Dependent Eligibility Chart
Required Documentation for Benefits Enrollment and Termination
Dependent Eligibility & Required Documentation for FCPS Health Plan Coverage
FCPS requires documentation demonstrating all insured dependents meet eligibility criteria. You have 30 calendar days from a qualifying event to complete and submit your medical and dental plan enrollment forms along with applicable documentation from the chart below to verify your dependent’s eligibility before coverage will become effective.
|Spouse||A person to whom you are legally married||
Photocopy of the first page of the employee's IRS Form-1040 for the most recent tax year that includes the employee's filing status, which must be "Married filing jointly" or "Married filing separately" (you may remove all financial information). A photocopy of IRS Form-4868 can be submitted in lieu of the Form-1040 if both employee and spouse are listed.
*Note: Not required if married in same year as being added to plan
Photocopy of marriage certificate
|Biological Child/Stepchild*||A biological son or daughter of the retiree||Photocopy of birth certificate showing the employee or spouse’s name as mother or father;
If adding a stepchild, must also provide a photocopy of the employee and spouse's marriage certificate and a copy of your most recent federal tax return documenting marital status
|Adopted Child*||An adopted son or daughter of the retiree or a child placed for adoption||
Photocopy of the Final Adoption Decree or an Interlocutory Decree of Adoption with the presiding judge’s signature and seal;
Photocopy of the child’s birth certificate showing the employee as the adopting parent
|Stepchild of a Current Marriage*||A stepson or stepdaughter of the retiree||
Photocopy of birth certificate showing employee’s spouse’s name;
Photocopy of marriage certificate showing the employee and child’s parent’s name
|Child under Legal Guardianship*||A child for whom the retiree has been appointed legal guardian||Photocopy of the final court order, with the presiding judge’s signature and seal, affirming the employee as the child’s legal guardian|
|Child under Legal Custody*||A child for whom the retiree has been granted legal custody||Photocopy of the court order of custody with the presiding judge’s signature and date, affirming the child’s placement in legal custody of the named employee|
|Foster Child*||Certain eligible foster children||Photocopy of the certified foster care documents with the name of the child and the name of the employee|
|Disabled Child||A child age 26 or older who is wholly dependent on the retiree for support and maintenance due to a disability that occurred prior to age 26||
Photocopy of birth certificate showing employee’s name as mother or father (this only verifies dependent eligibility - your health carrier determines the disability status of the child)
Completed Disability Certification form that has been approved by the carrier
*Children must be under age 26 unless disabled.
Examples of ineligible individuals include:
- Former spouse
- Former spouse’s child not biologically related to you (exceptions may apply with applicable court orders)
- Child age 26 or older unless they are disabled and dependent on you for support as defined above
If the source document is not in English, you must have the document translated prior to supplying it to the Office of Benefits Services.
Document copies can typically be obtained in the locality where the birth or marriage occurred, or via the following websites: www.vitalchek.com or www.vitalrec.com; www.irs.gov/taxtopics/tc156.html (for a copy of tax return). Fees will likely apply. If documentation is not in English, you must submit a certified translation of document(s) prior to supplying it to the Office of Benefit Services.