effective: september 1, 2013 · the employee’s commitment ceremony, to attend the wedding of the...

OFFICE OF HUMAN RESOURCES Benefits and Insurance Services

(ATTACHMENT 2) ACTION ON A RECOMMENDATION TO EXTEND DOMESTIC PARTNERSHIP BENEFITS ON A DISTRICT-WIDE BASIS

INSTRUCTIONAL GUIDE DOMESTIC PARTNER BENEFITS

Effective: September 1, 2013

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MPS Guide to Domestic Partner Benefits_2013 2-16

Table of Contents PAGE

OVERVIEW ...................................................................................................................................................... 3 GETTING STARTED ........................................................................................................................................... 4 WHEN TO ENROLL ........................................................................................................................................... 4 APPLICATION CHECK-OFF LIST .......................................................................................................................... 5 SUBMITTING YOUR APPLICATION ....................................................................................................................... 6 ‘IMPUTED INCOME’ AND EXAMPLES ................................................................................................................. 6-7 TERMINATING COVERAGE ................................................................................................................................. 8 COBRA COVERAGE .......................................................................................................................................... 9 SICK, BEREAVEMENT & MISCELLANEOUS LEAVE .......................... ……………………………………………………9

HEALTH & PRODUCTIVITY MANAGEMENT PROGRAM ................................ ……………………………………….9-10

MPS RIGHTS ........................................................................................... ……………………………………….10

NONDISCRIMINATION NOTICE .............................................................................................................................. 10

ATTACHMENTS ................................................................................... ……………………………………….11-16

• .................................................................................................................................. ATTACHMENT A - DEFINITIONS

• .................................................................................................................................. ATTACHMENT B - AFFIDAVIT OF DOMESTIC PARTNERSHIP

• .................................................................................................................................. ATTACHMENT C - AFFIDAVIT OF TERMINATION OF DOMESTIC PARTNERSHIP

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Instructional Guide to Domestic Partner Benefits OVERVIEW Active employees who are enrolled in an MPS health/vision and dental plan coverage may add domestic partners and the child(ren) of a domestic partner to their MPS health/vision and dental plan coverage. This benefit includes a required payroll tax on the value of health/vision and dental coverage for your domestic partner (and children of your domestic partner), which means your take home pay will be reduced. Eligible active employees (“you”) may also be entitled to a sick leave to care for a domestic partner or a child of a domestic partner; or a bereavement leave upon the death of a domestic partner or a domestic partner’s child, domestic partner’s parent, domestic partner’s brother, sister, spouse of domestic partner’s child, or niece or nephew of a domestic partner. Absences may also be covered: to attend the graduation of the domestic partner’s child, to attend the employee’s commitment ceremony, to attend the wedding of the domestic partner’s child, or to attend school activities of the domestic partner’s child. To add your domestic partner (and the eligible child(ren) of a domestic partner) to your MPS health/vision and dental benefits, or to be entitled to sick leave or bereavement leave, you and your domestic partner must meet the requirements as outlined in this MPS Instructional Guide to Domestic Partner Benefits (“Guide”). REQUIREMENTS To enroll an eligible domestic partner (and the eligible dependent child(ren) of a domestic partner) to your MPS health/vision and dental coverage, you must: 1. Be an active employee and enrolled in the MPS health/vision and dental benefit plans. 2. Review the MPS Affidavit of Domestic Partnership (“Affidavit”) thoroughly before completing. An Affidavit will

not be considered complete unless the required verification documents and the Affidavit provided are deemed authentic by MPS Office of Human Resources, Benefits and Insurance Services.

3. Comply with the benefit enrollment procedures explained in this Guide. (See Check-Off List on p.5) 4. Understand requirements applicable to a Domestic Partnership, such as: benefits available; termination of

coverage; and application of the Consolidated Omnibus Budget Reconciliation Act (COBRA) coverage. 5. Understand that you will be taxed on the fair market value of the health/vision and/or dental coverage provided to

your domestic partner and child(ren) of a domestic partner. This means your take-home pay will be reduced. If your current income is not sufficient to support the applicable withholding, you will no longer be eligible to cover your domestic partner and/or child(ren) of a domestic partner and such coverage will be terminated.

6. Organize your required documentation in advance and schedule an appointment early in September with an MPS benefit representative to review your paperwork. This gives you time to gather your documents and verify that your documentation is acceptable before the September 30, 2013 Open Enrollment deadline. New hires should contact a MPS benefit representative. 7. Remember to promptly remove your ineligible domestic partner (and/or children) from your health plan within 31 days of their ineligibility to avoid the district’s disciplinary action. Refer to MPS RIGHT OF RECOVERY. If you already cover a domestic partner and children of a domestic partner under your MPS health and/or dental plan, you do not need to re-enroll them during Open Enrollment and coverage for your domestic partner and domestic partner children will continue.

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------------------------------------------------------------------------------------------------------------------------------------------- GETTING STARTED ------------------------------------------------------------------------------------------------------------------------------------------- STEP 1: Verify you are an active employee who is eligible for and enrolled in the MPS health/vision or dental benefit plans. STEP 2: Review the MPS Affidavit of Domestic Partnership to make sure you meet all of the criteria. STEP 3: Collect your verification documents that you plan to submit with your Affidavit of Domestic Partnership. The Affidavit and verification documentation is how MPS verifies eligibility for benefits. These documents must be provided and completed to the satisfaction of MPS Benefits and Insurance Services. STEP 4: Go through the CHECK-OFF LIST to make sure you have all the required documentation. ----------------------------------------------------------------------------------------------------------------------------------------------- WHEN TO ENROLL ----------------------------------------------------------------------------------------------------------------------------------------------- Opportunities for enrollment of your domestic partner or child(ren) of your domestic partner are during the following times for MPS health and/or dental benefits: • DURING MPS ANNUAL OPEN ENROLLMENT (SEPTEMBER 1 – 30TH)

The MPS Affidavit of Domestic Partnership and the MPS Application/Change Form (benefit enrollment application) must be completed to the satisfaction of MPS Benefits and Insurance Services before the end of the annual open enrollment period. If you satisfy all of the requirements outlined in this Guide, your domestic partner and eligible child(ren) of your domestic partner will be enrolled effective November 1 immediately following the annual open enrollment period.

• UPON HIRE

The MPS Affidavit of Domestic Partnership and the MPS Benefit Application/Change Form must be completed within 31 days of your hire date. If you satisfy all of the requirements outlined in this Guide, your domestic partner and any child(ren) of your domestic partner will be enrolled effective when your coverage starts following your satisfactory completion of the MPS Affidavit of Domestic Partnership and the MPS Benefit Application/Change Form, including providing the necessary supporting documentation.

• TO ADD A CHILD(REN) OF A DOMESTIC PARTNER

To add a child of a domestic partner, your domestic partner must also be enrolled in coverage. A child of your domestic partner may be added within 60 calendar days of the infant’s birth, during the annual MPS open enrollment period, or at the time you are newly hired. Written documentation must be submitted as evidence that the child is a child of your domestic partner. Documentation that may be submitted is: 1. A valid birth certificate. This must be a certified document that has been filed or issued by the government,

such as a birth certificate issued by the city in which the child was born. If the child was born in another state, the following link may be helpful: http://www.cdc.gov/nchs/howto/w2w/w2welcom.htm

2. Certified court approved adoption order or certified or notarized placement letter from a court or adoption agency for pending adoptions.

3. Certified court ordered custody/guardianship papers.

If you, as the covered MPS employee, are the child’s parent, through adoption or otherwise, the rules that apply to your dependent children as explained in the MPS Open Enrollment booklet will apply. For example, if a newborn or adopted child is born to or placed for adoption with you andcoverage mid-year provided you follow the necessary requirements applicable to adding your own newborn or

your domestic partner, the child may be added to

adopted child mid-year within 60 days of the event (and coverage will appropriately be back to the date of the event). Again, the provisions of this Guide apply to a child(ren) of a domestic partner who is not also a legal child(ren) of your own. All forms and verification documentation are required to be completed to the satisfaction of MPS Benefits and Insurance Services. If this requirement is not met, the domestic partner or child(ren) of the domestic partner will not

2-4 be eligible to enroll until the following open enrollment period.

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Check-Off List Domestic Partner Benefit Application Process

Active employee enrolled in the MPS health/vision and dental benefit plans. Meet the following criteria

• Are the same or opposite sex; • Are in a domestic relationship of mutual support, caring and commitment, and intend to remain in that

relationship; • Are 18 years of age or older and competent to enter into a contract; • Are not married to or in a domestic partner relationship with any other person; • Are not related by blood/kinship to a degree of closeness that would prohibit a legal marriage in the state of

Wisconsin; • Live together in the same principal residence; • Have not been in a domestic partnership or a marriage with another individual during the six (6) months

immediately preceding this application date.

and

• Copies of three (3) of the interdependence domestic partnership verification documents for the Affidavit to be valid (see below).

Combination of Three (3) different documents - one of which must beRefer to Attachment B, Affidavit of Domestic Partnership, for more detail on the required verification documents.

from CATEGORY I

CATEGORY I

A mortgage, lease, or deed for your primary residence jointly listing you & your partner. (One : One document required (Or, you may choose all of your documentation from Category I)

document only) An auto title listing you & your partner as jointly owning the vehicle. (Two auto titles only count as one

verification document) A credit card bill not acceptable - both names must be listed on the (bill). (One account document only)

showing you & your partner are joint credit card account holders. “Authorized user” is

CATEGORY II: A joint bank account or credit union account

Two documents required (unless you have two or more documents from Category I) statement

A copy of you & your domestic partner’s will’s, properly executed in/or recognized by the state of WI. . (One account document only)

You must each be the other’s primary beneficiary. Both wills must be provided & will count as one verification document. A copy of a durable power of attorney for health care and/or financial matters properly executed in WI or compliant with WI state law. Both partners durable powers of attorney must be provided & count as one verification document.

A copy of your validly executed retirement plan with your domestic partner designated as your primary beneficiary (with no joint beneficiaries). Both partners must be each other’s primary/and sole beneficiary.

A copy of your validly executed life insurance policy with your domestic partner designated as your primary beneficiary (with no joint beneficiaries). Both partners must be each other’s primary & sole beneficiary to the extent you both have a life insurance policy. Adoption agreement and/or birth certificate designating the employee and the domestic partner as parents of the same child(ren). Milwaukee County Declaration of Domestic Partnership registration (this registry is available only

to same-sex domestic partners). Your signed and notarized DP Affidavit and required verification documents may be submitted to MPS Benefits and Insurance Services. If requesting an MPS notary for your Affidavit, both you and your Domestic Partner must be present at the appointment. See In-Person Application p. 6. A notarized Affidavit does not approval of DP benefits. 2-5

indicate final


Include an MPS Benefit Enrollment/Change

form to add your domestic partner and eligible child(ren). Remember to include a birth certificate or adoption documents for any newly added child(ren).

--------------------------------------------------------------------------------------------------------------------------------------------- SUBMITTING YOUR DOMESTIC PARTNER BENEFIT APPLICATION --------------------------------------------------------------------------------------------------------------------------------------------- • IN-PERSON

Your completed and notarized Affidavit and required verification documents may be submitted in-person to MPS Benefits and Insurance Services. Your copies will be time and date stamped so you have a “receipt” for your records. Review of your application by MPS may take additional time and we will follow up with a letter of approval or rejection. If you do not have your Affidavit notarized, a member of MPS Benefit and Insurance Services can notarize your Affidavit at our offices. This requires an in-person meeting with both you and your domestic partner in attendance. You are encouraged to make an appointment early in September to complete the necessary paperwork. You and your domestic partner must each bring proof of identity showing: photo I.D., date of birth, and address of residence. A current Wisconsin driver’s license with photo, a government issued employee photo I.D. badge, or U.S. passport. A form of identification that shows your current name and address (i.e., checkbook, signed lease, utility bill, etc.) is also required.

A notarized Affidavit does not indicate final approval of benefits. The determination whether or not the verification documents are valid are subject to the sole discretion of MPS Benefits and Insurance Services.

• SUBMITTING BY MAIL

If mailing your documents, be sure they are received by MPS Benefits and Insurance Services by the Open Enrollment deadline. Mail your original notarized Affidavit and verification documents to MPS Office of Human Resources, Benefits and Insurance Services, 5225 West Vliet Street, Room 124, Milwaukee, WI, 53208. Make sure to keep a copy for your records.

MPS Benefits and Insurance Services has the right to utilize the information provided by you in the Affidavit and verification documents to administer any domestic partner benefit you may be eligible for, as well as other matters related to your employee benefits eligibility. The 2013 Open Enrollment begins September 1st. MPS Benefits representatives are available during the September Open Enrollment (September 1st through the 30th) to meet with you and answer questions. Scheduling an appointment with an MPS representative early in September gives you and your partner time to gather and verify acceptable documentation before the September 30, 2013 Open Enrollment deadline. The following MPS benefits are not available to domestic partners or children of domestic partners; including, but not limited to, health care flexible spending account, dependent care flexible spending account, health reimbursement arrangement (“HRA”), continued coverage under the Consolidated Omnibus Budget Reconciliation Act (“COBRA”),or Federal FMLA as indicated. ----------------------------------------------------------------------------------------------------------------------------------------------- “IMPUTED” INCOME - TAX LIABILITIES RELATED TO COVERAGE OF YOUR DOMESTIC PARTNER ----------------------------------------------------------------------------------------------------------------------------------------------- Under IRS rules, you will be taxed (by payroll deduction) on the fair market value of the health/dental benefits provided to your domestic partner and child(ren) of your domestic partner. MPS uses a common industry practice to determine the fair market value. It is based on COBRA premium rates (less 2% administrative cost) to approximate the value of coverage on the open market. The value of this coverage means what the cost to you would be if you had to purchase private insurance coverage in the open market, less the amount of any premium contribution for the coverage paid by you on an after-tax basis. If you do not have enough income to allow MPS to take the necessary withholding, you will not be eligible to cover a domestic partner and/or a child of a domestic partner because everyone must comply with IRS requirements. One of the primary IRS Code exceptions to this general rule is health benefits. Under this exception, if your dependents are IRS tax dependents, the IRS Code allows you to exclude these benefits from your income. An IRS tax dependent includes your spouse and your dependent children; however, each must meet specific IRS rules.

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• A domestic partner and a child of a domestic partner will not be your IRS tax dependent unless the domestic partner meets the criteria for a qualifying relative.

• In general, the IRS requires that one meet the criteria for a qualifying relative by (1) the dependent does not meet the “qualifying child” tests; (2) the dependent must live with you all year as a member of your household; and (3) you, the employee, must provide more than half of the dependent’s support for the year.

Internal Revenue Service (IRS) Publication 501 provides criteria for determining tax dependent status and is available on the IRS Web site at www.irs.gov/formspubs.

Discuss the addition of a domestic partner and/or the child of a domestic partner with your tax adviser to determine the exact tax impact. MPS does not provide tax advice and is not responsible for any additional taxes, including tax penalties, which you may incur as a result of this coverage. If your domestic partner or a child of your domestic partner is your IRS Tax Dependent, you must notify MPS Benefits and Insurance Services in writing and request an MPS Affidavit of Legal Tax Dependents form to complete. If you fail to timely notify MPS of a modification to your domestic partner or a child of a domestic partner’s tax status applicable to you, imputed income will apply and can only be changed on a prospective basis, unless MPS is otherwise directed by the IRS. ---------------------------------------------------------------------- IMPUTED INCOME EXAMPLES ---------------------------------------------------------------------- As of August 1, 2011, MPS employee’s pay a portion of their health plan coverage on a before-tax basis. For ‘imputed income’, you are required to be taxed on the value of the coverage applicable to that before-tax premium. Therefore, the amount of your before-tax premium contributions will not be subtracted from the calculation of the fair market value of the coverage when determining the imputed income amount for domestic partner coverage under your health/vision or dental plan. MPS uses two “coverage tiers” for premium payment and employee premium contribution purposes – single and family. When you elect to cover a dependent(s) under your health/vision or dental plan, you move from “single” coverage to “family” coverage. The amount of imputed income that will appear on your paycheck varies based on the health/vision or dental plan you select and the number of Non-Tax Dependents covered under your plan. The following is an example of the method that will be used to charge imputed income for each non-tax dependent:

The chart below shows estimated taxes (Social Security and Medicare) that will be withheld from your paycheck per month and per year based on an example of a monthly health plan premium rate of $700/month for a single plan and $1,500 a month for a family plan. An example of income tax withholding from your paycheck cannot be provided as tax rates vary based on annual income. Health/vision premium and specific tax application are examples only:

Number of non-tax dependents added to plan (Taxable amount)

PPO Health/Vision (taxable amount) Dental

Enroll 1 (domestic partner) One single plan One single rate

Enroll 2 (domestic partner & his/her child) One single plan & 45% of a single plan Two single rate

Enroll 3 (domestic partner & his/her 2 children) One single plan & 90% of a single plan Family plan rate

Enroll 4 or more (partner & 3 or more children) Family plan rate Family plan rate

Example 1 Example 2 Example 3

You Elect to Cover Your

Domestic Partner

Domestic Partner + 1 Child

Domestic Partner + 2 Childr. Imputed Income Amount (Amt. taxes are based on)

Monthly Annually Monthly Annually Monthly Annually

$700 $8,400 $1,015 $12,180 $1,330 $15,960

Taxes on Imputed Income

Social Security Tax* (6.2% of imputed income)

$43.40

$520.80

$62.93

$755.16

$82.46

$989.52

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*MPS pays matching employer share -----------------------------------------------------------------------------------------------------------------------------------------------TERMINATING COVERAGE FOR YOUR DOMESTIC PARTNER IF YOUR PARTNERSHIP ENDS ----------------------------------------------------------------------------------------------------------------------------------------------- As soon as your domestic partnership ends, you or your domestic partner must submit a signed and notarized MPS Affidavit of Termination of Domestic Partnership to the MPS Office of Human Resources, Benefits and Insurance Services. The domestic partnership is considered terminated at the end of the month of the date of termination of the domestic partnership or, if earlier, on a date established to the satisfaction of MPS that the domestic partnership certified in the Affidavit no longer meets the definition of domestic partnership. The termination affidavit only requires the signature of one partner. It is the responsibility of the partner submitting the termination affidavit to notify their partner that he or she is terminating the domestic partnership. You must also complete an MPS Application/Change Form when terminating health and/or dental plan coverage for your domestic partner (and domestic partner‘s child(ren), if applicable). If you fail to promptly notify MPS of the termination of your domestic partnership (and children of your domestic partner) within 31 days and medical or dental expenses are erroneously paid on your domestic partner’s behalf (including any children of domestic partner), you are responsible for repaying the overpaid MPS benefits and any disciplinary action. Refer to: MPS Right of Recovery. Domestic Partner Your domestic partner’s coverage will terminate as of the last day of the month that contains the date that any of the eligibility requirements are not met, including termination of the domestic partner relationship, the domestic partner/subscriber’s death, termination, layoff, reduction in hours, retirement, resignation, or loss of subscriber’s eligibility due to non-payment of premium. A domestic partner, including the child(ren) of a domestic partner, is not eligible for continuation coverage upon the death, termination, layoff, reduction in hours, retirement, or resignation of the MPS employee. Dependent Child of a Domestic Partner Coverage for a dependent child of a domestic partner will end upon the earlier of the following: • When the domestic partner’s coverage terminates; or • At the end of the month in which the child marries (note: such child is not eligible to return to dependent child

status except under the State and Federal Law controlling adult child dependent eligibility); or • At the end of the month in which the employee or the domestic partner no longer provides 50 percent or more of

the child’s support as required under the Plan Provision or to age 26 per State and Federal Law; or • At the end of the month in which the child no longer meets the definition of “Dependent Child of a Domestic

Partner” outlined by this Guide or becomes legally emancipated from the domestic partner; or • At the end of the month the legal ward turns age 18; or • At the end of the month of the employee’s date of termination, resignation, layoff, reduction in hours, retirement, or

death. Return of a child to Dependent Child of a Domestic Partner status may occur only during open enrollment. Dependent Grandchild of a Domestic Partner. An eligible grandchild’s coverage will end upon the earlier of the following: • At the end of the month when the grandchild’s parent loses Dependent Child status; or • When the domestic partner’s coverage terminates; or • The grandchild’s parent turns 18; or • At the end of the month of the employee’s date of termination, resignation, layoff, reduction in hours, retirement, or

death.

Note: MPS retains the right to periodically require resubmission of the Affidavit and collection of any required verification documentation pertaining to eligibility.

Medicare Tax* (1.45% of imputed income)

$10.15

$121.18

$14.72

$176.64

$19.29

$231.48

Income Tax The exact amount of your tax withholding depends on your individual tax rate.

Based on your individual tax rate



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If you continue your MPS health/vision and/or dental coverage on a self-paid basis while on unpaid leave, you may also continue coverage for your domestic partner, and domestic partner child(ren), enrolled in your plan by paying the full premium. If you do not continue your coverage during your unpaid leave, your domestic partner and domestic partner dependent child(ren) who were covered on the date immediately preceding your unpaid leave can be re-enrolled in your health/vision and or dental plan upon application within 31 days of your return to work. ----------------------------------------------------------------------------------------------------------------------------------------------- COBRA COVERAGE FOR DOMESTIC PARTNERS AND CHILDREN OF DOMESTIC PARTNERS ----------------------------------------------------------------------------------------------------------------------------------------------- A federal law, the Consolidated Omnibus Budget Reconciliation Act of 1985 (“COBRA”), offers certain individuals the opportunity to continue coverage on a self-paid basis after coverage ends. If you or your dependents who are “qualified beneficiaries” elect COBRA coverage, you or your dependents who are qualified beneficiaries will need to pay the full premium rate for the covered person, plus a two percent administrative cost. COBRA is available to you and your “qualified beneficiaries.” A domestic partner does not meet the definition of a COBRA qualified beneficiary. Accordingly, COBRA will not be offered to your domestic partner if coverage is terminated. Generally, the child of a domestic partner will not be eligible for COBRA continuation coverage. However, if the child is your (the MPS employee’s) IRS tax dependent, he/she will be eligible for such continuation coverage. Please contact MPS Benefits and Insurance Services office for more information on COBRA rights if you or your dependents lose coverage under the MPS health/vision or dental plans. ----------------------------------------------------------------------------------------------------------------------------------------------- SICK LEAVE, BEREAVEMENT LEAVE, AND OTHER MISCELLANEOUS LEAVE ---------------------------------------------------------------------------------------------------------------------------------------------- Sick Leave In general and in accordance with the limits and provisions of the MPS Employee Handbook and/or Board policy, sick leave may be used for the illness of a “member of your immediate family” that is defined as husband, wife, stepchild, domestic partner, child, domestic partner’s child, brother, sister, parent, or stepparent (wherever they may reside), or other relatives living in the same dwelling unit.

Bereavement Leave In general and in accordance with the limits and provisions of the MPS Employee Handbook and/or Board policy, absence without loss of pay is permitted due to the death of a wife, husband, domestic partner, parent, parent-in-law, domestic partner’s parent, stepparent, child, stepchild, domestic partner’s child, brother, sister, or relative residing in the same household. Such absence is permitted not to exceed three full school days, provided the days are used within the calendar week (any seven consecutive days) starting with the day of death. In the case of the death of a relative listed in above paragraph (a) occurs when such relative is in the armed services of the United States, these provisions may apply to leave for the purpose of attending memorial or religious services held because of such death, without regard to the place where the death occurred or to the place where services are held. Absence of one day without loss of pay within the calendar week (any seven consecutive days) starting with the day of the death shall be permitted in case of the death of a grandparent, grandchild, brother-in-law, sister-in-law, son-in-law, daughter-in-law, uncle, aunt, nephew, niece, first cousin, domestic partner’s brother, sister, spouse of a domestic partner’s child, or nephew or niece of a domestic partner. Miscellaneous Leave In general and in accordance with the limits and provisions of the MPS Employee Handbook and/or Board policy, the total limit of not more than two days per year deductible from sick leave also includes the following reasons: Absence to attend the graduation of a son or daughter or the domestic partner’s son or daughter from high school or an institution of higher learning.

Absence due to the attendance at the employee’s wedding, the employee’s commitment ceremony, the wedding of the

employee’s son or daughter, or the wedding of the domestic partner’s son or daughter. -----------------------------------------------------------------------------------------------------------------------------------------------

MPS HEALTH & PRODUCTIVITY MANAGEMENT PROGRAM (LEARN GOOD HEALTH, LIVE GOOD HEALTH) 2-9


----------------------------------------------------------------------------------------------------------------------------------------------- This voluntary employee wellness and care management program is available to help eligible employees and their covered dependents take a more active role in their health. The first step toward participating in the Learn Good Health, Live Good Health program is for you and your eligible spouse/domestic partner to complete the annual Personal Health Assessment (PHA). The annual PHA is available online mpsgoodhealth.online.staywell.com, or by requesting a paper version. Call the HelpLine at 1-800-492-9812 Option 2. You must request a paper PHA no later than November 15 and return it to StayWell before the PHA December 15 deadline. Refer to the annual MPS Open Enrollment booklet for additional information. An active employee and their spouse/domestic partner enrolled in an MPS health plan, with an effective date on or before October 1 of that year, are reminded to each complete their annual, personal health assessment (PHA) by the annual December 15 deadline to avoid the $200 payroll deduction. For those employees/spouses/domestic partners who do not complete the annual PHA, the employee will have a $100 deduction from the second paycheck in February and a second $100 deduction from the second paycheck in March for a total deduction of $200. ----------------------------------------------------------------------------------------------------------------------------------------------- MPS RIGHT OF RECOVERY ----------------------------------------------------------------------------------------------------------------------------------------------- MPS reserves its rights to pursue appropriate disciplinary action against you, up to and including termination of your employment with MPS, as well as any available legal remedies to recover benefits wrongfully paid on behalf of ineligible dependent(s), including notification to local law enforcement authorities regarding possible insurance fraud. It is your responsibility to provide timely notification in writing to the MPS Benefits and Insurance office to remove your ineligible dependent(s) from your MPS health and/or dental plan. If you improperly cover an individual as an eligible domestic partner or child of a domestic partner and it is later discovered that the individual was not eligible (i.e., you and your domestic partner did not meet the terms of the domestic partnership as defined in Attachment A), MPS has a right to collect all benefits paid by the plan from you. This is more than premiums; it is the actual benefits paid by the MPS health/vision and or dental plan. -------------------------------------------------------------------------------------------------------------------------------------------- MPS OTHER RIGHTS -------------------------------------------------------------------------------------------------------------------------------------------- You and your dependents’ eligibility for benefits is determined by the MPS Benefits and Insurance Services office as communicated to you through your MPS Open Enrollment materials, benefit notices and application/change forms, affidavits, summaries, and union agreements. MPS reserves the right to interpret the terms of these plans as described in these materials and determine your eligibility for benefits under the plans’ terms. In some cases, MPS has delegated this authority, e.g., to a third party administrator. Although MPS presently intends to continue these benefits as described in this Guide, it reserves the right to act through its Board to amend, modify, suspend, or terminate the benefits described herein, in whole or in part, at any time, at its discretion, with or without advance notice to participants, for any reason and subject to applicable law, Board policy, and any duty to bargain collectively. MPS also reserves the right to change the amount of required participant contributions for coverage under the plan at any time, with or without advance notice to participants, subject to any duty to bargain collectively and Board policy. ----------------------------------------------------------------------------------------------------------------------------------------------- NONDISCRIMINATION NOTICE ---------------------------------------------------------------------------------------------------------------------------------------------- It is the policy of Milwaukee Public Schools that, as required by Wisconsin Statutes section 118.13, no person will be denied admission to any public school or be denied the benefits of, or be discriminated against in any curricular, extracurricular, pupil services, recreational or other program or activity because of the person’s sex, race, religion, national origin, ancestry, creed, pregnancy, marital or parental status, sexual orientation, or physical, mental, emotional or learning disability. This policy also prohibits discrimination under related federal statutes, including Title VI of the Civil Rights Act of 1964 (race, color, and national origin), Title IX of the Education Amendments of 1972 (sex), and Section 504 of the Rehabilitation Act of 1973 (disability), and the Americans with Disabilities Act of 1990 (disability). The information in this Guide describes the Domestic Partner Benefits offered by Milwaukee Public Schools in general terms only as of the date of this publication and is not intended to be a complete description of benefits. All benefits 2-10

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and eligibility provisions described in this Guide are subject and subordinate to the terms and conditions of the master contract of each plan, agreements, MPS Board policies and practices, federal and state statutes, and Internal Revenue Code and Regulations and are not intended, and should not be construed by any plan participant or dependent, to create rights that exceed or modify plan terms and conditions as set forth in or mandated by these other sources.

Attachment A

DEFINITIONS DOMESTIC PARTNER An individual is defined as a “Domestic Partner” if the individual and the MPS employee1

1. Are the same or opposite sex; :

2. Are in a domestic relationship of mutual support, caring and commitment, and intend to remain in that relationship; 3. Are 18 years of age or older and competent to enter into a contract; 4. Are not married to or in a domestic partner relationship with any other person; 5. Are not related by blood/kinship to a degree of closeness that would prohibit a legal marriage in the state of

Wisconsin; 6. Live together in the same principle residence; and 7. Have not been in a domestic partnership or a marriage with another during the six months immediately preceding

the application date. 8. You also must provide a copy of three (3) interdependence domestic partnership verification documents for the

Affidavit to be valid. MPS has the authority to deny the addition of an individual as a domestic partner or his/her dependent child if, in MPS Benefits and Insurance Services’ opinion, it is determined that the documentation is not authentic or valid or current. MPS retains the right to periodically require an individual and his or her domestic partner to re-execute an Affidavit of Domestic Partnership and resubmit the necessary documentation. DOMESTIC PARTNER DEPENDENT CHILD As an eligible employee, you are eligible to apply to cover a dependent child(ren) of your domestic partner under the MPS health/vision and dental plans if you cover your eligible domestic partner. A domestic partner dependent child is an unmarried child for whom the employee or domestic partner provides more than 50 percent of the child’s support during the calendar year in which the child is covered and the child is: • The natural or adopted child of the domestic partner; or • The legal ward of the domestic partner; or • A dependent child of a domestic partner will lose coverage at the end of the month in which the child attains age 19, regardless of support, unless prior to attaining age 19; or • The child is supported 50% or more by the employee or domestic partner; and then, the child can be covered until age 25; or • The child is deemed to be disabled in accordance with MPS Plan requirements. Anthem dental coverage ends at the end of the month in which the child attains age 25. For Care Plus dental and health/vision coverage ends at the end of the month in which the child attains age 25, regardless of support, unless prior to age 25 the child continues to be both incapable of self-sustaining employment by reason of mental or physical disability and chiefly dependent upon the domestic partner for support and maintenance. Proof of such incapacity and dependency must be furnished by the employee and/or domestic partner to the employee’s health plan, within 31 calendar days of the child’s attainment of age 25, and subsequently thereafter as required. A copy of a certified document that has been filed or issued by the government, such as a birth certificate as evidence that the child is a child of the employee’s domestic partner, must be provided within the enrollment timelines (generally 31 days of your eligibility to enroll). If such documentation is not received and accepted by MPS Benefits and Insurance Services within the enrollment timelines, the child will not be enrolled into health and/or dental coverage. 2-11


The domestic partner’s dependent child will next be eligible to enroll during the next open enrollment period. The following website may be helpful: http://www.cdc.gov/nchs/howto/w2w/w2welcom.html. DOMESTIC PARTNER DEPENDENT GRANDCHILD A child of a dependent child of a domestic partner for whom the employee or the domestic partner provides more than 50 percent of the grandchild’s support during a calendar year and the grandchild’s parent is under age 18 and enrolled in the MPS health/vision and dental plans is also a domestic partner dependent child eligible for coverage under the MPS health/vision and dental plans.

1 For this purpose, the MPS employee must be an employee who is eligible for health/vision and dental benefits and/or sick leave and bereavement benefits under MPS requirements.

Attachment A – p. 2

DEFINITIONS DOMESTIC PARTNER ADULT CHILD DEPENDENT ELIGIBILITY As a result of state and federal mandated changes to health and dental coverage, adult dependent children (age 19 and older) of a domestic partner must meet coverage eligibility in one of two ways in order to be covered under your MPS health and/or dental plans. These mandates do not require you to cover your domestic partner’s adult children under your MPS health and/or dental plans. The highlights are as follows:

Per MPS Health/Dental Plan Provisions Age 19 to 25

Per State and Federal Law1 Age 19 through 25

● Subscriber and/or spouse must provide 50% or more support.

● Adult child must be single (not married). ● Coverage limitations for grandchildren, legal ward still apply (see Open Enrollment booklet for complete eligibility). ● Application for disabled dependents continuation of health coverage and Care Plus dental coverage must be completed prior to turning age 25.

● Adult child can be single or married. NOTE: Eligibility requirements also include the adult child who is a full-time student, regardless of age and was under age 27 years when called to federal active duty in the National Guard or in a reserve component of the U.S. armed forces while the child was attending, on a full-time basis, an institution of higher education.

1 Under WI Statute 632.885 and in accordance with the Federal Patient Protection and Affordable Care Act (PPACA) and the Health Care and Education Reconciliation Act of 2010 (HCERA).

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http://www.cdc.gov/nchs/howto/w2w/w2welcom.html�


Affidavit of Domestic Partnership

Member Information (please print) Last Name

First Name

MI

Date of Birth

Gender (M/F)

MPS Employee I.D.

Domestic Partner Information (please print) Last Name

First Name

MI

Date of Birth

Gender (M/F)

Social Security No.

Address of Residence Shared by Both Domestic Partners (please print) Street Address

City

State

Zip Code

Certification: I, , and I, , (collectively referred to as we, the “Undersigned” or “Domestic Partners”) certify that we are each other’s sole Domestic Partner, as defined by this Affidavit. Accordingly, we certify that we are eligible for the MPS employee benefit programs. Acknowledgement/Definition of Domestic Partnership: 1. We are the same or opposite sex; 2. We are in a domestic relationship of mutual support, caring and commitment, and intend to remain in that relationship; 3. We are 18 years of age or older and competent to enter into a contract; 4. We are not married to or in a domestic partner relationship with any other person; 5. We are not related by blood/kinship to a degree of closeness that would prohibit a legal marriage in the state of Wisconsin; 6. We live together in the same principal residence; and 7. We have not been in a domestic partnership or marriage with another individual during the six months immediately preceding the

application date. 8. We possess and will provide to MPS Office of Human Resources, Benefits and Insurance Services, three (3) domestic partner

verification documents of which one must be from Category I. If these documents are not available or valid, as determined by MPS, the Affidavit will also not be valid and your domestic partner and/or domestic partner’s child will not be added to health/vision and/or dental coverage, and leave benefits will not be available.

---------------------------------------------------------------------------------------------------------------------------------------------------- THE DOMESTIC PARTNER VERIFICATION DOCUMENTS ARE NOTED BELOW. NOTE: A Combination of three (3) different documents must be submitted. ---------------------------------------------------------------------------------------------------------------------------------------------------- Category I: at least one document must be from this category • A mortgage agreement, lease, or deed for your primary residence jointly listing you and your domestic partner as responsible for the

mortgage or lease or owning the property. Or • An auto title listing you and your domestic partner as jointly owning the vehicle. Or • A credit card bill demonstrating that you and your domestic partner have a joint credit card account. ---------------------------------------------------------------------------------------------------------------------------------------------------

Category II: at least two documents must be from this category • A bank account or credit union statement demonstrating a joint account between you and your domestic partner. Or • A copy of your will and your domestic partner’s will, properly executed in or recognized by the state of Wisconsin, that demonstrates

you will be your domestic partner’s primary beneficiary and your domestic partner will be your primary beneficiary. To use this documentation, both you and your domestic partner’s wills must be provided. Or

• A copy of a durable power of attorney for health care and/or financial matters executed in Wisconsin or in compliance with Wisconsin state law with you as the principal and your domestic partner as the attorney-in-fact/agent and another durable power of

attorney for health care and/or financial matters with your domestic partner as the principal and you as the attorney-in-fact/agent. To use this documentation, both you and your domestic partner’s durable powers of attorney must be provided. Or

OFFICE OF HUMAN RESOURCES Benefits and Insurance Services Attachment B

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• A copy of your validly executed retirement plan beneficiary designation with your domestic partner designated as your primary beneficiary (with no joint beneficiaries) and if your domestic partner has a retirement benefit, a copy of your domestic partner’s validly executed retirement plan beneficiary designation with you designated as his or her primary beneficiary (with no joint beneficiaries). To use this documentation, both you and your domestic partner must be each other’s primary and sole beneficiary for retirement plan purposes and must provide this documentation, to the extent both of you have a retirement plan benefit. Or

• A copy of your validly executed life insurance beneficiary designation with your domestic partner designated as your primary beneficiary (with no joint beneficiaries) and if your domestic partner has a life insurance benefit, a copy of your domestic partner’s validly executed life insurance plan beneficiary designation with you designated as his or her primary beneficiary (with no joint beneficiaries). To use this documentation, both you and your domestic partner must be each other’s primary and sole beneficiary for life insurance purposes and must provide this documentation, to the extent both of you have a life insurance benefit . Or

• Adoption agreement and/or birth certificate designating the employee and the domestic partner as parents of the same child(ren). • Milwaukee County Declaration of Domestic Partnership registration (this registry is only available to same-sex domestic partners).

Attachment B – p. 2

MPS Domestic Partner Benefit Program – Affidavit of Domestic Partnership

Additional Acknowledgements: 1. We understand that tax status is separate from eligibility for medical/dental/vision benefits. Accordingly, MPS will add

income for the fair market value of the medical/vision and/or dental coverage offered to my partner and his/her dependent children. This is referred to as “imputed income.” I (employee) also understand that if I do not have income available to cover the additional withholding because of garnishments, child support, etc., my domestic partner or the child(ren) or grandchild(ren) of my domestic partner will no longer be eligible for coverage.

2. We understand that the information provided as part of this Affidavit, as well as supporting documentation, will be accessible by members of MPS Office of Human Resources, Benefits and Insurance Services, to administer the benefits available to the Domestic Partner.

3. We certify that the information provided in this Affidavit is complete, true, and correct subject to State, Federal, and Board policy insurance fraud penalties governing eligibility for and payment of health and dental insurance benefits for myself and my claimed dependents. MPS reserves the right to pursue appropriate disciplinary action against you, up to and including termination of your employment with MPS, as well as any available legal remedies to recover benefits wrongfully paid on behalf of ineligible dependent(s) including notification to local law enforcement authorities regarding possible insurance fraud.

4. MPS reserves the right to determine eligibility and obtain all necessary information to accomplish this. MPS also retains the right to conduct periodic audits, including random audits for eligibility verification.

5. If this domestic partnership terminates, we agree to promptly notify MPS in writing by filing a completed MPS Affidavit of

Termination of Domestic Partnership form available from the MPS Office of Human Resources. A termination of domestic partnership becomes effective at the end of the month of the date of termination of the domestic partnership or, if earlier, on a date established to the satisfaction of MPS that the domestic partnership certified in this affidavit no longer meets the definition of domestic partnership as defined herein. Failure to provide such written notice may result in (a) you being liable to MPS for overpaid benefits and any loss by MPS and its insurer in addition to aforementioned disciplinary action and (b) loss of coverage or denial of benefits for your dependents.

THIS SECTION MUST BE COMPLETED BY HAND

We have read and understand this Affidavit of Domestic Partnership, as well as the “MPS Instructional Guide to Domestic Partner Benefits.”

Notary Signature and Seal

State of County of

Signed before me by both partners on

Date (mm/dd/yyyy)

Notary Signature

My commission is permanent/expires on

MPS Employee Signature

Date (mm/dd/yyyy) Phone No.

Domestic Partner Signature

Date (mm/dd/yyyy) Phone No.

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Affidavit of Termination of Domestic Partnership

Employee Information (please print) Last Name

First Name

MI

Date of Birth

Gender (M/F)

MPS Employee I.D.

Street Address

City

State

Zip Code

Former Domestic Partner Information (please print) Last Name

First Name

MI

Date of Birth

Gender (M/F)

Social Security No.

Street Address

City

State

Zip Code

Declaration of Termination of Domestic Partnership: I, , hereby certify the termination of my domestic partnership as defined in the MPS Affidavit of Domestic Partnership with the above-named former domestic partner. The date of termination of my domestic partnership is . mm/dd/yyyy I understand that: • As of the date that this domestic partnership terminates, a domestic partner ceases to be eligible for the MPS

benefits that are available to domestic partners and MPS health/vision and/or dental benefits at the end of the month of the date of termination of domestic partnership.

• The termination of the domestic partnership is irrevocable once the MPS Office of Human Resources, Benefits and Insurance Services receives this completed affidavit.

• When a domestic partnership has been terminated by filing this completed Affidavit, my former domestic partner or I may not file another declaration of domestic partnership with MPS until at least 6 months after the date on which the MPS Office of Human Resources – Benefits and Insurance Services received this completed Affidavit.

THIS SECTION MUST BE COMPLETED BY HAND By signing this affidavit, I understand that it is my responsibility to notify my former domestic partner that I have terminated this domestic partnership.

I have read and understand this Affidavit of Termination of Domestic Partnership, including the back side. I certify that the above information is complete, true, and correct subject to State, Federal, and Board policy insurance fraud penalties governing eligibility for and payment of health and dental insurance benefits or myself and my claimed dependents. MPS reserves the right to pursue appropriate disciplinary action against you, up to and including termination of your employment with MPS, as well as any available legal remedies to recover benefits wrongfully paid on behalf of ineligible dependent(s) including notification to local law

Notary Signature and Seal

State of County of

Signed before me on

Date (mm/dd/yyyy)

Notary Signature


Attachment C

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enforcement authorities regarding possible insurance fraud. Failure to provide such written notice may result in (a) you being liable to MPS for overpaid benefits and any loss by MPS and its insurer in addition to aforementioned disciplinary action and (b) loss of coverage or denial of benefits for your dependents.

My commission is permanent/expires on

Signature Date (mm/dd/yyyy)

Phone No.

Attachment C – p. 2

Affidavit of Termination of Domestic Partnership General Information

Purpose The purpose of this affidavit is to certify the termination of a domestic partnership created under the MPS Affidavit of Domestic Partnership. The domestic partnership being terminated was created for the sole purpose of the benefit programs authorized by MPS, which are administered by the MPS Office of Human Resources, Benefits and Insurance Services. Terminating a domestic partnership through this Affidavit does not terminate a domestic partnership under Wisconsin Statute Chapter 770 or City of Milwaukee ordinance, nor does terminating a domestic partnership under Chapter 770 or City of Milwaukee ordinance terminate a domestic partnership for MPS benefit purposes. The only way to terminate a domestic partnership for MPS benefit purposes is for MPS to receive this completed affidavit, or if the domestic partnership terminated on an earlier date by providing evidence to MPS satisfaction of an earlier termination date when the domestic partnership no longer met the MPS definition. Filing an Affidavit of Termination of Domestic Partnership • Either partner can file an MPS Affidavit of Termination of Domestic Partnership. • Provide all of the requested information on the affidavit and sign in the presence of a notary. • Submit your completed affidavit directly to the Milwaukee Public Schools, Office of Human Resources,

Benefits and Insurance Services, P.O. Box 2181, Milwaukee, WI 53201. MPS Benefits and Insurance Services must receive your completed affidavit for it to be considered effective.

• You may send the affidavit to MPS Office of Human Resources - Benefits and Insurance Services via fax at 414-475-8562.The notary seal must be visible in the electronic copy, otherwise your affidavit will be rejected.

• Incomplete affidavits will be returned to you.

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effective: september 1, 2013 · the employee’s commitment ceremony, to attend the wedding of the...

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