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Dependents

For all employers regarding the eligibility and enrollment of dependents in Public Employees Benefits Board (PEBB) benefits.

Worksheets for determining dependent eligibility for PEBB benefits

When employees express an interest in adding an eligible dependent to their PEBB medical and/or dental coverage, provide them with the E-1 worksheet. If an employee is seeking to add an extended dependent or dependent child with a disability age twenty-six or older, provide the E-2 worksheet.

The informational worksheets contain:

  • A list of eligible dependents,
  • A list of valid verification documents,
  • The process to add dependents to PEBB coverage for employees, and
  • Guidance for processing dependent verification for benefits administrators.

Encourage employees to review the worksheet and explain that dependents will not be enrolled in coverage unless all verification requirements (and certification requirements if applicable) have been met within the required time frame.

See the table below for a list of eligible dependents who may be enrolled in PEBB benefits.

Legal spouse

  • Former spouses are not eligible upon finalization of a divorce or annulment, even if a court order requires the employee to provide health insurance for the former spouse.

State-registered domestic partner (SRDP)

WAC 182-12-109 and
RCW 26.60.020(1)

  • This includes substantially equivalent legal unions from other jurisdictions (RCW 26.60.090).
  • Former SRDPs are not eligible upon dissolution or termination of a partnership, even if a court order requires the employee to provide health insurance for the former partner.

Children through the last day of the month of their 26th birthday

The definition of children includes (WAC 182-12-260(3):

  • Children based on establishment of a parent-child relationship as described in RCW 26.26A.100, except when parental rights have been terminated. This includes the employee's children and children of the employee's spouse/SRDP.
    • Eligibility for children of the spouse/SRDP (children who are not legally adopted by the employee), ends on the same date the marriage or partnership ends through divorce, annulment, dissolution, termination, or death.
  • Children for whom the employee has assumed legal obligation for total or partial support in anticipation of adoption.

  • Children specified in a court order or divorce decree for whom the employee has a legal obligation to provide support or health coverage.

  • Children in legal custody or legal guardianship of the employee or the employee’s spouse/SRDP (extended dependent).

    • The legal responsibility is demonstrated by a valid court order and the child's official residence with the custodian or guardian.

    • Certification is required by the PEBB Program.

    • This does not include foster children unless the employee or the employee’s spouse/SRDP has assumed legal obligation for total or partial support in anticipation of adoption.

  • Children of any age with a developmental or physical disability that renders the child incapable of self-sustaining employment and is chiefly dependent on employee for support and maintenance.

    • The disability must occur prior to age 26.

    • Certification by the PEBB Program (with input from the applicable health plan) is required once the child turns 26 years of age.

The PEBB Program reserves the right to review eligibility at any time (PEBB Policy 31-1 and WAC 182-12-260).

Requirements to enroll eligible dependents in PEBB medical and dental

To enroll eligible dependent(s) in PEBB medical and/or dental coverage, employees must complete and submit the appropriate PEBB Employee Enrollment/Change form, valid dependent verification (DV), and any other required forms to their payroll or benefits office during the following time frames (WAC 182-12-262):

  • No later than 31 days after the employee becomes newly eligible for or regains eligibility for PEBB benefits.
    • Dependent coverage begins the same day as the employee’s effective date of coverage.
  • No later than the last day of the annual open enrollment period (November 1-30).
    • Dependent coverage begins on January 1 of the following year.
  • No later than 60 days after a qualifying special open enrollment event occurs (PEBB Policy Addendum 45-2A).
    • In most cases, dependent coverage will begin the first of the month following the event date or the date the required form is received, whichever is later. If that day is the first of the month, the change in enrollment begins on that day.
      • Exception: If enrolling a child due to birth or adoption, enrollment is effective the date of the birth, adoption, or day assuming legal obligation for total or partial support in anticipation of adoption. If enrolling a spouse/SRDP the effective date is the first day of the month of the birth, adoption, or when assuming legal obligation.

Employees enrolling a dependent in their PEBB medical coverage may be required to attest to the tobacco use and spouse/SRDP coverage premium surcharges. Learn more the premium surcharges.

Learn about enrolling eligible dependents in supplemental life and/or accidental death & dismemberment insurance.

Dependent verification

The PEBB Program requires all employees to provide documentation that verifies the relationship between the employee and their dependent(s) before the dependent(s) can be enrolled in an employee’s PEBB medical and/or dental coverage (WAC 182-12-260).

Review the list of acceptable dependent verification documents. You can also find the list in the E-1 worksheet, in PEBB Policy 31-1 located on the PEBB Rules and Policies page, and on the Dependent verification page located on the Public employees website.

Exception: When an employee moves from School Employees Benefits Board (SEBB) Program coverage to PEBB Program coverage, previous dependent verification data verified by the SEBB Program may be used if the employee is requesting to enroll an eligible dependent who has been previously verified under the SEBB Program.

Additional forms or documentation may be required when enrolling dependents. See below for more information.

PEBB Certification of a Child with a Disability form

To add a dependent child with a disability age 26 or older, employees must complete and submit the PEBB Certification of a Child with a Disability form along with evidence that the condition occurred before age 26, directly to:

  • The PEBB Program if adding the dependent to dental only, or
  • The medical plan selected by the employee if adding the dependent to medical.

The dependent’s enrollment will pend approval:

Approval

A medical review will be conducted to determine if the dependent meets the medical requirements of a dependent child with a disability. If the employee changes health plans, the new health plan will conduct a medical review to continue the dependent’s certification.

Denial

Dependents who fail the medical review may appeal to the entity that made the determination. If the denial is due to recertification, the PEBB Program will send a PEBB Continuation Coverage Election Notice.

Recertification

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. Verification will require renewed proof of disability and dependence from the employee. The initial verification and any following verification will be conducted according to WAC 182-12-260 (3)(g)(i) - (v).

Additional information can be found in the E-2 worksheet, in PEBB Policy 36-1 located on the PEBB rules and policies page, and on the Dependent eligibility page located on the Public employees website.

PEBB Extended Dependent Certification form

To add an extended dependent, employees must complete and submit the PEBB Extended Dependent Certification form along with a copy of a valid court order showing legal custody or guardianship to their payroll or benefits office. The court order serves as dependent verification for extended dependents.

Benefits administrators must send the PEBB Extended Dependent Certification form and valid court order to Outreach & Training through HCA Support for review and processing. Once received, the dependent’s enrollment will pend approval:

Approval

If the dependent meets the eligibility requirements, the PEBB Program will notify the employee and employing agency in writing. The copy of the approval letter sent to the employer should be placed in the employee’s file.

Denial

If the dependent does not meet eligibility requirements, the PEBB Program will notify the employee and employing agency in writing. A copy of the denial letter sent to the employer should be placed in the employee’s file. If the denial is due to recertification, the PEBB Program will also send a PEBB Continuation Coverage Election Notice to the dependent.

Recertification

Eligibility will be recertified annually. However, the PEBB Program reserves the right to review an extended dependent child’s eligibility at any time. When recertification is required, the employee will receive a letter from PEBB with instructions to submit all recertification information directly to the PEBB Program.

Additional information can be found in the E-2 worksheet, in PEBB Policy 37-1 located on the PEBB rules and policies page, and on the Dependent eligibility page located on the Public employees website.

PEBB Declaration of Tax Status form

The Declaration of Tax Status form is to indicate whether the employee’s dependents qualify for tax purposes under IRC Section 152, as modified by IRC Section 105(b). Employees must also complete and submit this form to their payroll or benefits office for processing if adding a dependent to coverage who does not qualify as a dependent for federal tax purposes, such as:

  • Extended dependent children
  • State-registered domestic partners
    • This includes all substantially equivalent legal unions from other jurisdictions, as defined in RCW 26.60.090
  • Children of a state-registered domestic partner

Learn more about reporting the tax status of a dependent.

Dependent verification process

Once the required forms and dependent verification (DV) have been received, verify that:

  • All forms and DV have been received within the required time frame, and
  • All forms are completed correctly, and
  • All changes requested are allowed, and
  • The DV is valid, legible, and complete.
    • If the DV documents are not valid, legible, or complete, follow-up with the employee to request valid DV within the required time frame.

If the forms and documents meet the criteria above, complete the following steps.

If you key enrollment in the PAY1 insurance system:

  • Create a record for the dependent in PAY1 and key the dependent verification.
  • If you process verification, key the dependent verification in PAY1.
    • If Outreach & Training processes verification for you, send the dependent verification documents through HCA Support for processing after you've created the dependent record in PAY1. Please include the employee’s last name and the last four digits of their SSN on each document.
  • Maintain a copy of the form(s) in the employee's file.

Review the PAY1 manuals for instructions on how to enter enrollment and verify dependents in PAY1. 

If Outreach & Training (O&T) keys enrollment for you:

  • Send the completed PEBB Employee Enrollment/Change form and dependent verification document(s) to O&T through HCA Support for processing. Please include the employee’s last name and the last four digits of their SSN on each document.
  • Maintain a copy of the form(s) in the employee's file.

If O&T keys enrollment for you, review the Processes and Procedures Manual for additional information.

If the completed forms and valid DV are not received timely, inform the employee that their dependents will not be enrolled and inform them of their right to appeal. The employee may enroll their dependents during the next annual open enrollment period or if they have a qualifying life event that triggers a special open enrollment.

If the employee is moving from SEBB Program coverage to PEBB Program coverage and requesting to enroll eligible dependents who have previously been verified under the SEBB Program, DV documents will not be required. The PEBB Program will use the DV data previously verified by the SEBB Program for dependent verification. Send a message to O&T to review SEBB DV documentation.

Add a newborn or adopted child

The birth or adoption of a child creates a special open enrollment. To add a newborn or child whom the employee has adopted or has assumed a legal obligation for total or partial support in anticipation of adoption, the employee should submit the required forms and dependent verification as soon as possible to ensure timely payment of claims.

  • If adding the child increases the premium, the required forms must be received no later than 60 days after the date of the birth, adoption, or the date the legal obligation is assumed for total or partial support in anticipation of adoption.
  • If adding the child does not increase the employee premium, required forms must be received as soon as possible to ensure timely payment of claims.

Erin Act (RCW 48.43.115(3)(f)): When the mother's medical plan has maternity benefits, a newborn child will receive 21 days of coverage under the plan automatically, regardless if the child is ultimately enrolled in the mother's plan or not.

Newborn children may be enrolled in medical and dental coverage upon birth and adopted children may be enrolled when the employee assumes legal obligation for total or partial support in anticipation of adoption.

  • If enrolling a newborn in medical and/or dental coverage, the child's coverage will begin on the date of birth.
  • If enrolling a newborn in supplemental life or accidental death and dismemberment insurance, coverage begins on the 14th day after birth.
  • If enrolling a newly adopted child, coverage will begin on the date of placement or the date a legal obligation is assumed in anticipation of adoption, whichever is earlier.

If adding the child increases the monthly premium: When a newborn or adopted child's effective date is before the 16th day of the month, the employee will pay the full month's employee premium. Otherwise the new premium will begin the next full calendar month.

  • If the employee previously waived medical coverage, they must enroll in medical to add an eligible dependent to medical. Coverage for the employee begins the first day of the month in which the event occurs.
  • The employee can also enroll an eligible spouse/SRDP due to enrolling a newborn or adopted child but cannot enroll other existing dependent children. Coverage for the spouse/SRDP will begin the first day of the month in which the event occurs.

Learn more by reviewing the special open enrollment matrix (PEBB Policy Addendum 45-2A).

When dependents lose eligibility for PEBB benefits

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 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 payroll or benefits office the appropriate PEBB Employee Enrollment/Change form within 60 days of the last day of the month the dependent loses eligibility, except in the following situations:

  • The PAY1 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)).

Dependent coverage ends on the last day of the month in which they no longer meet the eligibility criteria for PEBB benefits.

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).

Dependents who lose eligibility because they no longer meet the eligibility criteria are eligible to continue PEBB medical, dental, or both under provisions of the federal Consolidated Omnibus Budget Reconciliation Act (COBRA) (WAC 182-12-270).

Review the PAY1 Insurance System manuals for instructions on terminating coverage for dependents who lose eligibility. If Outreach & Training keys enrollment for you, send required form through HCA Support for processing.

Surviving dependents

If an employee dies, their dependents (spouse/SRDP or dependent child) will lose their eligibility to be enrolled in PEBB benefits.

Complete and provide the C-11 worksheet to the surviving dependent(s). The C-5 worksheet contains guidance and describes the surviving dependent's options to continue coverage.

A PEBB Continuation of Coverage Election Notice will be mailed to the dependent(s) no later than 14 days after benefits are terminated in the PAY1 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 182-12-180, WAC 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.