Life Events

Your benefits are designed to meet your needs at different stages of your life. This section shows how your coverage is affected when you experience certain “life events” and what you must do to make sure you get the most from your coverage.

If you have a change of address, you should notify the Health & Welfare Plan AND METRO if you are an active employee, or just the Health & Welfare Plan if you are a retiree. You should do this as soon as possible to make sure your records are up to date and to avoid any delay in payment of claims.

If you’re retired and enrolled in an HMO, and you move out of the HMO area, you may be required to change your enrollment. Contact the Health & Welfare Plan for more information.

If you get married, your spouse is eligible to receive dependent benefits under the Plan. You have 90 days to notify the Health & Welfare Plan that you are married and want to add a new spouse to your coverage. You will need to provide the Health & Welfare Plan with the following required documentation:

  • your original marriage certificate
  • your spouse’s birth date
  • your spouse’s Social Security Number or W-9 number
  • your most recent income tax form (if married for more than two years).

If you have married previously and are adding a new spouse to your coverage, you must present a valid divorce decree or death certificate.

If you have a new domestic partner, you must wait until open enrollment to add them to the Plan. However, if you get married in a same-sex marriage, the same rules as adding a spouse, mentioned above, apply.

If you want to designate your new spouse as your beneficiary on your life and/or other forms of insurance, you need to fill out a “Change of Beneficiary” form and submit it to the Health & Welfare Plan.

For more information on designating beneficiaries, visit the Designating a Beneficiary section.

If you have a baby, your child will be covered by the Plan from the date of birth, as long as you enroll the child within 30 days of that date. If you enroll the child between 31 days and 90 days after the date of birth, the child will be covered on the first of the following month. If you miss this 90-day period, you will not be able to enroll your newborn child until the next Open Enrollment Period.

You should provide the Health & Welfare Plan with the following within 90 days of your child’s birth:

  • the baby’s Social Security Number
  • the baby’s original birth certificate or the certificate of live birth with your name on it (or with your spouse’s name on it)
  • an English translation (if applicable).

If your covered dependent daughter becomes pregnant, the Plan will cover the related pre-natal and delivery services. However, the grandchild is not an eligible dependent.

If you acquire a child through marriage, you must provide the Health & Welfare Plan with the child’s birth certificate within 90 days of the date of the marriage. The name of the parent who is eligible to participate must appear on the birth certificate. Coverage for the child will be effective on the first day of the month after you provide the required documentation. If you miss the 90-day period, you must wait until the next annual Open Enrollment Period to enroll your child.

The Plan will cover your child from the date of adoption or placement if you enroll the child within 30 days. If you enroll the child between 31 days and 90 days after the date of adoption or placement, the child will be covered on the first of the following month. If you are unable to get the required paperwork to the Health & Welfare Plan within the 90-day period due to circumstances beyond your control, notify the Health & Welfare Plan immediately in writing to request an extension. If you miss the 90-day period, you will have to wait until the next Open Enrollment Period to enroll your child for coverage.

If you become the legal guardian of a child, you may be able to add him or her as a dependent provided the child meets the guardianship requirements of the Plan. You must enroll the child within 90 days or wait until the next annual Open Enrollment Period.

Legal Guardianship Requirements

If you are the legal guardian of a child, the Plan considers that child eligible for coverage if the child:

  • is under age 22, or age 22 up to age 25 and a full-time student
  • is age 22 or older and has a permanent physical or mental condition that began prior to age 22 (or prior to age 25 if a full-time student) and that prevents the child from engaging in any self-sustaining employment
  • came under your guardianship prior to turning age 22
  • has the same principal place of abode as you for the full year
  • is dependent upon you for over one-half of his or her support.

If you take family and medical leave to deal with a serious illness, birth of a child, or to care for a seriously ill parent or spouse, the Family and Medical Leave Act (FMLA) allows you to continue coverage for the period of authorized leave up to 12 weeks. You must continue paying your share of monthly health care premiums.

If your coverage ends due to termination of your employment with METRO, you may be eligible for COBRA for you and your family. Although METRO will notify the Health & Welfare Plan of your termination, you are also encouraged to inform the Health & Welfare Plan to avoid any delay.

If you lose Plan coverage as a result due to the termination of your employment, you may want to look into purchasing health coverage through a Health Insurance Marketplace.

One of the changes required by the Affordable Care Act (ACA) is the “individual mandate,” which requires that just about everyone have a minimum level of coverage or pay a penalty starting on January 1, 2014. Your health insurance coverage can come from your (or your spouse’s) employment, through a policy you buy on your own, or through a government-sponsored program like Medicare or Medicaid. To help people meet this mandate, the Health Insurance Marketplaces opened in October 2013.

The Marketplaces were created by the ACA. They are a new way to find health coverage for those who need it. You can compare your options and costs based on what’s available in your state.

The first open enrollment period began on October 1, 2013 and will last until March 31, 2014. If you signed up for a Marketplace plan during the initial open enrollment period in 2013, your coverage could begin as early as January 1, 2014. If you enrolled after December 15, you coverage will begin as soon as administratively possible after your enrollment is processed.

In the future, the annual enrollment period will last from October 15 to December 7 of each year, for coverage effective the following January 1.

If you experience a qualifying life event, such as moving to a new state, certain changes in your income, and changes in your family size (for example, if you marry, divorce, or have a baby), you may be eligible to sign up for a Marketplace plan outside of the annual enrollment period. If you experience a qualifying life event, you will have 60 days from the date of the event to enroll in a Marketplace plan.

Just about anyone* can purchase a medical plan through a Marketplace. However, if you are eligible for Plan coverage, you will have to pay the full cost of the Marketplace plan’s monthly premiums. This is because you are an eligible participant in a group health plan, so you are not eligible for a premium assistance tax credit.

*To be eligible to purchase health coverage through the Marketplace, you:

  • must live in the United States,
  • must be a U.S. citizen or national (or be lawfully present), and
  • can't be currently incarcerated.

If you are on COBRA, you pay the full share of your monthly medical coverage premium plus a 2% administrative fee. You may want to explore the coverage options in your state’s Health Insurance Marketplace. You may be able to find a medical plan that meets your needs and is cheaper than what you are currently paying. You may also be eligible for a premium assistance tax credit if you purchase a plan through the Marketplace and stop your COBRA coverage. Visit the federal government’s website www.healthcare.gov for more information about the Marketplace options. If you regain eligibility for Plan coverage, you can re-enroll in the Plan. Be sure to keep the Marketplace informed of any change in your eligibility for Plan coverage, especially if you are getting premium assistance.

If you and your spouse divorce, you should notify the Health & Welfare Plan immediately. If you fail to remove your divorced spouse from the Plan, you could be liable for any expenses claimed by your former spouse after the date of the divorce.

If you divorce, your former spouse may continue coverage under COBRA for up to 36 months. He or she must notify the Plan within 90 days of the day that the divorce becomes final.

If you want to change your beneficiary on your life and accidental health insurance after your divorce, you need to fill out a “Change of Beneficiary” form and submit it to the Health & Welfare Plan.

For more information on designating beneficiaries, look at the Designating a Beneficiary section.

A Qualified Medical Child Support Order (QMCSO) is a court order, judgment or decree that recognizes that children residing with a custodial parent may be entitled to benefits in the event of a divorce or other family law action. Orders must be submitted to the Health & Welfare Plan to determine whether the order is a QMCSO under federal law.

For information about how these orders are handled, you can obtain a copy of the Plan’s QMCSO procedures from the Health & Welfare Plan for no charge.

If the Plan receives a QMCSO, you must enroll in a plan that will cover the non-custodial child.

If you transfer from a part-time to a full-time position, and have not already selected a medical program, you must notify the Health & Welfare Plan to select a medical plan. Medical and dental coverage is mandatory for you if you are a full-time employee, unless you opt out of the Plan because you have coverage from another source.

If you do not respond, you will automatically be enrolled in the default medical plan and default dental plan, with single coverage. You have 30 days from the date you become full-time to change your coverage elections.

If you transfer from a full-time to a part-time position, you will have to pay more for your benefits coverage. Medical/vision and dental coverage is not mandatory for part-time employees. You have 30 days to notify the Health & Welfare Plan if you want to change or drop your coverage.

If you are on military leave for 31 days or less, you will continue to receive health care coverage for up to 31 days, under to the Uniformed Services Employment and Reemployment Rights Act of 1994 (USERRA). Coverage continues until the end of the month, after the month in which you are deployed.

If you are on military leave for more than 31 days, USERRA allows you to continue medical, prescription drug, vision, and dental coverage for you and your dependents at your own expense for up to 36 months. This continuation right is similar to COBRA. Your dependen(s) may also be eligible for health care coverage under TRICARE, the military health plan.

Coverage under the Plan is not offered for any illness or injury incurred in, or aggravated during, performance of service in the uniformed services. The Department of Veterans Affairs will provide care for service-connected disabilities.

If you become disabled and cannot work, you may qualify for short-term disability benefits from the Plan or long-term disability benefits.

While you are on extended sick leave for any reason from METRO, you are required to make your monthly premium payments directly to the Plan. The Plan does not send out notice that a payment is due. If you do not make timely payments, you will lose your medical coverage and also your short-term disability, life insurance and accidental death and dismemberment coverage.

Your Health & Welfare Plan monthly premium payments can be deducted from your short-term disability payments and from your long-term disability payments.

If you are disabled long enough to establish eligibility for a Social Security Disability award, you must enroll in Medicare as soon as you are eligible for Medicare.

If you retire under the Transit Employees’ Retirement Plan and are a member of the Health & Welfare Plan, you are eligible for life insurance, medical (including prescription drug and vision) coverage and voluntary retiree dental coverage through Delta Dental. Retirees are not eligible for short-term disability (STD), long-term disability (LTD) or accidental death and dismemberment (ADD) coverage.

Your dependents remain covered through your retiree benefits as long as they meet the requirements of an eligible dependent.

Retirees must make monthly premium payments. In most cases, your premium payments are automatically deducted from your pension check.

If you retire and discontinue enrollment in the medical plan, you cannot re-enroll later. A retiree who does not maintain medical plan coverage also loses Delta Dental Plan coverage, but continues to have life insurance coverage.

When you or your dependent becomes eligible for Medicare, you or your dependent should enroll in Medicare Part A and B. For most people, enrollment in Medicare Part A is automatic (there is no premium) when you get benefits from Social Security. You should sign up for Medicare Part B with the Social Security office three months before becoming 65. You pay a monthly premium to Medicare for Part B that will be deducted from your Social Security check.

When you become eligible, you are not required to enroll in Medicare Part B, but benefits will be paid by the Plan as if you are enrolled. This means that, if you do not enroll in Medicare or notify the Health & Welfare Plan Office of your enrollment, you or your dependent will be responsible for paying for the benefits Medicare Part B would have covered. After you submit evidence of your Part B enrollment for yourself or your dependent, your Health & Welfare Plan premium will be reduced.

If you die while you are covered under the Plan as an employee or retiree, your life insurance benefit will be paid to your designated beneficiary(ies). In order for your beneficiary(ies) to receive the benefit, he or she must contact the Health & Welfare Plan and provide a certified copy of the death certificate.

Survivors may be eligible to continue health coverage (medical and dental) until the last day of the month in which they: reach age 65; remarry; or fail to make required monthly payments.

At the end of this period, your survivor(s) may be able to continue their benefits through COBRA, if the 36-month COBRA period has not expired, counting from the date of your death. Your dependent children may continue their coverage until they would otherwise age off the Plan.

Your children may want to look into purchasing health coverage through a Health Insurance Marketplace.

One of the changes required by the Affordable Care Act (ACA) is the “individual mandate,” which requires that just about everyone have a minimum level of coverage or pay a penalty starting on January 1, 2014. Your health insurance coverage can come from your (or your spouse’s) employment, through a policy you buy on your own, or through a government-sponsored program like Medicare or Medicaid. To help people meet this mandate, the Health Insurance Marketplaces opened in October 2013.

The Marketplaces were created by the ACA. They are a new way to find health coverage for those who need it. You can compare your options and costs based on what’s available in your state. Enrollment for health insurance coverage through the Marketplaces began in October 2013 for coverage starting as early as January 1, 2014.

The first open enrollment period began on October 1, 2013 and will last until March 31, 2014. If you signed up for a Marketplace plan during the initial open enrollment period in 2013, your coverage could begin as early as January 1, 2014. If you enrolled after December 15, you coverage will begin as soon as administratively possible after your enrollment is processed.

In the future, the annual enrollment period will last from October 15 to December 7 of each year, for coverage effective the following January 1.

If you experience a qualifying life event, such as moving to a new state, certain changes in your income, and changes in your family size (for example, if you marry, divorce, or have a baby), you may be eligible to sign up for a Marketplace plan outside of the annual enrollment period. If you experience a qualifying life event, you will have 60 days from the date of the event to enroll in a Marketplace plan.

Just about anyone* can purchase a medical plan through a Marketplace. However, if you are eligible for Plan coverage, you will have to pay the full cost of the Marketplace plan’s monthly premiums. This is because you are an eligible participant in a group health plan, so you are not eligible for a premium assistance tax credit.

*To be eligible to purchase health coverage through the Marketplace, you:

  • must live in the United States,
  • must be a U.S. citizen or national (or be lawfully present), and
  • can't be currently incarcerated.

Individuals on COBRA pay the full share of their monthly medical coverage premium plus a 2% administrative fee. Your dependents may want to explore the coverage options in their state’s Health Insurance Marketplace. They may be able to find a medical plan that meets their needs and is cheaper than what they would pay for COBRA. They may also be eligible for a premium assistance tax credit if they purchase a plan through the Marketplace and stop their COBRA coverage. Visit the federal government’s website www.healthcare.gov for more information about the Marketplace options.

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FAQs

My girlfriend just had a baby. Can I add the child to our plan?

Yes, as long as the newborn child is your natural child, your legally adopted child, or you are the child’s legal guardian. If your girlfriend is covered under the Plan as your domestic partner, your child may also be added to the Plan. You’ll need to show documents of proof to the Health & Welfare Plan Office. For more information on dependent eligibility, see Eligibility for Your Spouse and Children.

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