Dependents

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

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

Who are eligible dependents?

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)

• This includes substantially equivalent legal unions from another state or jurisdiction (e.g., Out-of-state registered domestic partnerships, city or county domestic partnerships within the state of Washington, etc.) (RCW 26.60.090 and 26.04.260).
  • The PEBB Program must review and determine if the union meets the criteria listed in PEBB Policy 33-1.
• 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 26^th birthday

• Children based on establishment of a parent-child relationship as described in RCW 26.26A.100, except when parental rights have been terminated.
• Stepchildren: Children of the employee’s spouse/SRDP who are not legally adopted by the employee.
  • A stepchild’s eligibility as a dependent 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.

Dependent children with a disability age 26 and older

• Children, age 26 and older, with a developmental or physical disability that renders the child incapable of self-sustaining employment and is chiefly dependent on the employee for support and maintenance.
  • The disability must occur prior to age 26.
  • If the child is enrolled prior to turning 26, the employee must provide proof of the disability and dependency within 60 days of the child's attainment of age 26.
  • Certification is required by the PEBB Program (with input from the employee’s medical plan, if applicable).

Extended dependent children

• Children in legal custody or legal guardianship of the employee or the employee's spouse/SRDP.
  • 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.

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

Medical and dental coverage

To enroll eligible dependents in PEBB medical and/or dental coverage, employees must submit the following to their benefits administrator:

• The appropriate Employee Enrollment/Change form,
• Any additional required forms (if applicable), and
• Valid dependent verification (DV) documents.

All required forms and documents must be received no later than (WAC 182-12-262):

• 31 days after the employee becomes newly eligible or regains eligibility for PEBB benefits.
  • If approved, dependent coverage begins on the same day as the employee's effective date of coverage.
• The last day of annual open enrollment (November 1-30).
  • If approved, dependent coverage begins on January 1 of the following year.
• 60 days after a qualifying special open enrollment event occurs.
  • Generally, if approved, 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.
  • Proof of the qualifying event must also be provided. Learn more about making changes due to an SOE.

Life and accidental death and dismemberment (AD&D) insurance

To enroll eligible dependents in supplemental life and/or AD&D insurance employees must use the MetLife MyBenefits portal or complete and submit the MetLife Enrollment/Change form directly to MetLife using the submission instructions provided on the form.

Generally, coverage will be effective the first day of the month following the date MetLife receives the required form or approves the enrollment.

Learn more about Life and AD&D insurance.

Why is dependent verification required?

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

Exception: If an employee moves from School Employees Benefits Board (SEBB) Program coverage to PEBB coverage, previous dependent verification data may be used if the employee is requesting to enroll an eligible dependent who was verified under the SEBB Program. Send a message to Outreach and Training through HCA Support to request a review of dependents who may have been previously verified.

What are valid dependent verification documents?

Birth certificates, adoption decrees, tax returns, and parenting plans are among the types of documents that can be used to verify a dependent's eligibility. In some cases, additional forms and documentation may be required.

Review the information below for a list of valid dependent verification documents that can be used to verify a dependent as well as any additional forms or documents that may be required.

To verify a spouse

Employees adding a spouse to their coverage must provide a copy of one of the following:

• Most recent year's federal tax return (black out financial information), either:
  • A single return that lists their spouse if filed jointly.
  • Each return for the employee and spouse, if filed separately.
• Marriage certificate and proof that the marriage is still valid (the employee and spouse do not have to live together), such as a utility bill, life insurance beneficiary document, or bank statement, within the last six months showing both the employee and spouse's name (black out financial information).
  • If the spouse is being added within six months of marriage, only the certificate is required.
• A recently filed (within the past six months) petition for dissolution/invalidity of marriage, or legal separation notice.
• Defense Enrollment Eligibility Reporting System (DEERS) registration
• Valid J-1 or J-2 visa issued by the U.S. Government

To verify a state-registered domestic partner or partner of a legal union

Employees adding a state-registered domestic partner or partner of a legal union to their coverage must submit one of the following during the require timeframe:

• Certificate/card of a state-registered domestic partnership or a legal union and proof the partnership is still valid (the employee and partner do not have to live together), such as a utility bill, life insurance beneficiary document, or bank statement dated within the last six months showing both the employee and partner's name (black out any financial information).
  • If the partner is being added within six months of state registration, only the card is required.
• A recently filed (within the last six months) petition for dissolution or petition to invalidate state-registered domestic partnership.

Adding a partner of a legal union

This includes substantially equivalent legal unions from another state or jurisdiction (e.g., Out-of-state registered domestic partnerships, city or county domestic partnerships within the state of Washington, etc.) (RCW 26.60.090 and 26.04.260).

If enrolling a partner of a legal union, the employee must also provide:

• Proof of Washington State residency for both the employee and partner.
  • The PEBB Program must review and determine if the union meets the criteria listed in PEBB Policy 33-1. Submit documents to verify a partner of a legal union to the PEBB Program through HCA Support.
  • Additional dependent verification documents will be required within one year of the partner's enrollment for them to remain enrolled.

More information can be found in PEBB Policy 31-1 and 33-1.

Declaration of tax status

Employees adding a state-registered domestic partner or partner of a legal union to their coverage must also submit the Declaration of Tax Status form to their benefits administrator within the required timeframe to indicate whether their dependent qualifies for tax purposes under IRC Section 152, as modified by IRC Section 105(b).

The Declaration of Tax Status form is processed by the employer and should not be sent to the PEBB Program.

To verify a child

Employees adding a child to their coverage, must provide a copy of one of the following:

• The most recent year's federal tax return that includes the child as a dependent (black out financial information).
  • Employees can submit one copy of their tax return if it includes all family members that require verification.
• Birth certificate (or hospital certificate with the child's footprints on it) showing the name of the parent who is the employee or the employee's spouse or state-registered domestic partner (SRDP).
• Certificate or decree of adoption showing the name of the parent who is the employee or the employee's spouse or SRDP.
• Court-ordered parenting plan
• National Medical Support Notice
• Defense Enrollment Eligibility Reporting System (DEERS) registration
• Valid J-2 visa issued by the U.S. Government

Adding a stepchild

If the dependent is the employee's stepchild, The employee must also verify the spouse or SRDP in order to enroll the stepchild, even if not enrolling the spouse or SRDP in PEBB insurance coverage.

If the employee is adding their stepchild, who is a child of a state-registered domestic partner or partner of a legal union to their coverage, they must also submit the Declaration of Tax Status form to their benefits administrator within the required timeframe to indicate whether their dependent qualifies for tax purposes under IRC Section 152, as modified by IRC Section 105(b).

The Declaration of Tax Status form is processed by the employer and should not be sent to the PEBB Program.

To verify a dependent child with a disability age 26 or older

Employees adding a dependent child with a disability, age 26 or older, to their coverage must submit the following during the require timeframe:

• Valid dependent verification documents to enroll a child, and
• Certification of a Child with a Disability form.

The employee must submit the dependent verification documents to their benefits administrator and the Certification of a Child with a Disability form to either the PEBB Program or the medical carrier, using the submission instructions provided on the form. The form should not be submitted by the employer through HCA Support.

Moving from the SEBB Program to the PEBB Program

If the employee moves from School Employees Benefits Board (SEBB) Program coverage to PEBB Program coverage with a disabled dependent and the disabled dependent is currently enrolled in health plan coverage through the SEBB Program, they are not required to complete the Certification of a Child with a Disability form to recertify until their current certification issued, while they were enrolled in SEBB health plan coverage, expires.

Additional information can be found in the E-2 worksheet and PEBB Policy 36-1.

To verify an extended dependent child

Employees adding an extended dependent child to their coverage must submit the following during the required timeframe:

• Extended Dependent Certification form,
• Declaration of Tax Status form, and
• A copy of a valid court order showing legal custody or guardianship. The court order serves as dependent verification for extended dependents.

The employee must submit the forms and documents to their benefits administrator to be processed.

Moving from the SEBB Program to the PEBB Program

If the employee moves from School Employees Benefits Board (SEBB) Program coverage to PEBB Program coverage with an extended dependent, and the extended dependent is currently enrolled in health plan coverage through the SEBB Program, they are not required to recertify until the current certification issued, while the employee is enrolled in SEBB Program coverage expires.

Additional information can be found in the E-2 worksheet and PEBB Policy 37-1.

All dependent verification documents must be submitted in English. Any documents written in a foreign language must include a translated copy prepared by a professional translator and certified with a notary public seal.

How do BAs process dependent verification?

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 enrollments or 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 they submit valid DV within the required time frame.

If the forms and documents meet the criteria above, enroll and verify the dependent(s) in Benefits 24/7. See Chapter 3 of the Benefits 24/7 manual for instructions.

How are additional forms processed?

Certification of a Child with a Disability form

Employees adding a dependent child with a disability, age 26 or older, to their coverage must submit the Certification of a Child with a Disability form to either the PEBB Program or the medical carrier, using the submission instructions provided on the form. The form should not be submitted by the employer through HCA Support.

Enter the dependent in Benefits 24/7. Once the dependent has been entered into the insurance system, the dependent's enrollment will pend approval.

Once the form has been received and reviewed, the PEBB Program will notify the employee and the employer of the approval or denial.

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 and PEBB Policy 36-1.

Extended Dependent Certification form

Employees adding an extended dependent child to their coverage must submit the Extended Dependent Certification form and a copy of a valid court order showing legal custody or guardianship to their benefits administrator.

Once received, the employer must submit the Extended Dependent Certification form and the court order to Outreach and Training through HCA Support for review.

Enter the dependent in Benefits 24/7 before sending the certification form and court order to Outreach and Training. Once the dependent has been entered into Benefits 24/7, the dependent's enrollment will pend approval.

The PEBB Program will review the attachments and notify the employee and the employer of the approval or denial.

Approval

If the dependent meets the eligibility requirements, the PEBB Program will notify the employee and employing agency in writing. A 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 and PEBB Policy 37-1.

Declaration of Tax Status form

Employees requesting to enroll any of the following types of dependents must submit the Declaration of Tax Status form to their benefits administrator within the required timeframes to indicate whether their dependent qualifies for tax purposes under IRC Section 152, as modified by IRC Section 105(b):

• Extended dependent children
• State-registered domestic partner or partner of a legal union
• Children of a state-registered domestic partner or partner of a legal union

The Declaration of Tax Status form is processed by the employer and should not be sent to the PEBB Program. Learn about reporting the tax status of a dependent.

What if the required forms and valid DV are not received timely?

If the required forms and/or valid DV documents are not received within the required timeframe, 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.

Adding 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 must submit required forms and dependent verification (DV) within the following timeframes:

• If adding the child increases the employee's medical premium, the required forms and DV 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 and DV must be received as soon as possible to ensure timely payment of claims.

When is coverage effective for a newborn or adopted child?

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 AD&D insurance, the child must be at least 14 days old before supplemental life and A&D coverage can become effective.
• 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 the employee previously waived medical coverage, they must enroll in medical to add an eligible dependent to medical. Coverage for the employee begins on the first day of the month in which the event occurs.

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.

Learn more about what changes can be made due to birth or adoption by reviewing the SOE Matrix - PEBB Policy 45-2A.

When dependent eligibility for PEBB benefits ends

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

• The Benefits 24/7 enrollment 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 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.

Review the Benefits 24/7 enrollment system manuals for instructions on terminating coverage for dependents who lose eligibility. If Outreach and Training keys enrollment for you, send required form through HCA Support for processing.

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).

Surviving dependents

If an employee dies, their dependents 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 Benefits 24/7.

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 in PEBB retiree insurance coverage as a survivor.

Related rules and policies

• WAC 182-12-128: When may an employee waive enrollment in PEBB medical and when may they enroll in PEBB medical after having waived enrollment?
• WAC 182-12-260: Who are eligible dependents?
• WAC 182-12-262: When may subscribers enroll or remove eligible dependents?
• 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?
• PEBB Policy 31-1: Verifying dependent eligibility before enrollment
• PEBB Policy 33-1: Verifying legal union’s residency status
• PEBB Policy 36-1: Certifying eligibility for a dependent child with a disability who is age 26 or older
• PEBB Policy 37-1: Certifying eligibility for an extended dependent child
• PEBB Policy 45-2A: Special open enrollment matrix