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Eligibility and Enrollment

Important Benefits Information:

The following information is a high-level summary only.  Please refer to your Plan’s BENEFIT BOOKLET to review all Eligibility requirements.

Initial (new hire) Enrollment

You are eligible to enroll in the Plan if you work for a participating employer and you are a member of a group of employees designated by your participating employer as eligible to participate.

To enroll in the Plan, you must complete the online enrollment process within 31 calendar days after your hire date by logging into sebt-optimalhealth.benelogic.com

If you have difficulty in enrolling or uploading required documentation, then contact the Administrative Support Team at AST@planmanagementservice.com.

Proof of Eligibility Requirements

Documentation Required for Proof of Eligibility (PDF)
Disabled Dependent – Certificate of Impairment Form (PDF)-For disabled dependent over age 26
Spousal Employer Verification Form (PDF)

Dependent Enrollment and Eligibility

A Spouse and dependent children (up to the age of 26) who meet the Plan’s eligibility criteria are able to enroll in the School Employee’s Benefit Trust (SEBT) for medical coverage.                                 .

Spouses that are eligible for enrollment may enroll in SEBT for secondary coverage when they are primary on another plan.  For a Spouse to enroll in this Plan for primary medical coverage, the Spouse must meet the criteria eligibility listed here Eligibility Requirements for a Spouse to Enroll in Medical Plan.

As part of the enrollment process, you will be required to answer the spousal questions located in the Benelogic system.  If your Spouse is eligible to be secondary, their primary insurance information will need to be entered in the Coordination of Benefits (COB) section of the enrollment process.

If your Spouse is employed but does not have access to an employer-sponsored medical plan, you will be required to have your Spouse’s employer complete the Spousal Employer Verification Form.   Print the form from either this site or from the Resources Tab in the enrollment portal, complete, and upload to your Benelogic file cabinet.

Retiree Eligibility

Within ninety (90) days of retirement, medical coverage for an eligible retiree and his/her covered Dependents may be continued. The spouse of a retiree must be covered as a dependent under this Plan for twelve (12) months prior to the Employee’s retirement in order to be eligible to continue coverage, unless enrollment during that period is a result of a Special Enrollment event.

No coverage is provided for dependent children of a retiree, unless retired prior to 1/1/2018 and dependent coverage was elected at the date of retirement.

The retiree and/or dependent spouse may be required to pay the full cost of such coverage.

Continuing coverage under this provision of the Plan shall terminate for an eligible Covered Person as defined in the SEBT Benefit Book.

Family Status Changes

When family status changes occur, the last thing on your mind is to update your employer of these changes. However, failure to notify your employer may cause your medical claim payments to be delayed or denied. Also, your rights to enroll in the plan or continue coverage may expire. Notify your Business Office on the enrollment/change form of the following changes within 31 days of the qualifying event if loss of medical coverage due to:

  • Divorce
  • Death
  • Spouse’s coverage ends with employer due to termination or reduction of hours
  • COBRA exhausted
  • Marriage
  • Adoption
  • Qualified Medical Child Support Order
  • Child turns 26 on medical or dental plan
  • Child gets married
  • Address or phone number change

Special provision: Newborns are covered at the moment of birth ONLY if you enroll your new baby in the plan within 60 days immediately following birth.

Your medical claim payments may be delayed or denied if you do not notify your Employer Human Resources or Business Office.

When Coverage Can Be Added Or Terminated

In general you cannot change or drop your health benefits unless it is done during the plan’s annual Open Enrollment, or you experience a qualifying event and make the change within 31 days of the event.

Open Enrollment Period:
Each year you have the opportunity to participate in the Medical plan for the first time, change plan options or add or drop dependents without a qualifying event. Your must participate in open enrollment to enroll or make a change. Open enrollment occurs in the fall of each year with coverage effective January 1 of the following year.

Please contact your Employer’s Benefits Administration (Human Resources) office to obtain your Open Enrollment Brochure and Help Guide to assist you through the Open Enrollment process.

During the designated open enrollment time period, login to the Employee portal at sebt-optimalhealth.benelogic.com

Qualifying events include but are not limited to the following:

  • Marriage
  • Death of a spouse
  • Legal separation
  • Birth, adoption, placement for adoption or death of a dependent
  • Termination or commencement of employment of a spouse
  • A dependent or spouse fail to satisfy the plan’s definition of an eligible dependent or spouse
  • Loss of eligibility which includes a loss of coverage due to:
    • Divorce;
    • Legal separation;
    • Death;
  • Termination of employment, or reduction in hours of employment;
  • Relocating outside of a Plan’s network service area;
  • A plan no longer offering benefits to a class of similarly situated individuals even if the plan continues to provide coverage to other individuals;
  • The Employee or Dependent is covered under a Medicaid plan or under a state CHIP program, and coverage of the employee or dependent under such plan/program is terminated as a result of loss of eligibility for such coverage.

Remember that your health plan allows you to have your premiums deducted pre-tax. As a result the plan is considered a “cafeteria plan”, and is subject to IRS cafeteria plan regulations. Under these regulations employees cannot drop coverage at any time unless is during the plan’s open enrollment period, or within 31 days of a status change or qualifying event.

Your medical claim payments may be delayed or denied if you do not notify your Employer Business Office.

Enrollment Support Needed?

Contact the Administrative Support Team at AST@planmanagementservice.com