To be enrolled in a health plan, a dependent must be eligible under this section and the subscriber must comply with enrollment procedures outlined in WAC
182-12-262.
The PEBB program verifies the eligibility of all dependents periodically and reserves the right to request documents from subscribers that provide evidence of a dependent's eligibility. The PEBB program will remove a subscriber's enrolled dependents from health plan enrollment if the PEBB program is unable to verify a dependent's eligibility within a specified time.
The subscriber or dependent must notify the PEBB program, in writing, no later than sixty days after the date he or she is no longer eligible under this section. See WAC
182-12-262 for the consequences of not removing an ineligible dependent from coverage.
The following are eligible as dependents under the PEBB eligibility rules:
(1) Lawful spouse. Former spouses are not eligible dependents upon finalization of a divorce or annulment, even if a court order requires the subscriber to provide health insurance for the former spouse.
(2) Effective January 1, 2010, Washington state registered domestic partners, as defined in RCW
26.60.020(1). Former Washington state registered domestic partners are not eligible dependents upon dissolution or termination of a partnership, even if a court order requires the subscriber to provide health insurance for the former partner.
(3) Children. Children are defined as the subscriber's biological children, stepchildren, legally adopted children, children for whom the subscriber has assumed a legal obligation for total or partial support in anticipation of adoption of the child, children of the subscriber's Washington state registered domestic partner, or children specified in a court order or divorce decree. In addition, children include extended dependents in the legal custody or legal guardianship of the subscriber, the subscriber's spouse, or subscriber's Washington state registered domestic partner. The legal responsibility is demonstrated by a valid court order and the child's official residence with the custodian or guardian. "Children" does not include foster children for whom support payments are made to the subscriber through the state department of social and health services foster care program.
Eligible children include:
(a) Unmarried children through age nineteen.
(b) Married children through age nineteen who qualify as dependents of the subscriber under the Internal Revenue Code.
(c) Students: Unmarried children age twenty through age twenty-three who are attending high school or are registered students at an accredited secondary school, college, university, vocational school, or school of nursing. A married child is eligible as a student if the child is a dependent of the subscriber under the Internal Revenue Code.
(i) A child is eligible as a student or can maintain eligibility as a student when not registered for courses through the summer or off quarter/semester as long as the child meets all other eligibility requirements and is in any one of the following circumstances:
• The child attended the three consecutive quarters or two consecutive semesters before the off quarter/semester.
• The child recently graduated. Graduation is defined as the successful completion of studies to earn a degree or certificate, not the date of the graduation ceremony. The child is eligible for the three month period following graduation.
(ii) For student dependents who are not eligible for the summer or off quarter/semester according to (c)(i) of this subsection, student eligibility begins the first day of the month of the quarter or semester for which the child is registered, and eligibility ends the last day of the month in which the student is registered or in which the quarter or semester ends, whichever is first.
| Exception: | If a student becomes seriously ill or injured and requires a medically necessary leave of absence from attending school, his or her coverage may continue if qualified under and in accordance with the federal Michelle's Law (Public Law 110-381). |
(d) Adult dependents: Unmarried children age twenty through age twenty-four.
Subscriber must pay the adult dependent premium for adult dependents whom the subscriber has enrolled.
Adult dependents must enroll in the same health plan as the subscriber.
| Exception: | The adult dependent may enroll in a different health plan than the subscriber if the dependent does not reside within the subscriber's plan service area or the subscriber has waived or deferred medical. |
(e) Children of any age with disabilities, developmental disabilities, mental illness or mental retardation who are incapable of self-support, provided such condition occurs before age twenty or during the time the dependent was eligible as a student under (c) of this subsection.
The subscriber must provide evidence that such disability occurred as stated below:
(i) For a child enrolled in PEBB insurance coverage, the subscriber must provide evidence of the disability within sixty days of the child's attainment of age twenty.
(ii) For a child enrolled in PEBB insurance coverage as a student under (c) of this subsection, the subscriber must provide evidence of the disability within sixty days after the student is no longer eligible under (c) of this subsection.
(iii) For a child, age twenty or older, who is a new dependent or for a child, age twenty or older, who is a dependent of a newly eligible subscriber, the child may be enrolled as a dependent child with disabilities if the subscriber provides evidence that the condition occurred before the child reached age twenty or evidence that when the condition occurred the child would have satisfied PEBB eligibility for student coverage under (c) of this subsection had the subscriber been eligible for PEBB benefits at the time.
The subscriber must notify the PEBB program, in writing, no later than sixty days after the date that a child age twenty or older no longer qualifies under this subsection.
For example, children who become self-supporting are not eligible under this rule as of the last day of the month in which they become capable of self-support. The child may be eligible to continue enrollment as an adult dependent, as per (d) of this subsection, or in a PEBB health plan under provisions of WAC
182-12-270.
Children age twenty and older who become capable of self-support do not regain eligibility under (e) of this subsection if they later become incapable of self-support.
The PEBB program will certify the eligibility of children with disabilities periodically.
(4) Parents.
(a) Parents covered under PEBB medical before July 1, 1990, may continue enrollment on a self-pay basis as long as:
(i) The parent maintains continuous enrollment in PEBB medical;
(ii) The parent qualifies under the Internal Revenue Code as a dependent of the subscriber;
(iii) The subscriber continues enrollment in PEBB insurance coverage; and
(iv) The parent is not covered by any other group medical plan.
(b) Parents eligible under this subsection may be enrolled with a different health plan than that selected by the subscriber. Parents may not add additional dependents to their insurance coverage.
[Statutory Authority: RCW 41.05.160. 09-23-102 (Order 09-02), § 182-12-260, filed 11/17/09, effective 1/1/10; 08-20-128 (Order 08-03), § 182-12-260, filed 10/1/08, effective 1/1/09; 07-20-129 (Order 07-01), § 182-12-260, filed 10/3/07, effective 11/3/07. Statutory Authority: RCW 41.05.160, 41.05.350, and 41.05.165. 05-16-046 (Order 05-01), § 182-12-260, filed 7/27/05, effective 8/27/05. Statutory Authority: RCW 41.05.160 and 41.05.165. 04-18-039, § 182-12-260, filed 8/26/04, effective 1/1/05.]