When eligibility for benefits ends

Information about the requirements and processes when employees and their dependents lose eligibility for the employer contribution toward Public Employees Benefits Board (PEBB) benefits.

Looking for information about layoff? Visit the Going on or returning from layoff page.

When employees lose eligibility for the employer contribution

Eligibility for the employer contribution toward PEBB Benefits ends in any one of the following circumstances (WAC 182-12-131):

  • When an employee fails to maintain eligibility for the employer contribution per WAC 182-12-131.
  • When the employment relationship is terminated. As long as the employing agency has no anticipation that the employee will be rehired, the employment relationship is terminated:
    • On the date specified in an employee's letter of resignation; or
    • On the date specified in any contract or hire letter or on the effective date of an employer-initiated termination notice.
  • When an employee moves to a position that is not anticipated to be eligible for PEBB benefits as described in WAC 182-12-114, not including changes in position due to a layoff (WAC 182-12-129).

To regain eligibility for the employer contribution toward PEBB benefits, employees must meet the eligibility criteria in WAC 182-12-114.

When dependents lose eligibility

A dependent's eligibility for enrollment in PEBB medical, dental, and supplemental dependent life and accidental death and dismemberment insurance ends the last day of the month the dependent no longer meets the eligibility criteria listed in WAC 182-12-250 or 182-12-260.

Dependents who are no longer eligible must be removed from PEBB coverage.

To remove a dependent due to loss of eligibility, employees must submit to their benefits administrator (BA) the appropriate PEBB Employee Enrollment/Change form within 60 days of the last day of the month the dependent loses eligibility so the BA can terminate the dependent's eligibility in the insurance system, except in the following situations:

  • The insurance system will automatically terminate coverage when a dependent child reaches age 26 or when a certification expires for an extended dependent or dependent child with a disability.
    • The PEBB Program will mail a letter to the employee before the child's coverage is terminated. The letter notifies the employee of the dependent's coverage termination date and continuation coverage options.
  • If a dependent child with a disability is no longer eligible, the employee must provide written notice to the PEBB Program per the guidance provided on the PEBB Certification of a Child with a Disability form (WAC 182-12-260 (g)(ii)).

To cancel dependent life and/or AD&D insurance, employees must submit the PEBB Cancellation of Supplemental Life and AD&D Insurance form directly to MetLife using the submission instructions provided on the form. Terminating a dependent's medical and/or dental coverage in the insurance system does not automatically cancel dependent life and AD&D insurance. 

Consequences for not submitting the required form within 60 days to remove a dependent due to loss of eligibility are explained in WAC 182-12-262 (2)(a).

Learn more about dependents and access additional forms and publications.

When PEBB benefits end

When an employee loses eligibility, the following PEBB benefits end (for the employee and their enrolled dependents) the last day of the month in which the employee lost eligibility for the employer contribution or the last day of the month in which the premium and applicable premium surcharges were paid, whichever is later (WAC 182-12-131 and PEBB Policy Addendum 19-1A):

  • Medical
  • Dental
  • Basic and supplemental life
  • Basic and supplemental accidental death & dismemberment (AD&D)
  • Employer-paid and employee-paid long-term disability insurance

When a dependent loses eligibility, their coverage ends on the last day of the month in which they no longer meet the eligibility criteria for PEBB benefits (WAC 182-12-262).

For state agencies and higher education institutions only:

  • Participation in the Medical or Limited Purpose Flexible Spending Arrangement (FSA) or Dependent Care Assistance Program (DCAP) ends the last day of the month Navia Benefit Solutions received the employee's contribution through payroll deduction.
    • FSAs: Employees will no longer be eligible to participate in an FSA but may continue to claim expenses incurred on or before their termination date, up to the amount of funds available in their flexible spending account (FSA). Claims must be submitted to Navia by March 31 of the following plan year.
    • DCAP: Employees who have unspent DCAP funds, may continue to submit claims for eligible expenses as long as the expenses allow them to attend school full-time, look for work, or work full-time. Expenses may be incurred through December 31. Claims may be submitted to Navia, up to the available account balance, through March 31 of the following plan year.

Providing required notice and terminating PEBB benefits

When it is determined that an employee has lost or will lose eligibility for the employer contribution, benefits administrators (BAs) must:

  1. Provide written notice to the employee within a reasonable timeframe by completing the eligibility worksheet that best fits the employee's scenario. Worksheets are located on the Eligibility worksheets page for state agencies and institutions of higher education or the Notification requirements page for employer groups.
  2. Terminate the employee's PEBB coverage in the Benefits 24/7 insurance system, effective the last day of the month in which the employee lost eligibility or the last day of the month in which the premium and applicable premium surcharges were paid, whichever is later.

When it is determined that a dependent has lost or will lose eligibility to be enrolled in PEBB benefits, benefits administrators (BAs) must:

  1. Terminate the dependent's PEBB coverage in Benefits 24/7, effective the last day of the month in which the dependent lost eligibility.​

For instructions on keying or processing terminations, visit the Benefits 24/7 manuals on the forms and publications webpage. 

If terminations are not processed timely in the insurance system, it may affect an employee's or dependent's options to continue coverage and the employer's financial responsibility. See PEBB Policy Addendum 19-1A for more information. ​

Once PEBB benefits have been terminated:

  • Employees owe a full month’s premium for theirs and/or their dependent's benefits.
  • The PEBB Program will mail the Continuation Coverage Election Notice to the employee or dependent no later than 14 days after their coverage has been terminated in the insurance system.
  • MetLife will send information and an application to the employee if the employee is eligible to apply to port or convert their existing life insurance coverage to an individual policy. See the Life and AD&D administration manual for more information.

Options for continuing PEBB coverage

Medical and dental coverage

When an employee is no longer eligible for the employer contribution toward PEBB benefits due to employment ending they may:

  • Enroll in their spouse/SRDP's PEBB insurance as a dependent if their spouse/SRDP is also eligible as an employee (PEBB Policy Addendum 45-2A, SOE matrix).
  • Continue PEBB medical (with vision) and dental benefits (for themselves and their eligible dependents) on a self-pay basis by enrolling in PEBB Continuation Coverage (COBRA) (WAC 182-12-131 and 182-12-146).
  • Enroll in PEBB retiree insurance coverage if they are eligible to retire and meet the eligibility and procedural requirements (WAC 182-12-171). Eligible dependents may also be enrolled in PEBB retiree insurance.

When a dependent is no longer eligible to be enrolled in PEBB benefits they may:

  • Continue PEBB benefits on a self-pay basis by enrolling in PEBB Continuation Coverage (COBRA) (WAC 182-12-270).

Learn about PEBB Continuation Coverage (COBRA) and PEBB retiree insurance.

Medical FSA and Limited Purpose FSA

Employees enrolled in an FSA when employment ends must complete and submit the PEBB FSA Termination form to their benefits administrator (BA) within 30 days of coverage ending to elect whether they would like to:

  • Stop deductions,
  • Accelerate deductions, or
  • Continue with COBRA

Learn more by visiting the FSA and DCAP webpage or by reviewing the FSA enrollment guides available on Navia's Forms and Documents webpage.

There are no continuation options available for the DCAP.

What if an employee or their dependent dies?

If an employee or their covered dependent dies or experiences a covered loss, the family or beneficiary should notify MetLife to initiate a claim, as soon as reasonably possible, by calling 1-866-548-7139.

Death of an employee's dependent

If an eligible employee's covered dependent dies, the employee must submit the appropriate Employee Enrollment/Change form no later than 60 days after the date of the dependent's death to remove the dependent from coverage. Employees should also update their beneficiaries, if applicable.

The PEBB Program collects premiums for the entire calendar month and will not prorate them for any reason, including when an employee or dependent dies before the end of the month. The deceased dependent’s coverage will end the last day of the month in which the dependent dies. Any change to the employee's premium will be effective the first day of the following month.

If the employee has supplemental life insurance or supplemental AD&D insurance for their dependent, or if they are unsure, they should contact MetLife at 1-866-548-7139. Employees should also consider updating any beneficiary designations for benefits such as life or AD&D insurance, health savings accounts, Department of Retirement Systems administered pension benefits, or other administered deferred compensation program accounts.

Survivors (death of the employee)

If an eligible employee dies, their surviving dependents will lose eligibility to be enrolled in PEBB benefits.

Complete and provide a copy of the C-11 worksheet to the surviving dependent(s). the worksheet contains guidance and describes surviving dependent options to continue coverage.

A PEBB Continuation of Coverage Election Notice will be mailed to the dependent(s) no later than 14 days after coverage is terminated in the insurance system. Surviving dependents may continue PEBB medical and/or dental coverage on a self-pay basis by enrolling in PEBB Continuation Coverage (COBRA) or if eligible, enroll in or defer (postpone) PEBB retiree insurance coverage as a survivor (WAC 182-12-180WAC 182-12-250, and WAC 182-12-265).

Surviving dependents should contact the PEBB program as soon as possible at 1-800-200-1004 to determine their options.

Learn about PEBB Continuation Coverage (COBRA) or the options and requirements to enroll as a Survivor.

Related rules and policies

  • WAC 182-12-131: How do eligible employees maintain the employer contribution toward insurance coverage?
  • WAC 182-12-262: When can a subscriber enroll or remove eligible dependents?
  • WAC 182-12-146: What options for continuation of coverage are available to subscribers and dependents who become eligible under COBRA?
  • WAC 182-12-171: When are retiring employees eligible to enroll in retiree insurance?
  • WAC 182-12-265: What options for continuing health plan enrollment are available to a surviving spouse, state-registered domestic partner, or child, if an employee, a school employee, or a retiree dies?
  • WAC 182-12-270: What options for continuation coverage are available to dependents who cease to meet the eligibility criteria as described in WAC 182-12-260?
  • PEBB Policy Addendum 45-2A: Special open enrollment (SOE) matrix: Summary of permitted election changes
  • PEBB Policy Addendum 19-1A: Termination due to loss of eligibility or enrollment error

Contact

Outreach and Training
Benefits administrators contact O&T for eligibility, enrollment, or billing related questions.
Phone: 1-800-700-1555
Secure messaging: HCA Support

The PEBB Program
Employees and dependents may contact the PEBB Program to discuss their PEBB Continuation Coverage and PEBB retiree insurance options.
Phone:  1-800-200-1004 (toll-free) Monday through Friday, 8 a.m. to 4:30 p.m., or
Send a secure message: Employees need to set up an account to protect their privacy and sensitive health information. 

The Department of Retirement Systems (DRS)
Employees retiring under plans administered by the Department of Retirement Systems must contact DRS for information about retirement eligibility.
Online:  www.drs.wa.gov
Phone: 1-800-547-6657