If required documentation is not provided within 60 days of the date of hire or life event change, the dependent(s) will be removed from coverage retroactive to the date of their enrollment. COBRA benefits will not be offered as the dependent was not deemed eligible for coverage. If claims were incurred for an ineligible dependent, restitution will be required.
For dependents added during open enrollment that were not previously covered under the PEBTF Health Program, the required documentation must be provided by the end of the open enrollment period for the dependent’s coverage to be effective.
- Marriage Certificate (this is not the certificate provided from the official conducting the ceremony)
- Out of country marriage certificates can be accepted
- If the spouse is not yet a US citizen and does not have a Social Security Number, documentation should be provided with the PEBTF-2 form supporting why the SSN is not being submitted
Possible Resources
- County courthouse that issued original marriage certificate. A list of Pennsylvania County Courthouses can be found here.
HR Office must submit the completed Employee Enrollment/Change Form (PEBTF-2). Please ensure the box in Section 7 – Dependent Data has been initialed verifying the required documents were viewed
(only for those whom HR has collected information attesting that the marriage was in effect prior to September 17, 2003)
- Employee must present to the HR office with two of the documents as outlined below, dated prior to September 17, 2003. HR should make a copy and forward to the PEBTF with the other necessary documentation:
- Original deed to the employee’s home, if owned jointly
- Original automobile title, if owned jointly
- Original statement of a current bank account that is held in joint name
- Original copy of the employee’s will, identifying the spouse
- A copy of the coverage page (indicating filing status) and signature page (if a different page) of the employee’s 2002 Federal Income Tax Return, which indicates marital status
The HR Office should not retain any copies of these documents.
HR Office must submit the completed Employee Enrollment/Change Form (PEBTF-2) and Affidavit Attesting to the Existence of Common Law Marriage (PEBTF-5) along with the support documentation listed above. Please ensure the box in Section 7 – Dependent Data has been initialed verifying the required documents were reviewed.
- Original State issued Birth certificate
Possible Resources
- For Pennsylvania births, birth certificates are available from the PA Department of Health, Division of Vital Records and can be requested by fax, mail, or online at https://www.health.pa.gov . Fee is $10.
- Many states allow you to order a new birth certificate from their website. Access to other state websites can be linked through http://www.cdc.gov/nchs/w2w.htm
HR Office must submit the completed Employee Enrollment/Change Form (PEBTF-2). Please ensure the box in Section 7 – Dependent Data has been initialed verifying the required documents were reviewed.
- Court approved adoption order OR
- Placement letter from court/adoption agency for pending adoptions
Possible Resources
- County courthouse that issued final adoption order
- County court/adoption agency that issued placement letter
HR Office must submit the completed Employee Enrollment/Change Form (PEBTF-2) along with a copy of the adoption papers or new birth certificate. Please ensure the box in Section 7 – Dependent Data has been initialed verifying the required documents were reviewed.
- Court or agency order establishing guardianship or custodial relationship. If the employee provides a temporary court order, the PEBTF will request a new court order when the expiration date is reached.
Possible Resources
- County courthouse/agency that issued guardianship/custodial order
HR Office must submit the completed Employee Enrollment/Change Form (PEBTF-2). Please ensure the box in Section 7 – Dependent Data has been initialed verifying the required documents were viewed
- Birth certificate indicating the spouse is the parent of the child AND
- Marriage certificate
Possible Resources
- For Pennsylvania births, birth certificates are available from the PA Department of Health, Division of Vital Records and can be requested by fax, mail, or online at https://www.health.pa.gov. Fee is $10.
- Many states allow you to order a new birth certificate from their website. Access to other state websites can be linked through http://www.cdc.gov/nchs/w2w.htm
- County courthouse that issued original marriage certificate. A list of Pennsylvania County Courthouses can be found at here.
HR Office must submit the completed Employee Enrollment/Change Form (PEBTF-2). Please ensure the box in Section 7 – Dependent Data has been initialed verifying the required documents were viewed
To be qualified, a Medical Child Support Order must clearly:
- Specify the name and last known mailing address of the Member and the name
and mailing address of each alternate recipient covered by the order - Include a reasonable description of the type of coverage to be provided or the
manner in which the coverage is to be determined - Specify each period of time (beginning and end dates) to which the order applies
- Specify each plan to which the order applies
An Employee Enrollment/Change Form (PEBTF-2) is not necessary when the PEBTF receives the QMCSO or NMSN directly from the courts. The PEBTF will notify the Central Benefits System HR Office to have the dependent enrolled in coverage.
If the HR Office receives the QMCSO directly from the courts, the HR Office should complete it and send it to the PEBTF.
- Disabled Dependent Certification Form (PEBTF-6)
Possible Resources
- Disabled Dependent Certification Form is available on-line at www.pebtf.org
The employee must complete and submit an Employee Enrollment/Change Form (PEBTF-2) and the Disabled Dependent Certification Form (PEBTF-6) to the HR Office who in turn must submit these forms to the PEBTF.
(age 18 or older) who lives with the employee and is solely supported by the employee, if employee was the foster parent prior to the dependent’s 18th birthday.
- Documentation from Social Services that placed dependent in the home prior to 18th birthday
HR Office must submit the completed Employee Enrollment/Change Form (PEBTF-2) along with a copy of the court documents to validate the expiration date PEBTF will need to use when the child is no longer covered by the Social Services agencies. Please ensure the box in Section 7 – Dependent Data has been initialed verifying the required documents were viewed.
Foster children cannot be enrolled under the age of 18 as they must utilize benefits offered through Social Services agencies