How to determine eligibility

Find out if you are eligible for PEBB benefits.

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.

Employee eligibility

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 at least eight hours in each month for more than six consecutive months.

If your employer revises your work hours and you will work an average of at least 80 hours per month and at least eight hours in each month for more than six consecutive months, you become eligible when the revision is made.

If your employer determines you are ineligible, and you later work an average of at least 80 hours per month and 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.

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

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

You must notify your employer if you believe you are eligible for benefits based on stacking.

Higher-education faculty eligibility

As higher-education faculty, you are eligible for PEBB benefits 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 you will work the entire instructional year or equivalent nine-month period, 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), 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. When you work for more than one higher-education institution, you must notify both employers you work at more than one institution and may be eligible for PEBB benefits through stacking.

You may continue any combination of medical, dental, and life insurance coverage during periods when you are not eligible for the employer contribution by self-paying for the benefits (for a maximum of 12 months). See WAC 182-12-142. Your election to self-pay benefits must be received by the PEBB Program no later than 60 days from the date the health plan coverage ends or from the postmark date on the election notice sent by the HCA; whichever is later.

Seasonal employee eligibility

As a seasonal employee, you are eligible for PEBB benefits if you work, or your employer anticipates you will work, an average of at least 80 hours per month and work for at least eight hours in each month of at lease 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 revises your anticipated work hours to where you meet the eligibility criteria above, you become eligible when the revision is made.

If you are determined 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 or job within one state agency, you may stack or combine hours to establish and maintain eligibility. See WAC 182-12-114(2) for details.

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. 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 enrollment between periods of eligibility for a maximum of 12 months by self-paying for the benefits. See WAC 182-12-142. Your election to self-pay benefits must be received by the PEBB Program no later than 60 days from the date the health plan coverage ends or from the postmark date on the election notice sent by the HCA; whichever is later.

Eligibility for elected/appointed officials, justices, and judges

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. Your election to self-pay benefits must be received by the PEBB Program no later than 60 days from the date the health plan coverage ends or from the postmark date on the election notice sent by the HCA; whichever is later.

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.

Family member eligibility

You may enroll the following family members (dependents) as described in WAC 182-12-260:

  • Your lawful spouse or state-registered domestic partner.
  • Your children (see below) up to the last day of the month in which they become age 26, except for children with a disability (see below)

The PEBB Program verifies the eligibility of all dependents and will request proof of a dependent’s eligibility. The PEBB Program will not enroll a dependent if it cannot verify the dependent’s eligibility. See Dependent verification.

If I die, are my surviving dependents eligible?

As an eligible employee, your surviving spouse, state-registered domestic partner, or child may be eligible to enroll in PEBB Program retiree insurance if they meet both the procedural and eligibility requirements outlined in WAC 182-12-265. See COBRA/Continuation Coverage (formerly LWOP) eligibility and enrollment.

A surviving spouse, state-registered domestic partner, or dependent child who meets eligibility requirements and chooses to defer may enroll in a PEBB 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 enrollment in retiree insurance coverage no later than 60 days after the date of the employee’s death.

What happens when a dependent loses eligibility?

Your personnel, payroll, or benefits office must receive the appropriate Employee Enrollment/Change form no later than 60 days after the date the dependent no longer meets the PEBB Program’s eligibility criteria. Your dependent will be removed from coverage on the last day of the month in which he or she no longer meets the eligibility criteria.

Consequences for not submitting the form within 60 days after your dependent loses eligibility 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 an Employee Enrollment/Change form to your personnel, payroll or benefits office to remove the deceased dependent. 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 lower when they are removed.

The HCA collects premiums for the full 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 first of the month after the date of the event or the date your personnel, payroll, or benefits office receives your completed Employee Enrollment/Change form, whichever is later. If that day is the first of the month, coverage begins on that day.

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

Definition of children

Children are defined as your biological children, stepchildren, legally adopted children, children for whom you have assumed a legal obligation for total or partial support in anticipation of adoption, children of your state-registered domestic partner, children specified in a court order or divorce decree, or persons with whom you have parent-child relationship as defined in RCW 26.26.101.

Children may also include extended dependents in your, your spouse’s, or your state-registered domestic partner’s legal custody or legal guardianship.

An extended dependent may be your grandchild, niece, nephew, or other child for whom you, your spouse, or state-registered domestic partner have legal responsibility as shown by a valid court order and the child’s official residence with the custodian or guardian. This does not include foster children for whom support payments are made to you through the state Department of Social and Health Services (DSHS) foster care program.

Eligible children with disabilities

Eligible children also include children of any age with a developmental disability or physical handicap 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 age 26. You must provide evidence of the disability and evidence the condition occurred before age 26. The PEBB Program, with input from the health plan (if applicable), will periodically verify the disability and dependency of a child with a disability beginning at age 26, but no more than annually after the two-year period following the child’s 26th birthday. If PEBB does not receive your verification within the time allowed, the child will no longer be covered and you will not be able to add the child back onto your coverage.

A child with a developmental disability or physical handicap who becomes self-supporting is not eligible as of the last day of the month in which he or she becomes 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 dependent with a disability is not longer eligible. The PEBB Program must receive notice no later than 60 days after the date your dependent is no longer eligible.