BENEFIT ELIGIBILITY


Benefits under the CHEIBA
Trust Plan are available to
BEN
E E
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I
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Eligible Employees and
Dependents of the State

colleges, universities and
Employee
institutions of higher
“Employee” definition will be defined by each of the State colleges,
education who participate in
universities and institutions who participate in the CHEIBA Trust. Please
the CHEIBA Trust.
see the Eligibility document for your campus/institution. Eligible
Employees on an authorized leave of absence not to exceed a 24-consecutive month period, including
Employees on sabbatical and summer break, may be included as Eligible Employees until the Employer
notifies the insurance company of termination of eligibility.
Dependent
A. "Dependent" means an Employee's (a) legal spouse; (b) partner in a civil union pursuant to CRS §14-15-
101, et seq.; and (c) an Employee’s married or unmarried child or children until the end of the month of
their 26th birthday. Dependents must also satisfy the requirements of the Internal Revenue Code to
qualify as tax dependents of the Employee for life insurance purposes and satisfy the eligibility
requirements for coverage under a Benefit Plan. A Dependent shall also include any dependent which is
required by State insurance law to be covered or offered coverage under any insurance contract issued
to the Trust for a Benefit Plan.
B. Except as otherwise provided in Section (B)(3) hereof, for purposes of medical, dental, voluntary vision,
voluntary life, and voluntary accidental death and dismemberment benefits (hereinafter collectively
referred to as "Benefits"), including any COBRA rights related to such Benefits, a Dependent shall also
include an Employee's Domestic Partner as described in paragraph 1 below and the child or children of
an Employee's Domestic Partner as described in paragraph 2 below.
1. An Employee's Domestic Partner is an adult at least eighteen (18) years of age, who is the same or
opposite gender as the Employee, who is not married to another person and not a member of
another domestic partnership, who is not related to the Employee by blood closer than permitted
by state law for marriage in the State of Colorado, lives with the Employee as Domestic Partners in a
shared principal residence for at least twelve (12) consecutive months prior to enrollment with the
intent for the relationship to last indefinitely, and whose personal relationship with the Employee
meets all the criteria established by the Trust Committee for domestic partnership as certified in an
Affidavit of Domestic Partnership. The Employee must follow the procedures established by the
Trust Committee with regard to the enrollment and termination of a Domestic Partner. A Domestic
Partner is not a legal spouse of an Employee under Colorado law pursuant to C.R.S. §14-2-104.
2. A Domestic Partner’s child or children (who are not related by blood, adoption or court order to the
Employee), married or unmarried, until the end of the month of their 26th birthday. Dependents
must also satisfy the eligibility requirements for coverage under a Benefit Plan. A Dependent shall
also include any dependent which is required by State insurance law to be covered or offered
coverage under any insurance contract issued to the Trust for a Benefit Plan. The Employee must
follow the procedures established by the Trust Committee with regard to enrollment and
termination of coverage for the child or children of a Domestic Partner.
3. All eligibility and coverage for domestic partners and the children of domestic partners is closed
effective January 1, 2016, provided however that coverage for any domestic partner and the
children of the domestic partnership is effective through December 31, 2016, if such coverage was
in effect on December 31, 2015. After December 31, 2016, all coverage for domestic partners and
the children of domestic partners is terminated.
- 2 -

BENEFIT ELIGIBILITY

C. For the purposes of paragraphs A and B(2) above, the term “child” or “children” shall include a natural
or biological child, child of a partner in a civil union, step-child, legally adopted child, child under legal
guardianship, child or children of any age who are medically certified by a physician as disabled, and a
child for whom the Employee or Domestic Partner is required to provide health benefits pursuant to a
court order or qualified medical child support order, provided however, the term “child” or “children”
shall not include the grandchild or grandchildren of the Employee or the Domestic Partner.
D. For the purposes of an Anthem certificate of insurance evidencing medical, dental and voluntary life
coverage, any reference to the term "spouse" shall also include a Domestic Partner and a partner in a
civil union.
Required Dependent Eligibility Documentation
Registered copy of marriage certificate
AND
A document dated within the last 60 days showing current relationship
Legal Spouse
status, such as a monthly or quarterly household bill or statement of
account. The document must list your spouse’s name, the date and your
mailing address OR the first page and signature page of your most
recent federal tax return.
Common-law marriage affidavit
AND
Common-Law Spouse
A document dated within the last 60 days showing current relationship
status, such as a monthly or quarterly household bill or statement of
account. The document must list your spouse’s name, the date and your
mailing address.
All eligibility and coverage for domestic partners and the children of
domestic partners is closed effective January 1, 2016, provided however
that coverage for any domestic partner and the children of the domestic
Domestic Partnership (DP)
partnership is effective through December 31, 2016, if such coverage
was in effect on December 31, 2015. Children born to domestic partners
in 2016 shall be eligible provided the domestic partnership was in effect
on December 31, 2015. After December 31, 2016, all coverage for
domestic partners and the children of domestic partners is terminated.
The child’s birth or adoption certificate, naming you or your spouse as
the child’s parent, or appropriate custody or allocation of parental
responsibility documents naming you or your spouse as the responsible
Children
party to provide insurance for the child.
Newborns – The registered birth certificate must be provided within 31
days of birth. Social Security number must be provided within 90 days of
birth.
Registered copy of civil union certificate.
AND
Civil Union
A document dated within the last 60 days showing current relationship
status, such as a monthly or quarterly household bill or statement of
account. The document must list your partner’s name, the date and your
mailing address.
Within 31 days of benefits eligibility, or
The eligibility documentation
During the annual Open Enrollment period as scheduled by the member
must be provided within the
institutions for benefit changes effective the following January 1st, or
following timeframes:
Within 31 days of all changes related to IRS-defined change of status




► The eligibility documentation must be provided within the following timeframes:
- 3 -

BENEFIT ELIGIBILITY


Within 31 days of benefits eligibility, or

During the annual Open Enrollment period as scheduled by the member institutions for benefit
changes effective the following January 1st, or

Within 31 days of all changes related to IRS-defined change of status, or

Within 31 days of benefits changes due to meeting the criteria to establish a domestic
partnership as defined by the CHEIBA Trust.

The employee must provide a certified and notarized translation of any documents presented which are in a
foreign language.

Participant
“Participant” means an Eligible Employee, Dependent or Beneficiary who satisfies the requirements for
participating in any Benefit Plan offered under the Trust, and includes any former Employee, former
Dependent, qualified Beneficiary whose coverage under any Benefits Plan is continued or extended in
accordance with the provisions of the Benefit Plan and Trust.
Enrollment
Eligible Employees must complete and file an enrollment application within 31 days of their first day of
employment and authorize payroll deductions for the coverage elected. For eligibility, please contact your
Human Resources/Benefits Office. Eligible Employees may waive medical and dental coverage if they
submit evidence of coverage under another group health plan and submit a signed waiver form during
initial or annual enrollment. If coverage under the Medical and Dental Benefits Plans is waived, Dependent
coverage must also be waived. If coverage is waived, Eligible Employees and their Dependents may enroll in
coverage under a Benefits Plan only during the next annual open enrollment or within 31 days of a
qualifying event under IRC section 9801. Individual or family coverage through the Health Insurance
Marketplace is not group health insurance and does not qualify for a waiver of medical and dental coverage.

N
OTE ON MEDICAL AND DENTAL: Employees must enroll in both medical and dental insurance. If Employees
w aive medical insurance, dental insurance must also be waived. Coverage may also be waived due to religious
affiliation. All waiver and enrollment requests must be approved by your Human Resources/Benefits Office.



NOTE ON BASIC TERM LIFE & AD&D (provided by Anthem Life) AND LONG TERM DISABILITY (provided by
St andard Insurance): Employees must enroll in basic term life and accidental death and dismemberment
in surance provided by Anthem Life and long term disability insurance provided by Standard Insurance. Such
in surance coverages may not be waived.

Default Medical and Dental Coverage
If an Eligible Employee does not complete and file an enrollment application or waiver form within 31 days
of the first day of employment, the Employee will automatically be enrolled in the medical benefits PRIME
Health (PPO) Plan option and Anthem Blue Dental PPO Plus plan. Contributions will be deducted from the
Employee’s payroll on an after-tax basis as a condition of employment if the Employer requires Employee
contributions. Changes to default coverage are only permitted during the annual open enrollment and
within 31 days of a qualifying status change.
Annual Open Enrollment
Each fall the CHEIBA Trust and the CHEIBA Trust Members announce an annual open enrollment period,
during which time Eligible Employees may make certain coverage changes. During open enrollment,
Employees may add or delete Eligible Dependents from coverage under the Plan. Employees and qualified
beneficiaries may add dependents only during open enrollment or during “special enrollment and qualifying
status changes” described later in this summary.
- 4 -

BENEFIT ELIGIBILITY-DOMESTIC PARTNERSHIP

DOM
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All eligibility and coverage for domestic partners and the children of domestic partners is closed effective
January 1, 2016, provided however that coverage for any domestic partner and the children of the domestic
partnership is effective through December 31, 2016, if such coverage was in effect on December 31, 2015.
After December 31, 2016, all coverage for domestic partners and the children of domestic partners is
terminated.

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Domestic Partners and their eligible dependents will be eligible for medical, dental, voluntary vision,
voluntary life, and voluntary accidental death and dismemberment insurance in the same manner as for an
Employee's spouse and other dependent children.

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In the event a domestic partnership ends in 2016, the Employee is required to file a Statement of
Termination of Domestic Partnership form within 31 days of the termination of the domestic partnership. If
there is any change in status of the criteria set forth in the Affidavit of Domestic Partnership that would
terminate the domestic partnership, the Employee must similarly complete a Statement of Termination of
Domestic Partnership and return it to the Human Resources/Benefits Office within 31 days of the change.

Medical, dental, life, vision and accidental death and dismemberment benefits for the Domestic Partner and
their eligible children, if any, will be discontinued on the first day of the month following the date of
termination of the domestic partnership. The respective employer will provide any applicable notice of
rights to continue benefit coverage to the former Domestic Partner.

The Employee must also mail a copy of the Statement of Termination of Domestic Partnership to the former
Domestic Partner within ten days of completing the Statement.

Em
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If the Employee fails to file a Statement of Termination of Domestic Partnership on a timely basis, or
otherwise supplied any false or misleading statements in order to obtain Domestic Partner benefits to which
the Employee is not otherwise entitled, the Employee shall be liable to the CHEIBA Trust or his or her
employer for all resulting monetary damages, costs and attorneys' fees which result from such actions. In
addition, the Employee may be subject to disciplinary action, up to and including termination of
employment.

Fl
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If the Domestic Partner and his/her children are the Employee's tax dependents for medical and dental plan
purposes and the Employee has completed a Certification of Tax-Qualified Dependents, then the Employee
may receive reimbursements of their expenses from the Employee's flexible spending account. If the
Domestic Partner and his/her children are not the Employee's tax dependents, however, then their
expenses are not eligible for reimbursement from the Employee's flexible spending account.

Benefits relating to the Domestic Partner and his/her children under dependent care spending accounts will
depend on how the Domestic Partner and/or his or her children fit within the guidelines established by the
tax code for these benefits.

CO
C B
O R
B A
R
A
While continuation of medical, dental and voluntary vision coverage is not required under federal COBRA
laws, such coverage is allowed under the same terms that would apply to an Employee's spouse and
children. A registered Domestic Partner and/or children of the Domestic Partner enrolled in medical, dental
and voluntary vision plans have 60 days from the date that eligibility for coverage ends to enroll in COBRA
coverage.

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IRS regulations require the employer to tax the Employee for the excess of the fair market value of coverage
provided to the Domestic Partner and his/her children over the amount the Employee pays, if any, for the
coverage. In general, an Employee’s premiums for coverage of a Domestic Partner or dependent of a
Domestic Partner are paid on an after-tax basis. There is an exception to this rule if the Domestic Partner
and his/her children are tax dependents for medical and dental plan purposes. Please review the document
titled, "Important Tax Information for Domestic Partners - Medical and Dental Benefits", and complete the
Certification of Tax-Qualified Dependents, if appropriate


- 5 -

BENEFIT ELIGIBILITY CHANGES



CHA
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After your institution’s annual open enrollment period is closed, you may change your benefits election
during the Plan Year only after a qualifying status change. Within 31 days of a qualifying status change, you
must submit a written request to your Human Resources/Benefits Office specifying the change you are
seeking. Upon approval of the change by your Human Resources/ Benefits Office, the election change is
then completed by you on a new Employee Election Form. This approved election change will continue until
another eligible event occurs or until you change your election during the next annual open enrollment
period.

Eligible Events that May Allow Election Changes
All changes requested after open enrollment must be approved by the Human Resources/Benefits Office.
Requested changes must be on account of and corresponding with a qualifying status change that affects
eligibility for coverage under an employer’s plan. Employee’s transferring from one CHEIBA Trust institution
to another may or may not be eligible for a plan change. See your Human Resources/Benefits Office for
more details if you believe this applies to you.

Election changes must be requested within 31 days of the qualifying status change event. Changes allowed
under federal regulations must fit within one of these categories: HIPAA, FMLA, COBRA or Qualifying Status
Change (see the following definitions).


He
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Special enrollment provisions may allow you to enroll or add Dependents during the Plan Year and
waive pre-existing condition exclusion waiting periods. This option applies only to insurance coverage
changes. Special enrollment is only permitted if you properly waive coverage because you have other
coverage and your other coverage involuntarily terminates. Special enrollment is also permitted when
an Employee who was previously not enrolled marries or has a new child. You must request special
enrollment in writing within 31 days of the event. See your Human Resources/Benefits Office for more
details if you believe this applies to you.

When you or a covered Dependent terminates coverage under the medical plan, the plan will send you
a certificate of coverage that identifies the length of coverage under the plan. The HIPAA Certificate of
Coverage may be needed if you enroll in another medical plan that imposes a pre-existing condition
waiting period. If you are eligible for Medicare and did not enroll in the Medicare drug card program,
Medicare Part D, during the initial open enrollment in November 2005, you are also entitled to a notice
of creditable prescription drug coverage. You will need this notice to later enroll in Medicare Part D
without penalty.

The CHEIBA Trust will not use or further disclose Protected Health Information (PHI) in a manner that
would violate the requirements of state or federal law or regulation. The CHEIBA Trust and the CHEIBA
Trust Members will use PHI to the extent of and in accordance with the uses and disclosures permitted
by HIPAA.


- 6 -

BENEFIT ELIGIBILITY CHANGES




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You are only allowed to change your election during a Plan Year, if certain life changes occur. Any
approved election change must be on account of and corresponding with a qualifying change in status
that affects eligibility for coverage under an employer’s plan.

Eligible changes listed under IRS regulations include the following status changes:
change in Employee’s marital status; marriage, divorce, annulment, legal separation or death of a
spouse;
change in number of tax-eligible Dependents; birth, adoption, placement for adoption, court
ordered change in legal custody status or Qualified Medical Child Support Order (QMCSO) or
death of a Dependent;
change in employment status: transition from full-time to part-time, part-time to full-time, strike
or lockout, affecting an Employee, Employee’s spouse or Eligible Dependent;
commencement of/or return from an unpaid leave of absence Family Medical Leave Act (FMLA)
or other approved unpaid leave of absence by an Employee, Employee’s spouse or Eligible
Dependent;
commencement or termination of employment by an Employee, Employee’s spouse or Eligible
Dependent;
attainment or loss of Dependent eligibility as defined by the Plan, i.e., exceeding the Plan’s
established age limitations or eligibility for coverage under another health plan would all qualify
as an eligible change in status events;
entitlement to/or loss of Medicaid or Medicare coverage by an Employee, Employee’s spouse or
Eligible Dependent;
residence and/or worksite change: a required change in place of residence and/or work site of an
Employee, Employee’s spouse or Eligible Dependent, i.e., a move outside a health plan’s service
area would qualify as a change in status event;
an Employee may revoke his/her election or make a prospective election change during the Plan
Year if the change corresponds with an open enrollment period change made by the Employee’s
spouse or Eligible Dependent, provided that the election change is consistent with the changes
under the group plan; or
significant change in available benefits and/or their costs, i.e., if a fully insured health plan
imposed a change in benefit coverage levels or increases premiums substantially, this would
qualify as a change in status event. NOTE: This does not allow election changes in the Health
Care Spending Account.
Other eligible changes include the establishment of a civil union and the termination or
dissolution of the civil union.


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- 7 -

BENEFIT ELIGIBILITY TERMINATION

TER
E M
R I
M N
I A
N T
A I
T O
I N
O
N O
F
O
F ELI
L G
I I
G B
I I
B L
I I
L T
I Y
T
Eligibility to participate in the Benefit Plans under the Trust shall terminate on the earliest of the following
dates:
The last day of the month in which an Employee terminates employment for any reason including death
and retirement or the last day of the month following the month in which an Employee terminates
employment for any reason including death and retirement,
The last day of the month in which an Employee ceases to satisfy the definition of an Eligible Employee
either because of a change in status or a reduction in the scheduled work hours per week falls below the
minimum number of hours required for coverage under the Trust,
The last day of the month for which contributions are paid in a timely manner,
The date the Trust or any Benefit Plan under the Trust is terminated or amended to terminate benefits for
any class of Participants,
The effective date an Employee elects to waive coverage under any Benefit Plan,
The date a Participant enters the armed forces of any country on active full-time duty,
The date any certificate of insurance coverage issued under any Benefit Plan is terminated or amended to
terminate coverage for any Participant, or
The date a Participant falsifies or misuses documents or information relating to coverage or services
under any Benefit Plan or any certificate.

Dependent coverage terminates on the earliest of the date coverage would otherwise terminate above, and
the following:
The date a Dependent enters the armed forces of any country on active full-time duty,
The last day of the month in which the Dependent ceases to satisfy the definition of a Dependent under
the Trust, any Benefit Plan under the Trust or any certificate of insurance coverage,
The last day of the month a Dependent child turns age 26.

Leaves of Absence
Coverage under the Plan may continue for certain Employees on an Approved Leave of Absence, including
but not limited to:
Short Term Disability/Long Term Disability
Workers Compensation Leave
Family and Medical Leave Act
Military Leave under the “Uniformed Services Employment and Reemployment Rights Act”

Civil Union Benefits
Pursuant to the Colorado Civil Union Act, CRS §14-15-101, et seq., the CHEIBA Trust modified the definition
of “Dependent” to include partners in a civil union of covered Employees effective as of January 1, 2014. A
Civil Union is a relationship established by two eligible persons pursuant to CRS §14-15-103(1) that entitles
them to receive the benefits and protections and be subject to the responsibilities of spouses. This means
that Civil Union Partners are eligible for group medical, dental, voluntary vision, voluntary life and voluntary
accidental death and dismemberment benefits offered by the CHEIBA Trust Members.


El
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Civil Union Partners and their eligible dependents will be eligible for medical, dental, term life, voluntary
vision, voluntary life and voluntary accidental death and dismemberment insurance in the same manner
as for an Employee's spouse and other dependent children.


- 8 -

BENEFIT ELIGIBILITY TERMINATION



En
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Enrolling a Civil Union Partner is subject to the same limitations that apply to a spouse or child.
Enrollment is limited to:
-
within 31 days of being hired into a benefits eligible appointed position, or
-
during an annual Open Enrollment period for benefits effective the following January 1st, or
-
within 31 days of all qualified IRS-defined change of status (e.g., birth/adoption of a child or loss of a
partner's coverage through his or her employer), or
-
within 31 days of the issuance of a valid civil union certificate.

To enroll, the Employee must present the civil union certificate to your Human Resources/Benefits Office.


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In accordance with CRS §14-15-115(2), the dissolution, legal separation and invalidity of civil unions shall
follow the same procedures as the dissolution, legal separation and invalidity of marriages.

Fl
F e
l x
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x P
l
P a
l n
a s
n
If the Civil Union Partner and his/her children are the Employee's tax dependents for medical and dental
plan purposes, and the Employee has completed a Certification of Tax-Qualified Dependents, then the
Employee may receive reimbursements of their expenses from the Employee's flexible spending
account. However, if the Civil Union Partner and his/her children are not the Employee's tax
dependents, their expenses are not eligible for reimbursement from the Employee's flexible spending
account.
Benefits relating to the Civil Union Partner and his/her children under dependent care spending
accounts will depend on how the Civil Union Partner and/or his or her children fit within the guidelines
established by the tax code for these benefits.

CO
C B
O R
B A
R
A
While continuation of medical, dental and voluntary vision coverage is not required under federal
COBRA laws, such coverage is allowed under the same terms that would apply to an Employee's spouse
and children. A Civil Union Partner and/or children of the Civil Union Partner enrolled in medical, dental
and voluntary vision plans have 60 days from the date that eligibility for coverage ends to enroll in
COBRA coverage.

Ta
T x
a
x E
f
E f
f e
f c
e t
c
IRS regulations require the employer to tax the Employee for the excess of the fair market value of
coverage provided to the Civil Union Partner and his/her children over the amount the Employee pays, if
any, for the coverage. In general, an Employee’s premiums for coverage of a Civil Union Partner or
dependent of a Civil Union Partner are paid on an after-tax basis. There is an exception to this rule if the
Civil Union Partner and his/her children are tax dependents for medical, dental and term life plan
purposes. Please review the document titled, "Important Tax Information for Partners in a Civil Union –
Medical, Dental and Term Life Benefits", and complete the Certification of Tax-Qualified Dependents, if
appropriate.



- 9 -