Dependent Eligibility Definitions

Definitions

When you enroll in benefits through PEBB, you can only cover people who meet eligibility requirements under Oregon Administrative Rules (OARs). The Dependent Eligibility Verification (DEV) audits (reviews) ensures those rules are followed. Read the definitions below to make sure each dependent you enroll is eligible.

Looking for Retiree and Retiree dependent information?

Child

You can cover a child who is 25 or younger on the first day of the month if they meet one of these criteria:

• Your biological child
• Your spouse’s or domestic partner’s biological child
• Your legally adopted child or a child placed for adoption
• A child placed in your custody by the court (you must provide legal documentation)
• Your stepchild

Grandchild

You can only cover a grandchild if you are their legal guardian or adoptive parent.

• You must provide legal documentation (e.g., court order)

Disabled Dependent Child

If your child has a qualifying disability and you want to continue their coverage, you must apply before the child reaches age 26.

• Contact PEBB up to 60 days before your child turns 26.
• Coverage won't continue automatically, even if the carrier (Moda, Kaiser, Providence) knows about the disability.

To meet eligibility requirements, all the following must be true:

• Your child can’t support themselves due to a developmental disability, physical disability, or mental illness.
• A medical provider confirmed the disability before your child turned 26.
• Your child has had continuous health coverage (no breaks).

AND one of these applies:

• You claim your child on your federal tax return
• You have legal guardianship ordered by a court
• Your child files their own tax return and earns less than 150% of the Federal Poverty Level (FPL)

Ask your doctor to send proof of disability to your medical carrier (Moda, Kaiser, Providence)

• Use your medical carrier’s Disabled Dependent form which you can ask for to get approval from the carrier.

After your child is enrolled as a Disabled Dependent, you must continue coverage for the child to stay eligible.

• If you stop PEBB coverage for any reason other than loss of your own coverage, you cannot re-enroll the Disabled Dependent child in the future.
• If you become eligible for PEBB benefits again and want to cover your Disabled Dependent child, you must show that you continued coverage for the child during the gap that you lost eligibility (no breaks in coverage for the child).

Important: You may owe extra taxes (called “imputed income”) for covering someone who isn’t a tax dependent. A tax dependent is a qualifying dependent who relies on you for financial support and is claimed on your tax return.

What you need to do now?

Send copies of these required documents for you Disabled Dependent to PEBB.

1. A copy of their birth certificate AND
2. A copy of your Proof of Guardianship or tax status
   

Spouse

• You can cover your spouse if you're legally married under the laws of Oregon or another state or country.
• You cannot cover a former spouse.

Domestic Partnerships

Retirees

If you're a retiree with an PEBB medical or vision plan and you become eligible for Medicare (except for End-stage Renal Disease (ESRD)-related eligibility), your PEBB coverage must end on the last day of the month before your Medicare starts.

• You must report your Medicare coverage to PEBB and your former employer within 31 days.

Important:

Not reporting this information with 31 days may count as fraud and lead to retroactive termination of your benefits.

Retiree Dependents

If your covered dependents also become eligible for Medicare, their PEBB medical or vision coverage must end unless:

• Your district or union contract (as of Feb. 1, 2010) allows them to stay on until you (the retiree) become eligible for Medicare.
• You’re enrolled in a Kaiser Permanente medical plan—in that case, coverage must end for Medicare-eligible dependents.