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How to determine eligibility

Find out if you are eligible for PEBB benefits.

On April 2, 2020, the Public Employees Benefits Board (PEB Board) held a special telephonic meeting to approve policy resolutions that establish temporary eligibility for PEBB coverage for certain job classes hired during the Governor’s state of emergency due to COVID-19. Learn more about the approved emergency resolution.

Determining eligibility

Your employer will determine if you are eligible for PEBB benefits based on your specific employment circumstances, and whether you qualify for the employer contribution (see WAC 182-12-114 and 182-12-131). If you disagree with the determination, see File an appeal.

Employees from an employer group 

If you are an employee from an employer group that received PEBB benefits through a contract with HCA, such as a county, municipality, political subdivision, tribal government, or educational service district, contact your payroll or benefits office for eligibility criteria.

Employees

You are eligible for PEBB benefits upon employment if your employer anticipates you will work an average of at least 80 hours per month and for at least eight hours in each month for more than six consecutive months.

If your employer determines you are not eligible, but later revises the hours you are anticipated to work or the length of your employment such that you would meet the criteria described above, you become eligible for PEBB benefits on the first day of the month after the revision.

If your employer determines you are not eligible, but based on your work pattern you later meet the criteria described above, you become eligible for PEBB benefits on the first day of the month after the six month averaging period.

You may also “stack” or combine hours worked in more than one position to establish and maintain eligibility as long as the work is within one state agency where you do one of the following:

  • Work two or more positions at the same time (concurrent stacking).
  • Move from one position to another (consecutive stacking).
  • Combine hours from a seasonal position to hours from a nonseasonal position or job.

You must notify your employer if you believe you are eligible for benefits based on stacking. See WAC 182-12-114(1)(c)

Higher-education faculty

“Faculty” means an academic employee of an institution of higher education whose workload is not defined by work hours but whose appointment, workload, and duties directly serve the institution’s academic mission.

As higher-education faculty, you are eligible for PEBB benefits upon employment if your employer anticipates you will work half-time or more for the entire instructional year or equivalent nine-month period.

If your employer doesn’t anticipate that this will happen, then you are eligible for PEBB benefits at the beginning of the second consecutive quarter or semester of employment, if you are anticipated to work (or has actually worked) half-time or more. Spring and fall are considered consecutive quarters/semesters when first establishing eligibility for faculty that work less than half-time during the summer quarter/semester.

If you receive additional workload after the beginning of the anticipated work period (quarter, semester, or instructional year), and anticipated to work (or have actually worked half-time or more) making your workload meet the eligibility criteria above, you become eligible when the revision is made.

You may become eligible by working as faculty for more than one higher-education institution. Faculty workloads may only be stacked with other faculty workloads to establish or maintain eligibility. When you work for more than one higher-education institution, you must notify all employing agencies that you work at more than one institution and may be eligible for PEBB benefits through stacking. A faculty becomes eligible for PEBB benefits through stacking when the employer anticipates they will work half-time or more for the entire instructional year or equivalent nine-month period.

Continuing coverage

You may continue any combination of medical, dental, life and AD&D insurance when you are between periods of eligibility and are not eligible for the employer contribution by self-paying for the benefits (for a maximum of 12 months). See WAC 182-12-142. The PEBB Program must receive your election to self-pay benefits no later than 60 days from the date the PEBB health plan coverage ended or from the postmark date on the election notice sent by the PEBB Program, whichever is later. See PEBB Continuation coverage How to determine eligibility for more information.

Seasonal employee

“Seasonal employee” means a state employee hired to work during a recurring, annual season with a duration of three months or more, and who is anticipated to return each season to perform similar work.

As a seasonal employee, you are eligible for PEBB benefits upon employment if you are anticipated to work an average of at least 80 hours per month and work for at least eight hours each month of at least 3 consecutive months of the season. A season means any recurring, annual period of work at a specific time of year that lasts 3 to 11 consecutive months.

If your employer changes your anticipated work hours or anticipated length of employment to where you meet the eligibility criteria above, you become eligible when the change is made.

If you are found ineligible for benefits but later work an average of at least 80 hours per month and work for at least eight hours in each month for more than six consecutive months, you become eligible the first of the month following the six-month averaging period.

If you work in more than one position within one state agency, you may stack or combine hours to establish and maintain eligibility. See WAC 182-12-114(2)(C) for details. You must notify your employing agency if you believe you are eligible for benefits through stacking. An employee becomes eligible for PEBB benefits through stacking when they meet the requirements described above.

If you are a benefits-eligible seasonal employee who works a season of nine months or more, you are also eligible for the employer contribution through the off season following each season worked, but the eligibility may not exceed a total of twelve consecutive calendar months for the combined season and off season.

Continuing coverage

If you work a season of less than nine months, you are not eligible for the employer contribution during the off season, but may continue any combination of medical, dental, life and AD&D insurance when you are between periods of eligibility and not eligible for the employer contribution by self-paying for benefits for a maximum of 12 months. See WAC 182-12-142. The PEBB Program must receive your election to self-pay benefits no later than 60 days from the date PEBB health plan coverage ended or from the postmark date on the election notice sent by the PEBB Program, whichever is later. See Continuation coverage How to determine eligibility for more information.

Elected and full-time appointed officials

As a legislator, you are eligible for PEBB benefits on the date your term begins. All other elected and full-time appointed officials of the legislative and executive branches of state government are eligible on the date their terms begin or the date they take the oath of office, whichever occurs first. 

Justices and judges

A justice of the Supreme Court and judges of the court of appeals and the superior courts become eligible for PEBB benefits on the date they take the oath of office.

Are my dependents eligible?

You may enroll the following dependents as described in WAC 182-12-260:

  • Your legal spouse
  • Your state-registered domestic partner as defined in WAC 182-12-109 and RCW 26.60.020(1). This includes substantially equivalent legal unions from other jurisdictions as defined in RCW 26.60.090. Strict requirements apply to these partnerships, including that one partner is age 62 or older and you live in the same residence.
  • Your children (as defined in WAC 182-12-260(3)) through the last day of the month in which they turn age 26. Children with a disability may be covered past the age of 26 if they qualify (see below).

When you enroll eligible dependents on your PEBB health plan coverage, you are required to provide poof of their eligibility with a document that shows they are your dependents.

If I die, are my surviving dependents eligible?

If you are an eligible employee, your surviving spouse, state-registered domestic partner, or child may be eligible to enroll or defer (postpone) enrollment in PEBB retiree insurance coverage if they meet both the procedural and eligibility requirements outlined in WAC 182-12-265. See PEBB Continuation Coverage Eligibility and enrollment.

A surviving spouse, state-registered domestic partner, or dependent child who meets eligibility requirements and chooses to defer (postpone) enrollment in may later enroll in a PEBB retiree health plan by meeting the requirements described in WAC 182-12-200 and 182-12-205.

All required forms must be received by the PEBB Program to enroll in or defer (postpone) enrollment in retiree insurance coverage no later than 60 days after the later of the date of the employee’s death or the date the survivor's PEBB insurance coverage ends.

What happens when a dependent loses eligibility?

Your payroll or benefits office must receive the a PEBB Employee Enrollment/Change form within 60 days of the last day of the month the dependent no longer meets the PEBB Program’s eligibility criteria due to divorce, annulment, dissolution, or a qualifying event of a dependent ceasing to be eligible as a dependent child as described in WAC 182-12-260(3). Your dependent will be removed from coverage on the last day of the month in which they no longer meets the eligibility criteria.

Consequences for not submitting the form within the required 60 days are explained in WAC 182-12-262(2)(a). The consequences may include, but are not limited to:

  • The dependent may lose eligibility to continue health plan coverage under one of the continuation coverage options.
  • You may be billed for claims paid by the health plan for services that were rendered after the dependent lost eligibility.
  • You may not be able to recover paid insurance premiums for dependents who lost eligibility.
  • You may be responsible for premiums paid by the state for a dependent’s health plan coverage after the dependent lost eligibility.

What happens when a dependent dies?

If your covered dependent dies, you must submit a PEBB Employee Enrollment/Change form to your payroll or benefits office to remove the deceased dependent from your coverage no later than 60 days after the event. By submitting this form, your premium may be reduced to reflect the change in coverage. For example, if the deceased individual was the only covered dependent on your account, then the premium withheld from your paycheck will be less.

The PEBB Program collects premiums for the entire month and will not prorate them for any reason, including when a member dies before the end of the month. Any change to your premium will be effective the first of the month after the date of  death. 

If you have supplemental life insurance or supplemental AD&D insurance coverage for your dependent, or are unsure if you elected supplemental life insurance for the dependent, contact MetLife at 1-866-548-7139. Also consider updating any beneficiary designations for  benefits such as life insurance, retirement (through the Department of Retirement Systems), and health savings account, if applicable.

How are children defined?

Children are defined based on the establishment of a parent-child relationship as described in RCW 26.26A.100, except when parental rights have been terminated. This definition includes:

  • Your children.
  • Children of your spouse.
  • Children you are legally required to support ahead of adoption.
  • Children of your state-registered domestic partner
  • Children specified in a court order or divorce decree for whom you are legally required to provide support or health care coverage.
  • Children with disabilities age 26 and older.
  • Extended dependent children who meet specified eligibility criteria.

Eligible extended dependents

Children may also include extended dependents (such as a grandchild, niece, nephew, or other child) for whom you, your spouse or state-registered domestic partner are legal custodians or legal guardians. The legal responsibility is demonstrated by a valid court order and the child’s official residence with the custodian or guardian.

Extended dependent child does not include a foster child unless you, your spouse, or your state-registered domestic partner are legally required to provide support ahead of adoption. Along with a copy of your valid court order, also submit the PEBB Extended dependent Certification form.

Eligible children with a disability age 26 and older

Eligible children also include children of any age with a developmental or physical disability that renders the child incapable of self-sustaining employment and chiefly dependent upon the employee for support and ongoing care, provided the condition occurred before the age of 26. You must provide proof of the disability and evidence the condition occurred before age 26 and before their certification can be approved.

How do I add my child with a disability?

You must provide evidence of the disability and evidence the condition occurred before age 26. The PEBB Program with input from the medical plan (if applicable), will periodically verify the eligibility of a dependent child with a disability beginning at age 26, but no more frequently than annually after the two-year period following the child's 26th birthday. 

A child with a disability who becomes self-supporting is not eligible as of the last day of the month in which they become capable of self-support. If the child becomes capable of self-support and later becomes incapable of self-support, the child does not regain eligibility as a child with a disability.

You must notify the PEBB Program in writing when your child with a disability is no longer eligible. The PEBB Program must receive notice within 60 days of the last day of the month your child loses eligibility for health plan coverage.

In addition to dependent verification documents, also submit the PEBB Certification of a Child with a Disability