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UC2004

Behavioral Health Benefits for Blue Cross PLUS

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Eligible Dependents (Family Members)

When you enroll any Family Member, your signature on the enrollment form or the confirmation number on your

electronic enrollment attests that your Family Member meets the eligibility requirements outlined below. The

University and/or the Plan reserves the right to periodically request documentation to verify eligibility of Family

Members including any who are required to be your tax dependent(s). Documentation could include a marriage

certificate, birth certificate(s), adoption records, Federal Income Tax Return, or other official documentation.

Spouse:

Your legal spouse.

Child:

All eligible children must be under the limiting age (18 for legal wards, 23

for all others), unmarried, and may not be emancipated minors. The following categories are eligible:

(a) your natural or legally adopted children;

(b) your stepchildren (natural or legally adopted children of your spouse) if living with you,

dependent on you or your spouse for at least 50% of their support and are your or your spouse's

dependents for income tax purposes;

(c) grandchildren of you or your spouse if living with you, dependent on you or your spouse for at

least 50% of their support and are your or your spouse's dependents for income tax purposes;

(d) children for whom you are the legal guardian if living with you, dependent on you for at least

50% of their support and are your dependents for income tax purposes.

Any child described above (except a legal ward) who is incapable of self-support due to a physical or

mental handicap may continue to be covered past age 23 provided:

- the incapacity began before age 23, the child was enrolled in a group medical plan before age 23

and coverage is continuous,

- the child is dependent on you for at least 50% of his or her support and is your dependent for

income tax purposes, and

- the child lives with you if he or she is not your or your spouse's natural or adopted child.

Application must be made to the Plan at least 31 days before the child's 23rd birthday and is subject to

approval by the Plan. The Plan may periodically request proof of continued disability. Incapacitated

children approved for continued coverage under a University-sponsored medical plan are eligible for

continued coverage under any other University-sponsored medical plan; if enrollment is transferred

from one plan to another, a new application for continued coverage is not required.

If you are a newly hired Employee with an incapacitated child, you may also apply for coverage for

that child. The child must have had continuous group medical coverage since age 23, and you must

apply for University coverage during your Period of Initial Eligibility.

Other

Eligible

Dependents

(Family

Members):

You may enroll a same-sex domestic partner (and the same-sex domestic

partner's children/grandchildren) as set forth in the University of

California Group Insurance Regulations. An adult dependent relative is no

longer eligible for coverage effective January 1, 2004. Only an adult

dependent relative who was enrolled as an eligible dependent as of

December 31, 2003 may continue coverage in UC-sponsored plans.

For information on who qualifies and how to enroll, contact your local Benefits

Office or the University of California's Customer Service Center.

No Dual Coverage

Eligible individuals may be covered under only one of the following categories: as an Employee, an Annuitant, a

Survivor Annuitant or a Family Member, but not under any combination of these. If an Employee and the Employee’s

spouse or same-sex domestic partner are both eligible Subscribers, each may enroll separately or one may cover the

other as a Family Member. If they enroll separately, neither may enroll the other as a Family Member. Eligible

children may be enrolled under either parent's or same-sex domestic partner’s coverage but not under both.

Additionally, a child who is also eligible as an Employee may not have dual coverage through two University-sponsored

medical plans.

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