Special Eligiblity Situations
If You and Your Spouse are Both Public Employees
Two public employees who are married to each other, and 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;
4. as “Employee Only” and “Employee and Child(ren)” in the same managed care plan. All children must be enrolled under the same policyholder; or
5. If no children are to be covered, you may enroll as “Family with Employee Spouse” or as separate “Employee Only” plans.
Both employees are eligible to enroll for the basic life policy, as well as optional and dependent life insurance. To qualify for the Family with Employee Spouse premium, both employees MUST have basic life insurance. The Family with Employee Spouse premium discount will not be granted unless both employees are basic life insurance policyholders in the plan. The Family with Employee Spouse discount is also offered when the ‘employee spouse’ is a retired public employee. The premium for this coverage is based on the active employee’s salary. The retired public employee must carry the basic life insurance.
Generally, since both spouses, as policyholders, are eligible to make independent benefit elections, both spouses receive the Shopper’s Guide, Summary Plan Description, and other relevant benefit information.
If the employee spouse on an active employee’s plan is retired and Medicare-eligible, that employee spouse may want to consider becoming a “policyholder only” in PEIA’s Medicare Advantage plan. Doing so could reduce your total premium and cost-sharing, depending on your situation.
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 employment, 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 make changes in your health or life insurance coverage. You can only change health 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.
Disabled Child
Your dependent child may continue to be covered after reaching age 26 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 26
• the child must have been covered by PEIA upon reaching age 26; 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 26 and periodically thereafter.
Court-Ordered Dependent (COD)
If a PEIA-insured employee and his or her spouse divorce, the employee must remove the ex-spouse from coverage, even if the court orders the employee to provide medical coverage for the ex-spouse. Ex-spouses are NOT eligible dependents in the PEIA plan. To provide the coverage for an ex-spouse as ordered by the court, the employee must look to COBRA coverage or for other privately available coverage.
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 noncustodial 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 or the dependent of an active employee becomes eligible for Medicare and has no other insurance, the PEIA PPB Plan remains the primary insurer, except if the policyholder or dependent attains Medicare eligibility due to End Stage Renal Disease (ESRD). As long as you are an active employee, you and your Medicare-eligible dependents are not required to sign up for Medicare Part B and pay the premium. When you prepare to retire, you and your Medicare-eligible dependents must enroll for Medicare Part B. If you do not enroll in Medicare Parts A & B, your coverage may be terminated.
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.
When you or your dependent become eligible for Medicare, please send a copy of the Medicare card to PEIA.
Medicare-Eligible Members Who Reside Outside of the U.S.
Medicare-eligible retirees who reside outside the United States will have benefits through PEIA’s Special Medicare Plan. Medical claims will be processed by HealthSmart, and PEIA will pay only the amount we would have paid if Medicare had processed your claim and made a payment. Prescription drug claims will be processed by Express Scripts.