IVY TECH COMMUNITY COLLEGE OF INDIANA
Questionnaire for Health and Dental Coverage of a Spouse
The Working Spouse rule requires employed spouses of covered employees to join their employer’s group health and dental plans (for
at least “employee only” coverage), if creditable coverage (preventive care, major medical, prescription benefits, preventive dental,
major restoration for dental) is available. Your spouse’s claims occurring on or after January 1, 2011 will not be considered for
payment under any of the Ivy Tech health or dental plans until this form is returned to your regional Human Resources
Department. Due date for returning this completed form is November 30, 2010, if you wish your spouse to be covered by the Ivy
Tech plans for primary or secondary coverage.
Complete this questionnaire if:
A. You wish to enroll your spouse for primary coverage under any of the College’s health or dental plans.
B. Your spouse is enrolled in his/her employer-sponsored health and/or dental plans or is covered as a retiree through an
employer-sponsored plan and you are electing secondary spousal coverage under any of the Ivy Tech health or dental plans.
Employee Name:________________________________________________________ C#____________________
Spouse’s Name:_________________________________________________________ SSN#______-_____-_______ (optional)
Name of Spouse’s Employer:____________________________________________________________
Please answer questions 1-4 below. If you answer “No” to all questions, proceed to questions 5-7 below.
1. Yes No My spouse is employed by Ivy Tech.
2. Yes No My spouse is currently unemployed.
3. Yes No My spouse is retired, is not actively employed and is not covered as a retiree on any employer-sponsored plan.
4. Yes No My spouse is self-employed and does not have access to a group health and dental plan.
If you answered “Yes” to any of the above questions: Your spouse will be eligible for “primary” coverage under the Ivy Tech
health and dental plans as long as the condition applies.
If you answered “No” to Question 1, 2, 3 or 4 and your spouse is actively employed, please answer each of the following
questions:
5. Yes No My spouse is employed but does not currently have access to a group medical plan.
6. Yes No My spouse is employed but does not currently have access to a group dental plan.
7. Yes No My spouse is employed but the available medical or dental plan does not provide creditable coverage (preventive
care, major medical, prescription benefits for medical or preventive care, major restoration for dental).
8. Yes No My spouse’s employer does not pay at least 50% of the premium cost for “employee only” coverage in the group
medical plan available.
9. Yes No My spouse is employed and enrolled in his/her employer’s group plan (circle all that apply: health / dental). I want
my spouse to be covered by Ivy Tech’s plan (circle all that apply: health / dental) for secondary coverage.
If you answered “Yes” to question 5, 6, 7, 8 or 9: Page 2 of this form must be completed by a representative of your spouse’s
employer and returned to your regional Human Resources Department before claims for your spouse will be considered for
payment.
Employee Acknowledgment
If my spouse’s employment status changes in the future, I understand that I am responsible for completing a new enrollment form and
the Questionnaire for Health and Dental Coverage of a Spouse within 31 days of the employment status change. In addition, by my
spouse’s signature below, authorization is given to his/her employer to release the required dependent information indicated on Page 2
of this form. I understand that failure to notify Ivy Tech of my spouse’s employment change or falsifying his/her employment status
is fraud and could result in financial penalty, loss of coverage and/or possible termination of employment.
______________________________________________________ __________ __________________________
Employee Signature Date Daytime Contact Phone No.
______________________________________________________ __________
Spouse’s Signature Date
DUE DATE: NOVEMBER 30, 2010
Return completed form to your regional Human Resources Department
11/27/2011
IVY TECH COMMUNITY COLLEGE OF INDIANA
Name of Ivy Tech Employee: _________________________________________ C#: __________________
Name of Spouse: ____________________________________
TO BE COMPLETED BY EMPLOYER OF SPOUSE
Ivy Tech requires spouses of covered employees to join their employer’s group health and dental plan (on at least an “employee only”
basis) where such availability to coverage exists. Please complete the section below in order for your employee’s health and dental
claims to be considered as “primary” under the Coordination of Benefits (COB) provision of the College’s health and dental plans.
PLEASE CHECK THE APPROPRIATE BOX BELOW:
1. Yes____ No____ Is your employee currently enrolled or will he/she be enrolled in your employer-sponsored group
health coverage as of 1/1/11?
2. Yes____ No____ Is your employee currently enrolled or will he/she be enrolled in your employer-sponsored group
dental coverage as of 1/1/11?
If yes to questions 1 and 2, please skip the remaining questions and sign this form at the bottom.
If no to either question 1 or 2, please complete the remaining questions and sign this form at the bottom.
Yes ____ No ____ Does your employee have access to employer-sponsored health coverage through
employment with your company? If yes, does the company pay at least 50% of the “employee only”
premium? _____ Yes _____ No
Yes ____ No ____ Does your employee have access to employer-sponsored dental coverage through
employment with your company? If yes, does the company pay at least 50% of the “employee only”
premium? _____ Yes _____ No
Does the employer-sponsored health and dental coverage offered to your employees provide the following types of coverage? (Please
check all that apply)
Medical Preventive Care ____ Yes Major Medical ____ Yes Prescription Drug ____ Yes
____ No ____ No ____ No
Dental Preventive Care ____ Yes Dental Major Restoration Services ____ Yes
____ No ____ No
Answering “Yes” to all of the above questions regarding medical coverage and a response of at least 50% on the employer premium
percentage requires that your employee must be enrolled for primary coverage through your employer-sponsored health plan (on at
least an “employee only” basis) in order to remain an eligible dependent under any of Ivy Tech’s health plans for secondary coverage.
Answering “Yes” to all of the above questions regarding dental coverage and a response of at least 50% on the employer premium
percentage requires that your employee must be enrolled for primary coverage through your employer-sponsored dental plan (on at
least an “employee only” basis) in order to remain an eligible dependent under any of Ivy Tech’s dental plans for secondary coverage.
Please indicate if your company will consider the implementation of Ivy Tech’s Working Spouse rule, effective 1/1/11, as a
qualifying event whereby allowing your employee to join your employer-sponsored health and/or dental plans on 1/1/11.
_____ Yes _____ No
If you answered “No” to the question immediately above, what is the earliest date that your employee will be allowed to join
your employer-sponsored health and/or dental plans? ______________
_____________________________________________________
Name of Employer
_____________________________________________________ _________ _________________
Employer Representative Signature Date Phone Number
_____________________________________________________
Printed Name and Title of Employer Representative
DUE DATE: NOVEMBER 30, 2010
Return completed form to the Ivy Tech employee’s regional Human Resources Department
11/27/2011