Qualified Status Changes

A Status Change is an IRS qualified event that allows you to make a change in your enrollment elections during the plan year. Below you will find the University’s recognized Qualified Status Changes. In order to make a status change to your benefit selections, you will need to download and complete both the “Change In Status Form” and the “Benefits Enrollment Form”.

Completing the Status Change Forms

On the Change in Status Form, please provide the reason you are requesting the change. Next, select the Benefits Enrollment Form that corresponds to your position with the University (i.e., staff, full-time faculty, part-time faculty, etc.) and complete only the sections that pertain to the changes you are making for the life event. All other elections will remain the same. Forms must be accompanied by supporting documentation of the life event. Please see the Qualified Status Change Request Requirements for examples.

IMPORTANT NOTE: Medical, dental, vision plan changes cannot be made for a qualified life event. You can only modify your tier level to accommodate an eligible dependent(s) or remove a dependent(s).

A change to your benefit elections can only be made within 60 days of the qualified life event.

  • For an event date that occurs on the first day of a month, the coverage becomes effective the first of that same month.

    Marriage Life Event Example: If the employee was married on October 1st and wants to add their new spouse to their benefits, the spouse’s coverage would begin effective October 1. The employee must complete the status change forms and provide a copy of their marriage certificate within 60 days of their date of marriage.

    NOTE: Coverage is only processed to begin based on the event date for a qualified status change. If you submit your paperwork on October 31st, the coverage will begin retroactively on October 1st.

  • For an event date that occurs after the first day of a month, the coverage becomes effective the first of the next month.

    Marriage Life Event Example: If the employee was married on October 13th and wants to add their new spouse to their benefits, the spouse’s coverage would begin effective November 1. The employee must complete the status change forms and provide a copy of their marriage certificate within 60 days of their date of marriage.

    NOTE: Coverage is only processed to begin based on the event date for a qualified status change. If you submit your paperwork on November 30th, then the coverage will begin retroactively on November 1st.

You may either fax, mail, or deliver the forms in person to the Benefits Department.

University of Pittsburgh
Benefits Department
320 Craig Hall
200 South Craig Street
Pittsburgh, PA 15260
Fax: (412) 624-3485

Qualified Status Change Request Requirements