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Status Changes

You have 31 days from the date of the Change of Status event to notify your benefits representative and change your benefit selections. Please reference UT System Office of Employee Benefits Policy 310, Change In Status to determine qualifying status changes. Below are examples of common status changes:

Family Status Changes
Employment Status Changes
  • Marriage or Divorce
  • Birth or Death of Dependent
  • Over Age 25 or Over Age 26 of dependent
  • Full Time (100%) to Part Time (>50% but < 75%)
  • Non-Benefits Eligible to Benefits Eligible
  • Spouse gains or loses coverage
  • Beginning or ending an Unpaid Leave of Absence

The appropriate packet below must be completed and returned within the appropriate timeframe. Along with the packet, you must also submit proof of the qualifying status change. For example, proof of benefits lost include a COBRA or other notice listing medical, dental, or vision coverage ended on a specific date.

To help you estimate the cost changes, access the Interactive Benefits Cost Worksheet or view the Benefits Cost Worksheet. If you have questions or need assistance completing the forms, please call (210) 458-4250 or email

Active Employee Packet
Retiree Packet

The packet with the documentation may be faxed to (210) 458-7890, scanned and emailed to or mailed to:

    Department of Human Resources - Benefits
    University of Texas at San Antonio
    One UTSA Circle
    San Antonio, TX 78249-1610

While on Leave of Absence without FMLA, no employer premium sharing dollars are available. The full monthly medical premium rates apply as follows:

Medical Rates for Plan Year 2015-2016
(ending August 31, 2016)

Employee Only Employee and Spouse Employee & Child(ren) Employee & Family
$566.96 $1,108.27 $1,012.42 $1,536.81

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Updated: September 19, 2015