Or. Admin. R. 101-015-0011

Current through Register Vol. 63, No. 5, May 1, 2024

Section 101-015-0011 - Dependent Child

(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.

Or. Admin. R. 101-015-0011

PEBB 3-2009, f. 9-29-09 cert. ef. 10-1-09; PEBB 1-2010(Temp), f. & cert. ef. 6-1-10 thru 11-28-10; Reverted to PEBB 3-2009, f. 9-29-09 cert. ef. 10-1-09; PEBB 7-2010, f. 12-10-10, cert. ef. 1-1-11; PEBB 1-2017(Temp), f. & cert. ef. 6-8-17 thru 12-4-17; PEBB 3-2017, amend filed 12/11/2017, effective 12/11/2017; PEBB 1-2018, amend filed 01/09/2018, effective 1/9/2018; PEBB 2-2018, temporary amend filed 02/16/2018, effective 02/16/2018 through 08/14/2018; PEBB 5-2018, amend filed 08/15/2018, effective 8/15/2018; PEBB 8-2018, amend filed 08/17/2018, effective 8/18/2018; PEBB 9-2018, temporary amend filed 08/22/2018, effective 8/22/2018 through 2/17/2019; PEBB 3-2021, temporary amend filed 12/28/2021, effective 12/31/2021 through 6/28/2022; PEBB 1-2022, amend filed 03/31/2022, effective 3/31/2022

Statutory/Other Authority: ORS 243.061 - ORS 243.302

Statutes/Other Implemented: ORS 243.125(1), Chapter 342, 2021 Laws