---

TEAM MEMBER BENEFITS ELIGIBILITY

Hours per Pay Period	72-80	60-71.99	40-59.99	<= 39.99 Scheduled or as needed
Hours per Week	36-40	30-35.99	20-29.99	<= 19.99 Scheduled or as needed
401(k)/ 403(b) Retirement Plan	Yes	Yes	Yes	Yes
Health Plan and Dental Plan Rates	Full-Time	Full-Time	Part-Time	Not Eligible
Vision Insurance	Yes	Yes	Yes	No
Other Voluntary Benefits	Yes	Yes	Yes	No
Vacation	Yes	Yes	Yes	No
Life Insurance	Yes	Yes	Yes	No
Sick Time	Yes	Yes	No	No
Company Provided Short-Term Disability	Yes	Yes	No	No
Company Provided Long-Term Disability	Yes	Yes	No	No
Parental Leave	Yes	Yes	No	No
Holidays/Personal Holiday	Yes	No	No	No

FAMILY MEMBERS (DEPENDENT) 

Eligible dependents can be covered on many of our benefit plans. Carle Health requires eligibility documentation such as a federal tax return or birth certificate for all new dependents added to health and/ or dental plans. This chart lists eligible dependents and which documents can be used to prove dependent eligibility for insurance coverage.

DEPENDENT TYPE AND DEFINITION	REQUIRED DOCUMENTATION
SPOUSE The covered team member's spouse according to the laws of the state where the team member lives or was married.	OPTION 1 Copy of most recent federal tax return showing spouse (front and signature pages only). OPTION 2 Marriage certificate; AND Proof of joint ownership dated within the past 60 days (e.g. joint bank statement, credit card, mortgage, etc.). Social Security numbers and financial information can be marked out.
DOMESTIC PARTNER The covered team member's domestic partner according to the laws of the state where the team member lives.	The Employee and the individual must have a signed and notarized Affidavit of Domestic Partnership and at least two of the following items: • A joint mortgage or lease agreement; • A notarized mutual assignment of Power of Attorney for financial and medical purposes; • A joint checking or credit account; • A formal commitment ceremony document, which is subject to validation; • A primary beneficiary designation for will, life insurance and/or retirement benefits.
DEPENDENT CHILD UNDER AGE 26* Natural-born children or legally adopted children, whether or not such children live with the team member.	NATURAL-BORN CHILD: Birth certificate. ADOPTED CHILD: Amended birth certificate naming employee as parent; OR Copy of adoption papers.
Step-children (as long as a natural parent remains married to and resides with the team member)	STEP-CHILD Birth certificate; AND Proof of marriage to a natural parent (see required documents for Spouse above).
Any child of a plan participant who is an alternate recipient under a qualified medical child support order shall be considered as having a right to dependent coverage under this plan.	COURT-ORDERED COVERAGE FOR DEPENDENT: Final court order with presiding judge’s signature; OR Qualified Medical Child Support Order (QMCSO) showing date of birth.
CHILD WITH DISABILITIES (AGE 26+) A covered child who reaches the limiting age (26 years old) and is totally disabled, incapable of self-sustaining employment by reason of mental or physical disability, primarily dependent upon the covered team member for support and maintenance and unmarried. The plan administrator may require, at reasonable intervals during the two years following the dependent’s reaching the limiting age, subsequent proof of the child’s total disability and dependency.	CHILD WITH DISABILITIES Birth certificate; AND Physician letter with a statement of Total and Permanent Disability, completed and signed by the dependent’s physician (stamped signature not acceptable); AND Copy of current federal tax return (front and signature pages only); AND Copy of Supplemental Security Income (SSI) award, if eligible.

We can't add a dependent to your coverage if they're:

• In the armed forces. However, those on active military duty are eligible for coverage under TRICARE effective the date of their active-duty orders.
• An ex-spouse. Team members must cancel dependent coverage when the dependent no longer meets the eligibility requirements.

Our commitment to diversity, equity and inclusion.

​Carle Health is committed to being an inclusive space for our team members. We know receiving the best care and service in the most culturally responsive way is vital to our team members. Our benefits include access to providers who will care for you and your dependents in a gender-inclusive, respectful way and coverage for domestic partners based on your state’s laws.