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 Eligibility & Enrollment 

Below are special circumstances that may affect your eligibility and enrollment as a PEIA member:

If You and Your Spouse are Both Public Employees

Two public employees who are married to each other, but who are both eligible for benefits under PEIA may elect to enroll as follows: 1/ as Family with Employee Spouse in any plan; 2/ as “Employee Only” and “Employee and Child(ren)” in two different plans; 3/ as “Employee Only” and “Employee and Child(ren)” in the PPB Plan (remember you’ll have two deductibles and two out-of-pocket maximums this way); or 4/ as “Employee Only” and “Employee and Child(ren)” in the same managed care plan. All children must be enrolled under the same policyholder. If no children are to be covered, you may enroll as “Family with Employee Spouse” or as separate “Employee Only” plans.

Transfer from One Participating Agency to Another

If you transfer from one participating State agency to another in the middle of a plan year without a lapse in coverage, you may continue your PEIA coverage uninterrupted. Such a transfer does not create an initial enrollment period, and does not give you the right to change health plans. You can only change plans if the transfer moves you out of the enrollment area of a plan so that accessing care is unreasonable. Since the PEIA PPB Plan has an unlimited enrollment area, you will not be permitted to transfer out of it during the plan year, even if you move.

When an employee transfers from one participating State agency to another, PEIA will collect updated salary information, and the premium at the new agency will be based on the salary at the new agency, whether it is a salary increase or a decrease. In this case. a plan change may be permitted, if the transfer creates a qualifying change in family status under the Premium Conversion Plan. Transfer from a State agency to a non-State agency may permit a change in coverage based on financial hardship.

Dependents

If you elect PEIA coverage, you may also enroll the following dependents:

• our legal spouse;
• your biological or adopted children under age 19*;
• •stepchildren who live with you and are under age 19*;
• children under age 19 who are members of your household and dependent upon you for more than 50% of their support and maintenance (a notarized statement from the member affirming the member’s financial responsibility for the dependent is required); and
• children or stepchildren over age 19 who live with you, have been continuously covered by PEIA since before age 19, and who are incapacitated and cannot support themselves due to a physical or mental disability which began before age 19, or before age 25 if coverage was extended as a “qualifying child “ or “qualifying relative”. For newly hired employees in their initial enrollment period in PEIA it is not necessary that the dependent be covered before age 19.

Married children are not eligible for coverage.

*Your unmarried 19-25-year-old child or stepchild who shares your principal place of residence will qualify for benefits if he or she meets the definition of a “qualifying child” OR a “qualifying relative.” To qualify for coverage, the dependent must meet ALL of the criteria in one of the following categories: (NOTE that these definitions have been simplified for PEIA eligibility purposes. For your taxes, refer to IRS publications.)

A “qualifying child” (QC) is a child who:

• has a specific, family-type relationship to the employee-taxpayer (i.e. child or stepchild).
• resides with the employee in his/her household for more than half of the tax year (with certain exceptions such as “temporary absences” if a full-time student).
• is under age 19, or if a full-time student for at least 5 months of the year is under age 24 as of the end of the tax year. There is no age requirement if a child is permanently and totally disabled
• has not provided more than half of his/her own support.

A “qualifying relative” (QR) is a “too old” child (that means over age 19, or over 24 if a full-time student) who:

• has a specific, family-type relationship to the employee-taxpayer, (i.e. child or stepchild).
• has gross income for the tax year that is less than the annual exemption amount permitted by the IRS (this income limit does not apply to full-time students).
• receives over half of his/her own support from the employee-taxpayer.
• is not anyone’s “qualifying child.”

From time to time PEIA may conduct eligibility audits to verify that dependents in the plan qualify for coverage. If you are audited, you will have to produce either a student verification form for the dependent in question, or your most recent Federal tax return showing that you’ve claimed this dependent on your taxes. If you cannot prove that the dependent qualifies for coverage, coverage will be terminated retroactively to the date the child would otherwise have been terminated, and PEIA will pursue reimbursement of any medical or prescription drug claims paid during the time the dependent was ineligible.

Withdrawal for Medical Necessity

If it becomes medically necessary for your child to cut back to part-time status or withdraw temporarily from school, he or she may continue to be covered under the PEIA plan for one year under an approved medical leave. You will be asked to provide documentation from your child’s physician verifying that the illness or injury prevents the student from attending classes full-time, and the date your child may be expected to return to full-time status. If the medical leave extends beyond one year, you may apply to cover that child as a disabled child. Approval will be granted at the discretion of PEIA’s medical director.

Loss of Full-time Student Status

If your child loses eligibility because he or she is no longer a full-time student, you should notify your benefit coordinator promptly. Continued coverage under COBRA will be available if the loss of eligibility is reported promptly. If you fail to notify your benefit coordinator promptly, your employing agency may look to you for reimbursement of premiums your employer paid in error.

Return to Full-time Status

If your child (age 19 or over) voluntarily withdraws from school, has a lapse in coverage, and later re-enrolls as a full-time student, he or she may be reinstated for PEIA coverage. You must complete a Change-in-Status form and add this child to your list of dependents again to reinstate this coverage. This child may be subject to pre-existing condition limitations.

Working FamiliesTax Relief Act (WFTRA) of 2004

As a result of the Working Families Tax Relief Act (WFTRA) of 2004, the federal IRS has changed the way it treats children under the tax code. This change may affect you if you pay your health and life insurance premiums pre-tax through a Section 125 premium conversion plan.

The IRS has developed a new definition for “qualified child” and “qualified relative.” If you have dependents, they must meet one of these definitions to qualify for you to pay your premiums on a pre-tax basis. In nearly all circumstances, if your dependent meets PEIA eligibility criteria, they will also meet one of these federal definitions. The new definitions are as follows:

A “qualifying child” (QC) is a child who:
1/ has a specific, family-type relationship to the employee-taxpayer
2/ resides with the employee in his/her household for more than half of the tax year (with certain exceptions such as “temporary absences” if a full-time student)
3/ is under age 19 and not a full-time student (under age 24 if a full-time student) as of the end of the calendar year in which the employee’s taxable year begins. There is no age requirement if a child is permanently and totally disabled 4/ has not provided more than half of his/her own support. The employee-taxpayer no longer has to provide over half of the dependent-child’s support for the tax year, unless s/he is a full-time student.

A “qualifying relative” (QR) is a “too old” child or other individual who:
1/ has a specific, family-type relationship to the employee-taxpayer, or is someone (other than a spouse) who resides with the employee in his/her household for the employee’s taxable year. A person will not be a member of the employee’s household if at any time during the taxable year the relationship between the employee and the person violates local law
2/ receives over half of his/her own support from the employee-taxpayer
3/ is not anyone’s “qualifying child”

This change from the IRS does not change PEIA’s eligibility rules. It does not create any new category of eligible dependents, or make people who were previously ineligible for coverage now eligible. It simply redefines the way the IRS treats dependent children age 24 and over for tax purposes. We are required to provide this information in the Summary Plan Description.

Disabled Child

Your dependent child may be covered after reaching age 19 if he or she is incapable of self-support because of mental or physical disability. To be eligible: the disabling condition must have begun before age 19, or before age 25 if a full-time student; and the child must be incapable of self-sustaining employment and chiefly dependent on you for support and maintenance.

To continue this coverage, contact PEIA for an application. You will be asked to provide documentation when the child reaches age 19 and periodically thereafter.

Court-Ordered Dependent (COD)

If a PEIA-insured employee and his or her spouse divorce, and the employee is not the custodial parent for the dependent child(ren), the employee may continue to provide medical benefits for the child(ren) through the PEIA plan. If the non-custodial parent is ordered by the court to provide medical benefits for the child(ren), the custodial parent may submit medical claims for the court-ordered dependent(s), and benefits may be paid directly to the custodial parent. Special claim forms are required. The custodial parent will also receive Explanations of Benefits (EOBs) for the CODs as claims are processed. Contact PEIA to discuss this benefit.

Medicare and Active Employees

If an active employee becomes eligible for Medicare, the PEIA PPB Plan remains the primary insurer for that employee, except if the employee attains Medicare eligibility due to End Stage Renal Disease (ESRD). As long as you are an active employee, you do not need to sign up for Medicare Part B and pay the premium. When you prepare to retire, you must enroll for Medicare Part B. If you do not enroll in Medicare Part B, PEIA will process your claims as if you did have the Part B coverage. In other words, PEIA will pay only the amount we would have paid if Medicare had processed your claim and made a payment.

For PEIA PPB Plan active employees who are also eligible for Medicare, and Medicare is the primary payor (as in the case of ESRD), PEIA will use the traditional method of coordinating benefits.

If you become eligible for Medicare prior to age 65, please send a copy of your Medicare card to PEIA. This notification will make the claims payment process go much more smoothly.

If the spouse or dependent of an active employee becomes eligible for Medicare, the PEIA PPB Plan remains the primary insurer for that spouse or dependent as long as the policyholder remains an active employee. When the policyholder retires, PEIA becomes the secondary insurer for any spouse or dependent(s) on Medicare.