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Qualifying Status Change (QSC)

Qualifying Status Change Form

Employees may not change their benefit elections during the course of a plan year unless they experience a Qualifying Status Change (QSC) event. The IRS regulations regarding pre-tax premium plans do not allow for enrollment, additions, changes, or cancellations except with the occurrence of a Qualifying Status Change event, followed by written application for a change within a prescribed time frame. The Federal Government determines the events that qualify as QSC's, and this list is subject to periodic change.

An employee who wishes to change a benefit election on the basis of a QSC must complete the following steps within 31 days of the QSC event:

1. Contact the People First Service Center (1-866-663-4735) to report the QSC event and date.

2. Complete all required forms authorizing the desired change

3. Provide the supporting documentation (as listed in the chart below)

4. People First must receive the required enrollment forms within 31 days of the QSC event. If the forms are received more than 31 days after the event, the request will be denied and can not be made until the next Annual Open Enrollment period, which usually occurs in October each year.

Code	Qualifying Event	Documentation Requirements
1	Marriage	Marriage Certificate, Proof of Eligibility if adding other Dependents
2	Divorce	Divorce Decree
3	Employee begins Unpaid Leave (including Military Leave)	Documentation will be provided by your Employer
4	Employee returns from Unpaid Leave (including Military Leave)	Proof of Eligibility if adding Dependents
5	Death of Spouse of Dependent	Death Certificate
6	Ineligibility of Dependent	No Documentation needed
7	Birth of Adoption (including foster care placement, guardianship, adoption placement)	Birth Certificate, Adoption Papers, Court Documents, Proof of Eligibility if adding other Dependents
8	Employment of Employee’s Spouse (resulting in coverage)	Documentation from Spouse’s Employer with coverage effective date
9	Termination of Spouse’s Employment (resulting in loss of coverage)	Documentation from Spouse’s former Employer with coverage end date
12	Change from Part-Time to Full-Time by Employee	Documentation will be provided by your Employer
13	Change from Full-Time to Part-Time by Employee	Documentation will be provided by your Employer
17	Change in Coverage due to Spouse’s Employment (open enrollment, health plan addition or deletion; by a non-state employer)	No Documentation needed
20	Spouse Program Enrollment	Spouse Program Enrollment Form
21	Spouse Program Dis-enrollment	Spouse Program Enrollment Form
22	Termination of Employment (except retirement)	Documentation will be provided by your Employer
23	Dependent satisfies Eligibility Requirements	Proof of Eligibility if adding Dependents
24	Retirement	Documentation will be provided by your Employer
27	Commencement or Return from Family Medical Leave (FMLA)	Documentation will be provided by your Employer
30	Court Order that requires Coverage for a Child under the Employee’s Plan	Copy of Court Order

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