enrollment:
31 days following the date of event

Supporting Documentation Required:
Birth certificate

Enrollment Reason:
Court ordered dependent

Coverage start date:
Coverage is effective on the first day of the month following the date on which the enrollment request is received by Medica.

Period to request special enrollment:
31 days following the date of event

Supporting Documentation Required:
Court order with judge’s signature

Enrollment Reason:
Adoption or placement for adoption

Coverage start date:
Coverage is effective retroactive to the date of adoption or placement for adoption

Period to request special enrollment:
31 days following the date of event

Supporting Documentation Required:
Adoption decree or court order with judge’s signature

Enrollment Reason:
Marriage

Coverage start date:
Coverage is effective on the first day of the month following the date on which the enrollment request is received by Medica.

Period to request special enrollment:
31 days following the date of event

Supporting Documentation Required:
Marriage certificate

Enrollment Reason:
Other

Coverage start date:
Coverage is effective on the first day of the month following the date on which the enrollment request is received by Medica.

Period to request special enrollment:
31 days following the date of event

Supporting Documentation Required:
Certificate of creditable coverage or term letter with the date and reason coverage was lost

Enrollment Reason:
Loss of SCHIP/Medicaid coverage eligibility

Coverage start date:
Coverage is effective on the first day of the month following the date on which the enrollment request is received by Medica.

Period to request special enrollment:
60 days following the date of event

Supporting Documentation Required:
Certificate of creditable coverage or term letter with the date and reason coverage was lost

Enrollment Reason:
Loss of coverage

Coverage start date:
Coverage is effective on the first day of the month following the date on which the enrollment request is received by Medica.

Period to request special enrollment:
60 days following the date of event

Supporting Documentation Required:
Certificate of creditable coverage or term letter with the date and reason coverage was lost

Enrollment Reason:
Loss of SCHIP/Medicaid premium assistance eligibility

Coverage start date:
Coverage is effective on the first day of the month following the date on which the enrollment request is received by Medica.

Period to request special enrollment:
60 days following the date of event

Supporting Documentation Required:
Certificate of creditable coverage or term letter with the date and reason coverage was lost