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Required Documentation for Endowed Health Plans

In addition to completing the applicable endowed medical, dental, and/or vision enrollment in Workday (or paper form/s), you must provide documents to support your dependent’s eligibility for coverage.

How To Submit Documentation

Send the endowed medical, dental, and/or vision​ enrollment form(s) (if applicable) and supporting documentation to:

HR Services and Transitions Center (HRSTC)
395 Pine Tree Road
East Hill Office Building, Suite 130
Ithaca, New York 14850

Please note:

  • SSN: the IRS requires employers to provide the Social Security Number (SSN) for employees and dependents who enroll in their health care plans as part of the Affordable Care Act (ACA) SSN reporting regulations. Be sure to enter the SSN for you and your family members in Workday if you decide to enroll in an endowed medical plan.

  • Foreign documentation is accepted if translated by the employee (e.g., marriage certification, birth certificate, divorce decree and death notice).

Documentation Deadlines

The employee must provide the required documentation and enrollment (via Workday or paper forms) within 60 days of the date of hire in a benefits-eligible position or a qualifying event to enroll in or make changes to endowed health plans.

If the 60-day deadline is missed, the next opportunity to enroll or make changes to these health plans will be during the annual fall open enrollment period.

Types of Documentation

Spouse

To enroll a spouse, you must provide:

  • Copy of marriage certificate

Domestic Partner

To enroll a domestic partner, you must provide:

  • Statement of Domestic Partnership or “Affidavit of Domestic Partnership” from the City of Ithaca, NY or other municipality authorized by state law to recognize domestic partner status.

Children

To enroll natural, adopted or stepchildren in the endowed medical plan, you must provide:

  • Copy of birth certificate, visa and/or passport
  • Court order confirming custody (adopted child)

To enroll Special Dependent Children (other than natural, adopted, or stepchildren), you must provide:

Paternity

In cases where a father is not married to a child’s mother and the father’s name is not listed on the child’s birth certificate:

The father is required to produce one of the following documents in order to add the child to endowed medical, dental, and/or vision plan coverage:

  • The child’s birth certificate noting their status as the father;
  • A court order noting that their status as the father has been adjudicated by a court;
  • A voluntary acknowledgment of Paternity that has been executed and filed with the County Registrar of the county in which the child was born (all states have a paternity acknowledgment process; if the child was born in another state, the enrollee may produce a filed Voluntary Acknowledgment of the Paternity from the other state.)

Additional Documentation

This summary does not account for all enrollment situations. Depending on the circumstances, additional documentation may be required to support a dependent's eligibility. 

While every attempt has been made to ensure the accuracy of this Summary, in the event of any discrepancy the Summary Plan Description and Plan Document will prevail.