Dependent Eligibility Verification

Dependent Eligibility Verification With medical plan costs on the rise, Ardent continues to look for ways to make sure our health plans run as effectively as possible. One way to do this is to make sure that payments for health care services are made only for those who are truly eligible for coverage in our plan. Dependent eligibility verification: To enroll a dependent (including your spouse, domestic partner and children), you must provide a Social Security number and other required documentation to verify eligibility. Spousal eligibility verification: Spouses (and domestic partners) who have medical coverage available through their employer must enroll in their employer s plan for primary coverage. They may select the Ardent plan for secondary coverage only. If your spouse is enrolled in the medical plan, you will be asked to complete a Spousal Employment Verification Form to verify his or her employment status and your spouse s employer will be asked to verify his or her enrollment in the employer s plan. If you are unable to verify eligibility for your spouse and dependents within 30 days of the benefit effective date, coverage will be terminated and you may be responsible for any claims paid. Page 1 of 9

Dependent Eligibility Matrix Review the Dependent Eligibility Matrix below to determine if all of your dependents meet our Plan s eligibility criteria. Then, complete the Dependent Verification Affidavit, the Spousal Employment Verification Form (if applicable) and provide documentation to confirm their eligibility. Provide your supporting documentation for each enrolled dependent to Benefit Harbor. Online: Scan and upload your documents at www.getardentbenefits.com/enroll Fax: Toll-free to 1.866.770.6393 using the Fax Cover Sheet Please only submit your most recent tax return and blackout any sensitive information (see sample provided) Dependent Number Dependent Type Eligibility Criteria Documents Required for Verification 1 Spouse Your current legal spouse A copy of your marriage certificate Recent (within 6 months) documentation establishing current marital status such as: Joint household bill Joint bank/credit account Joint mortgage or lease Page 1 of your most recent federal tax return (If you are married and file separately, Page 1 of both Federal Income Tax Returns must be provided.) Completed Spouse Employment Verification Form. Page 2 of 9

Dependent Dependent Number Type 2 Domestic Partner Eligibility Criteria Two people (same-sex or opposite sex) who have met ALL of the following criteria: For at least 12 months have shared the same principal residence in an intimate, committed relationship of mutual caring and intend to do so indefinitely. Agree to be responsible for each other s basic living expenses during the domestic partnership and agree that anyone who is owed these expenses can collect from either of them. Are both 18 years of age or older and of sufficient mental competence to enter binding legal contracts. Are not married to anyone and are not so closely related by blood that a legal marriage between them would be prohibited for that reason in their state of residence. Do not presently have a different domestic partner. Did not have a different domestic partner in the last 12 months. If you have an opposite-sex domestic partner and the two of you generally represent yourselves as married, you may have a common-law marriage if it is recognized by the state in which you reside. A common-law husband or wife is considered a spouse rather than a domestic partner. Documents Required for Verification A signed notarized Affidavit of Domestic Partnership (available online at www.getardentbenefits.com or from Benefit Harbor or your Human Resources Department) TWO forms of documentation providing proof of financial interdependence: Mortgage or deed showing joint ownership of permanent residence Lease showing joint tenancy for residence Proof of common ownership of a motor vehicle Joint bank account statement Documentation of joint responsibility for debt Joint credit card account statements Designation as primary beneficiary for life insurance, retirement benefits, or under a partner s will Assignment of durable property power of attorney to partner Assignment of health care power of attorney to partner Completed Spouse/Domestic Partner Employment Verification Form. 3 Natural Born Child Your natural born child who has not attained age 26 A copy of the child s birth certificate naming you as the child s parent. Page 3 of 9

Dependent Dependent Number Type 4 Stepchild OR Child of Domestic Partner Eligibility Documents Required Criteria for Verification Your stepchild who has not attained age 26 Verification of Spouse (See Spouse) or Domestic Partner (See Domestic Partner) A copy of the child s birth certificate naming your Spouse or Domestic Partner as the child s parent 5 Legally Adopted Child OR Child Placed for Adoption or in Legal Guardianship OR an Eligible Foster Child 6 Child covered by a NMSN or QMCSO 7 Disabled/ Incapacitated Natural Born Child, Stepchild or Legally Adopted Child/Child Placed for Adoption Your legally adopted child or child placed for adoption or in legal guardianship OR A foster child who is placed with you by an authorized placement agency or by judgment, decree, or other order of any court of competent jurisdiction Not attained age 26 A child covered under a National Medical Support Notice or a Qualified Medical Child Support Order Same as natural born child, stepchild, legally adopted child or child placed for adoption or in legal guardianship, OR eligible foster child Age 26 or older A child who is physically or mentally incapable of self-support if the incapacity occurred before age 26 A copy of adoption decree or legal court documents naming you as the child s adoptive parent, foster parent, or guardian A legal document showing age of child A copy of NMSN or QMCSO Same as natural born child, stepchild, legally adopted child or child placed for adoption or in legal guardianship, OR eligible foster child Statement of Disability from the Social Security Administration In all cases, the Summary Plan Description is the governing document with respect to eligibility. Page 4 of 9

Fax Cover Letter Toll-Free Number: 1-866-770-6393 Please use this cover sheet for any fax sent to Benefit Harbor and include your Name, Employee ID, and Personal Contact Information. Employee Name: Employee ID: Mobile Phone Number: Email Address: Do not forget to include: Completed and signed Dependent Verification Affidavit Completed Spousal Employment Verification Form (if applicable) Required documentation Questions? Consult the website at www.getardentbenefits.com/enroll. Or call Benefit Harbor tollfree at 1.888.391.3856. Benefit Counselors are available to you Monday through Thursday from 7:30 a.m. 7:00 p.m. and on Friday from 7:30 a.m. 4:00 p.m. Central/Standard Time. Page 5 of 9

Dependent Verification Affidavit EMPLOYEE NAME: EMPLOYEE ID: COMPLETE THE TABLE BELOW 1. Please review and refer to the Dependent Eligibility Matrix for eligible dependent types and required documentation. 2. In Column A list all of your dependents. Please note that adding a name to the list does not add the dependent to your medical, pharmacy, dental, or vision plans. You must enroll them online at www.getardentbenefits.com/enroll or by calling Benefit Harbor at 1.888.391.3856. 3. In Column B, provide the Social Security Number for each of your covered dependents. 4. In Column C, fill in the Dependent Number from the first column of the Dependent Eligibility Matrix. For example, fill in a 1 for your Spouse. Column A Column B Column C Dependent Name Dependent Social Security Number Dependent Type (Dependent Number from Matrix) COLLECT THE REQUIRED DOCUMENTATION For each of your dependents, collect and copy the required documentation as outlined in the Dependent Eligibility Matrix. Please only submit your most recent tax return and blackout any sensitive information (see sample enclosed). Page 6 of 9

SIGN BELOW By my signature on this form, I certify and warrant that all information on this affidavit is true, correct, and current as of the date signed and any misrepresentation of information about a dependent relationship to obtain benefit coverage is fraud and grounds for immediate termination. In addition, it may lead to prosecution under state and federal law. Employee Name: Employee ID: Signature: Date Signed: SUBMIT TO BENEFIT HARBOR Send completed and signed Dependent Verification Affidavit, Spousal Employment Verification Form (if applicable) and your supporting documentation for each eligible dependent to Benefit Harbor online or by fax: Online: Execute your Affidavit with a PIN Signature and scan and upload your documents at www.getardentbenefits.com/enroll. Fax: Fax your Affidavit and supporting documentation using the Fax Cover Sheet to 1-866-770-6393. QUESTIONS? If you have questions, you can call Benefit Harbor toll free at 1.888.391.3856. Representatives are available to you Monday through Thursday from 7:30 a.m. 7:00 pm, on Friday from 7:30 am 4:00 p.m. Central/Standard Time. Page 7 of 9

FEDERAL TAX RETURN REQUIREMENTS Please only submit your most recent federal income tax return. If you are married and file separately, Page 1 of both Federal Income Tax Returns must be provided. Circled areas are required. Please black out any sensitive information, as shown below. Page 8 of 9

Frequently Asked Questions Why is Ardent requiring us to submit proof of our dependents eligibility for benefits? Medical, pharmacy, dental, and vision care are shared costs. Ardent is sensitive to the rising cost of health care and recognizes that covering ineligible dependents drives up the cost of health care for all plan participants. As such, Ardent must ensure that the benefit dollars are being spent only on eligible participants. Who is Benefit Harbor? Benefit Harbor is an independent third-party company headquartered in Dallas, Texas. Ardent has contracted with Benefit Harbor to provide benefit administration services for many years. Because of their knowledge of Ardent and our benefit plans, asking them to verify dependent eligibility was a natural extension of their ongoing services. What is the deadline for returning the Dependent Eligibility Affidavit and providing the documents verifying eligibility? Your completed Dependent Eligibility Affidavit, Spousal Employment Verification Form and supporting documentation must be provided to Benefit Harbor within 30 days of your benefit effective date. Failure to complete and submit all required documents will result in your dependent coverage being terminated. Who can answer my questions about the definition of an eligible dependent? If you ve read the Dependent Eligibility Matrix and still have questions, you can call Benefit Harbor toll free at 1.888.391.3856. Benefit Counselors are available to you Monday through Thursday from 7:30 a.m. 7:00 p.m., on Friday from 7:30 a.m. 4:00 p.m. Central/Standard Time. Can I appeal the determination of my dependent s eligibility? Yes. If you disagree with the final determination, you can appeal the decision. If the appeal results in a determination that your dependent(s) meet the eligibility requirements of the plan, coverage will remain in place. How do I protect my sensitive information? When you are sending verification documents that contain sensitive financial or personal identification information, please black out the information using the sample tax form on the attached page as a guide. Please note that it is a felony to falsify IRS tax forms in any way. Be careful not to obscure information that will be needed to verify your dependent s eligibility. Page 9 of 9

Section 1 PLEASE PRINT ALL INFORMATION REQUESTED YOUR FULL NAME Spouse/Domestic Partner Employment Verification Form Fax completed form to 866-770-6393 or Email to ardent@benefitharbor.com or See bottom of Page 2 for direct upload instructions. YOUR EMPLOYEE NUMBER OR LAST FOUR DIGITS OF YOUR SOCIAL SECURITY NUMBER YOUR E-MAIL ADDRESS YOUR PHONE NUMBER SPOUSE S FULL NAME SPOUSE S DATE OF BIRTH SPOUSE INFORMATION Select the applicable statement: My spouse is employed and is eligible for medical coverage through his/her employer. My spouse must enroll in his/her employer s plan for primary medical coverage. Coverage under the Ardent plan will be secondary. (Sections 1, 2, & 3 of this form are required.) My spouse is employed, but is not eligible to participate in his/her employer s medical plan. (Sections 1, 2, & 3 of this form are required.) My spouse s employer does not offer medical coverage. (Sections 1, 2, & 3 of this form are required.) My spouse is not employed. (Section 1 & 2 of this form are required.) My spouse is self-employed and does not have access to a group medical plan. (Section 1 & 2 of this form are required.) My spouse is an Ardent Health Services employee at (location/process level). (Section 1 & 2 of this form are required.) If any of this information changes, a new form must be completed within 30 days. NAME ADDRESS OF SPOUSE S EMPLOYER SPOUSE S EMPLOYER PHONE Page 1 For purposes of this form, the term spouse includes Domestic Partner as well.

Spouse/Domestic Partner Employment Verification Form Fax completed form to 866-770-6393 or Email to ardent@benefitharbor.com or See bottom of Page 2 for direct upload instructions. Section 2 EMPLOYEE ACKNOWLEDGEMENT OF RESPONSIBILITY: I have read and completed this Spousal Employment Verification Form. I understand that if my spouse is employed and has other health care coverage that is available, my spouse must enroll in his/her employer s coverage. My spouse may be enrolled in the Ardent medical plan as secondary coverage. I also acknowledge and agree that (i) the plan has the right to cancel coverage retroactively in the case of fraud or an intentional misrepresentation of a material fact and seek reimbursement for any wrongfully paid claims from me or the individual on whose behalf the claims were paid; (ii) I am responsible for providing accurate and up-to-date information about enrolled family members; and (iii) any falsification of enrollment information (including the identification of an individual as an eligible dependent when he or she is not) may be subject to discipline up to and including termination of employment. Employee s Name (please print) Employee Number or Social Security Number Employee s Signature Date Fax completed form to 866-770-6393 Direct Upload 1. Log on to your personal account at www.getardentbenefits.com/enroll 2. Select Dependents, then List from the tab at the top of the page. 3. Choose Submit Documents 4. Submit all documents online securely from your computer to your personal account. Page 2 For purposes of this form, the term spouse includes Domestic Partner as well.

Form Spousal Employment Verification Section 3 SPOUSE S EMPLOYER COMPLETES THIS FORM Fax completed form to 866-770-6393 or Email to ardent@benefitharbor.com Spouse s Employer: Name of Spouse: Name of Ardent Employee: DOB DOB Ardent Health Services requires that spouses who have medical coverage available through their employer enroll in their employer s plan for primary coverage. They may select the Ardent medical plan for secondary coverage only. Please complete the box below. Answer all questions in relation to the spouse who is named above. After completing this form, you may return it to the spouse named above, or fax it to 866-770-6393. Inquiries can be directed to 888-391-3856. Yes No 1. Does your employee (spouse named above) have access to group medical coverage through his or her employment? If no, please explain why in the space provided. If yes, please also complete question 2. Why: Yes No 2. Is the spouse covered by the group medical coverage? Plan Name: Group Number: Coverage Effective Date: The above responses are correct to the best of my knowledge. Employer Representative (please print) Phone Number Employer Representative (signature) Date Fax Completed Form To: 866-770-6393 Page 3 For purposes of this form, the term spouse includes Domestic Partner as well.