Current through Register Vol. 63, No. 9, September 1, 2024
(1) A
dependent child must meet the following eligibility conditions to receive PEBB
health plan coverage:
(a) The child is:
(A) An eligible employee's, spouse's, or
domestic partner's son, daughter, stepson, stepdaughter, adopted child;
or
(B) A Child by Affidavit which
includes but is not limited to a foster child, grandchild, child placed for
adoption, or court ordered placement of a child who lives in the household of
the eligible employee, and is the eligible employee's IRS dependent. The
employee must provide court ordered documentation of guardianship and the
notarized Affidavit of Child Dependency upon enrollment. The exception would be
newborns or adopted children who are automatically covered as an eligible PEBB
individual the first 31 days from birth or placement without documentation and
Affidavit in place. The Affidavit and documentation must be on file the first
of the month following the event date in order to meet eligibility and continue
coverage under the PEBB plans. Coverage ends the last day of the month in which
the court ordered guardianship ends or age 18, whichever comes first. An
eligible employee may not add a child by affidavit age 18 or older to PEBB
coverage unless they can provide court ordered documentation for responsibility
of the child beyond the age of 18; or,
(C) The biological child of an eligible
dependent child of an eligible employee, spouse, or domestic partner (a
grandchild by affidavit) and meets all the following criteria:
(i) The child's parent will not be older than
age 26, is unmarried and without a domestic partner. Both the child's parent
and the child live in the household of the eligible employee, and both the
child and grandchild are the eligible employee's IRS dependent and must claim
both child and grandchild on their most recent years tax return. The child's
parent has PEBB health coverage through the eligible employee. The grandchild
is automatically covered as an eligible PEBB individual the first 31 days from
birth without documentation and Affidavit in place. The Affidavit and any
appropriate documentation must be on file the first of the month following the
event date to meet eligibility and continue coverage under the PEBB rules. An
eligible employee may not add a grandchild age 18 or older to their PEBB
coverage unless they can provide court ordered documentation for responsibility
of the child beyond the age of 18.
(ii) Once the child no longer meets the
requirements of section (5) of this rule, the child and grandchild will no
longer be eligible.
(D)
Covered if the eligible employee loses their spouse or domestic partner by
death, the dependents (i.e. child of domestic partner, stepchild, grandchild)
may continue PEBB health plan coverage provided they are currently enrolled,
and eligibility is still being met. For biological, stepchildren or children of
domestic partners, coverage ends the last day of the month in which they turn
26. For Child by Affidavit of Dependency, coverage ends the last day of the
month in which the court ordered guardianship ends or age 18. For Grandchild by
Affidavit, eligibility ends when the grandchild no longer meets the definition
of Grandchild by Affidavit.
(2) During Enrollment, as a new hire and
during annual open enrollment, the employee may enroll a Child by Affidavit or
Grandchild by Affidavit if the appropriate notarized affidavit and court
ordered documentation is submitted within seven calendar days after enrollment
closes. If the employee does not submit the court ordered documentation as
required, the child's enrollment will not activate. PEBB Coverage ends the last
day of the month in which the court ordered guardianship ends or age 18,
whichever comes first.
"Example: Jack's foster child Joe is receiving PEBB coverage.
Jack's legal documentation used at the time of Joe's enrollment stated that
Jack will no longer be responsible for Joe when Joe turns 18. Joe's birth date
is November 11, if there is no change to the court ordered responsibility,
Joe's PEBB coverage will terminate November 30 the year he turns 18."
(3) Employees with a midyear
change requesting to enroll a Child by Affidavit or Grandchild by Affidavit
must submit the appropriate court ordered documentation and the notarized Child
by Affidavit or Grandchild by Affidavit to the agency within the allowable
enrollment time. The agency will not process the employee's enrollments until
the employee submits all the following:
(a)
Completed and signed appropriate forms;
(b) Completed and notarized affidavit;
and
(c) Court ordered documentation
as required.
(4) There is
no age limit for a dependent child who is incapable of self-sustaining
employment because of a developmental disability, mental illness, or physical
disability, when all the criteria in this section are met.
(a) The employee must submit to PEBB any
appeal and enrollment forms to enroll a disabled child age 26 or older, or to
indicate the child disabled in the PEBB benefit record when the child is
already receiving coverage.
(b) The
child's attending physician must submit documentation of the child's disability
to the employee's health plan. The health plan provides a medical review of the
physician's medical documentation and provides PEBB a disability determination
based on the review.
(c) When the
employee requests to enroll a disabled child over the age of 26:
(A)
(i) The
child must be the employee's qualifying IRS dependent and must be claimed on
the eligible employees' most recent years tax return, or
(ii) The child files a tax return and
demonstrates that their adjusted gross income does not exceed 150 percent of
the federal poverty level (FPL), or
(iii) The employee is the legal guardian of
the disabled dependent child.
(B) The physician must verify to the health
plan that the disability existed before the child attained age 26.
(C) The child must be unable to engage in
substantial gainful activity because of a medically determinable physical or
mental impairment which can be expected to result in death or which has lasted
or can be expected to last for a continuous period of not less than 12
months.
(D) The employee must
provide evidence to PEBB that the child has had continuous health plan
coverage, group or individual, prior to attaining age 26 and the coverage
remains in effect. The other coverage must continue until the employee's
medical plan approves the child's health status as disabled and the PEBB plan
is effective. If the child has not had continuous coverage, the child is not
eligible for PEBB coverage.
(d) When a disabled child is receiving
coverage beyond the age of 26, the employee's health plan can review the
child's health status at any time and determine if the child continues to meet
the criteria for a disabled child.
(e) If a disabled dependent child's PEBB
health coverage terminates for any reason after the age of 26, the child is
ineligible for future enrollment as a dependent child under that PEBB coverage.
The exception is termination of the child's coverage due to the employee's
termination of employment when the employee is rehired later into a PEBB
benefit eligible position. In this situation, to enroll the child again as
disabled all PEBB criteria for disabled child within (4) of this rule must be
met.
(f) Imputed taxes may apply,
per IRC provisions, when an employee enrolls and covers dependents on their
PEBB coverage that are not claimed on their federal taxes, and thus are not tax
dependents.
(5) Beginning
January 1, 2019, PEBB will terminate all plan coverage for dependent children
who reach age 26 during a calendar year at midnight on the last day of the
month in which the dependent turned 26. PEBB will not terminate coverage for
children age 26 or older when approved by the health plan as incapable of
self-sustaining employment because of a developmental disability, mental
illness, or physical disability pursuant to section (4) of this rule. The
exception is Child and Grandchild by Affidavit, see section B.
Statutory/Other Authority: ORS
243.061 - ORS
243.302
Statutes/Other Implemented: ORS
243.125(1),
Chapter 342, 2021 Laws
