You may enroll your eligible Dependent at any time. However, the effective date cannot be more than 60 days retroactive from the date the PEBTF-2 Enrollment/Change Form is received by your HR office. The necessary documentation must be presented when adding a new Dependent to PEBTF coverage. 

Documentation Requirements  PEBTF Summary Plan Description

 

Who is eligible for coverage under the PEBTF health plans?

  • Spouse (original marriage certificate required). An Affidavit Attesting to the Existence of Marriage Performed Outside of the United States (PEBTF-FM) should be completed if an employee was married outside of the country and cannot produce a valid marriage certificate.

  • Child under age 26, including:
    • Your natural child (original birth certificate required)
    • Legally-adopted child, including coverage during the adoption probationary period (Court Adoption Decree is required)
    • Stepchild for whom you have shown an original marriage certificate and a birth certificate indicating that your spouse is the parent of the child
    • Child who is under age 18 and for whom you are the legal guardian or legal custodian, as demonstrated by an appropriate court order
    • Eligible foster child
    • Child for whom you are required to provide medical benefits by a Qualified Medical Child Support Order or National Medical Support Notice

You may enroll your eligible Dependent at any time. However, the effective date cannot be more than 60 days retroactive from the date the PEBTF-2 Enrollment/Change Form is received by your HR office. The necessary documentation must be presented when adding a new Dependent to PEBTF coverage. 

NOTE: You must reside in the service area to enroll in an HMO. The HMO plan offered by the PEBTF is a Custom HMO and offers a limited network of Providers and facilities. Emergency Services only are covered outside of the service area. Seek Emergency Services and contact the plan. If you have a Dependent who resides outside of the HMO’s service area, they will have Emergency Services coverage only and would have to return to the service area for all other medical care; therefore, you may want to enroll in a PPO. 

Coverage for Dependent Children to Age 26: You may cover your child to age 26. Marriage, residency, tax support and student status are not considered in determining eligibility for children under age 26. Coverage for an eligible child ends on the last day of the month in which the child turns 26 unless the child qualifies as a disabled Dependent.

Important: It is your responsibility to advise your HR office of any event that would cause your Dependent to no longer be eligible for coverage. If you fail to advise the appropriate party of any such event within 60 days of the event, your Dependent will not be able to elect COBRA continuation coverage. You will be responsible for any claims incurred when your Dependent was not eligible for benefits.

  • Disabled Dependent
    Your unmarried disabled Dependent child age 26 and older may be covered if all of following the requirements are met:
    • Is totally and permanently disabled, provided that the Dependent became disabled prior to age 26; and
    • Was your or your spouse’s Dependent before age 26; and
    • Depends on you or your spouse for more than 50% support; and
    • Is claimed as a Dependent on your or your spouse federal income tax return. In the event of a divorce, your child may be eligible for coverage if the child is claimed as a Dependent by you every other year pursuant to a divorce decree or similar judgment; and
    • Completes a Disabled Dependent Certification Form (must be completed by Employee Member)


NOTE: A disabled Dependent child will not automatically be excluded from coverage if they live outside your home, but the child’s living situation and its ramifications will be taken into account in determining whether the child meets the support requirements. For example, a disabled adult child who lives in a group home or other facility and whose care
and expenses are subsidized significantly by the government may no longer be deemed to receive more than half of their support from you or your spouse.

Important: It is your responsibility to advise the PEBTF of any event that would cause your disabled Dependent to no longer be eligible for coverage. If you fail to advise the PEBTF of any such event within 60 days of the event, your Dependent will not be able to elect COBRA continuation coverage. You will be responsible for any claims incurred
when your Dependent was not eligible for benefits.

Recertification will occur every two years and will require a recertification form to be completed and returned within 45 days of the mailing. Based on the responses on the recertification form (PEBTF-6RC) the Dependent status will be continued or ended. A Dependent shall be considered “Totally and Permanently Disabled” if they are unable to perform any substantial, gainful activity because of physical or mental impairment that has been diagnosed and is expected to last indefinitely or result in death. The determination whether an individual is Totally and Permanently Disabled will be made by the Board of Trustees (or their delegate) in reliance upon medical opinion and/or other documentation (e.g. evidence of gainful employment) and shall be made independently without regard to whether the individual may or may not be considered disabled by any other entity or agency, including without limitation, the Social Security Administration. Accordingly, the Board of Trustees may require from time to time the provision of medical records and/or employment information, and/or may require an individual to submit to an examination by a physician of the Board of Trustees’ own choosing, to determine whether the individual is, or continues to be Totally and Permanently Disabled. Failure to cooperate in this regard is grounds for the Board of Trustees to determine, without more information, that the individual is not, or is no longer, Totally and Permanently Disabled.

  • Adult Dependent Coverage
    The PEBTF provides coverage for adult Dependents age 26 to age 30 on a self-paid basis
    under certain conditions. Your Dependent must meet the following criteria:
    • Is not married
    • Has no dependents
    • Is a resident of Pennsylvania or is enrolled as a full-time student at an accredited educational institution of higher education
    • Is not eligible for coverage under any other group or individual health insurance
    • Is not enrolled in or entitled to benefits under any government health care benefits program (for example, Medicare or Medicaid)

The adult Dependent must enroll in the same PEBTF medical, prescription drug and supplemental benefits (vision, dental and hearing aid) coverage as you and must pay a monthly premium for coverage to continue. Coverage ends when your coverage ends.

While this option is available, you will have to pay a monthly premium directly to the PEBTF.

You may contact the PEBTF for information on Adult Dependent Coverage and the monthly premium amounts.

NOTE: You must reside in the service area to enroll in an HMO. The HMO plan offered by the PEBTF is a Custom HMO and offers a limited network of Providers and facilities. Emergency Services only are covered outside of the service area. You should seek Emergency Services and contact the plan. If you have a Dependent who resides outside of the HMO’s service area, they will have Emergency Services coverage only and would have to return to the service area for all other medical care; therefore, you may want to enroll in a PPO.

  • Common Law Marriages
    If you and your spouse are married by common law, the PEBTF will permit you to enroll your common law spouse as a Dependent, provided you complete a Common Law Marriage Affidavit and provide any additional information requested by the PEBTF to demonstrate the validity of your common law marriage. There are no exceptions to this
    rule.

    Your common law marriage must be recognized as such by the state in which it was contracted. Most states do not recognize common law marriage and while some states still recognize common law marriage, there is no such thing as a common law divorce. If you list an individual as your common law spouse and subsequently remove them from coverage, you will not be permitted to subsequently add someone else as your spouse, common law or otherwise, without first producing a valid divorce decree from a court of competent jurisdiction certifying your divorce from your prior common law spouse. The PEBTF will only recognize a Pennsylvania common law marriage entered into prior to September 17, 2003.

    If you entered into a common law marriage prior to September 17, 2003, and would like to cover your common law spouse, you will be required to provide proof of such a common law marriage by presenting documents dated prior to September 17, 2003, such as a deed to a house indicating joint ownership, joint bank accounts, and/or a copy of the cover page (indicating filing status) and signature page (if different) of your federal income tax return indicating marital status as of 2002. Figures reflecting income and deductions may be redacted, i.e. blacked out. Additional documentation may be required by the PEBTF. 

 

No Duplication of Coverage
If you and your spouse both work for the Commonwealth or a PEBTF-participating employer, you may not be enrolled as both an Employee Member and as a Dependent under your spouse’s coverage.

Also, you cannot participate in both the PEBTF’s Plan for Active Employees and the Retired Employees Health Program (REHP) of the Commonwealth of Pennsylvania. Finally, your Dependent child may be enrolled under your or your spouse’s coverage, but not both.

The only exception to this rule is that RPSPP members and REHP members may be covered on a spouse’s Active Member contract for supplemental benefits (vision, dental, hearing aid) only. The RPSPP member’s and REHP member’s coverage under their retiree plan will be primary for prescriptions and/or dental coverage, where applicable.