CurrentWashington State Health Care AuthorityPolicy 36-1

Certifying eligibility for a dependent child with a disability who is age 26 or older

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This policy governs how the Washington State PEBB Program determines, verifies, enrolls, and recertifies a dependent child age 26 or older who has a developmental or physical disability. It applies to subscribers requesting initial or continued PEBB health plan coverage for such a dependent.

Policy Summary

PayerWashington State Health Care Authority

PolicyCertifying eligibility for a dependent child with a disability who is age 26 or older

Policy CodePolicy 36-1

Change TypeNo material change

Effective DateJanuary 1, 2027

Next Review DateNot specified

Key ActionSubmit the completed certification and supporting documentation within the applicable deadline for the enrollment event.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

Age 26+Dependent age threshold

Before age 26Disability onset

6 monthsProvider certification recency

31 daysNew employee enrollment deadline

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CurrentWashington State Health Care AuthorityPolicy 36-1

Certifying eligibility for a dependent child with a disability who is age 26 or older

Customize your policy alerts

Sign up for Washington State Health Care Authority Policy 36-1 alerts

Get alerted when Policy 36-1 changes without checking for updates manually.

Monitor payer policy activity

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Policy Summary

PayerWashington State Health Care Authority

PolicyCertifying eligibility for a dependent child with a disability who is age 26 or older

Policy CodePolicy 36-1

Change TypeNo material change

Effective DateJanuary 1, 2027

Next Review DateNot specified

Key ActionSubmit the completed certification and supporting documentation within the applicable deadline for the enrollment event.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

Age 26+Dependent age threshold

Before age 26Disability onset

6 monthsProvider certification recency

31 daysNew employee enrollment deadline

Eligibility, Enrollment, and Effective Dates

Eligibility and certification criteria

Covered when all substantive eligibility and certification requirements are met.

ALL of the following

The dependent is age 26 or older and has a developmental or physical disability that was present before age 26.
The disability renders the dependent incapable of self-sustaining employment.
The dependent is chiefly dependent on the subscriber for support and maintenance.
The subscriber provides the required PEBB Certification of a Child with a Disability form and supporting documentation within the applicable enrollment timeframe.
The PEBB Program or applicable medical plan receives complete information needed to determine eligibility and verifies the dependent's eligibility.

Enrollment and recertification timing

Certification or recertification is required according to the enrollment event and coverage circumstances.

Applicable enrollment or recertification circumstance

For initial enrollment as a new employee, submit the certification no later than 31 days after the employee becomes eligible.
For continuation, retiree, survivor, special enrollment, or employer-group termination enrollment, submit the certification within the applicable 60-day deadline.
For recertification, submit the certification by the last day of the month in which the child's current PEBB certification is scheduled to end.
A dependent moving from one subscriber account to another must be recertified by the PEBB Program to continue enrollment.
A dependent changing to a health plan administered by a different contracted vendor must be recertified by the PEBB Program, unless the dependent was recertified within the preceding 12 months after the two-year period following the child's 26th birthday.

Coverage effective dates

When eligibility and procedural requirements are met, the coverage effective date depends on the enrollment pathway.

Applicable enrollment pathway

When the subscriber becomes eligible and enrolls in PEBB benefits, coverage begins on the same effective date as the subscriber's PEBB benefits.
For enrollment during the PEBB Program's annual open enrollment, coverage begins January 1 of the following year.
For enrollment due to a special open enrollment event, coverage begins the first day of the month following the later of the event date or eligibility certification.
For enrollment required by a National Medical Support Notice, coverage begins the first day of the month following receipt by the employing agency or the PEBB Program; if received on the first day of the month, coverage begins that day.

Certification and Verification Parameters

Minimum disability onset requirement

Disability onsetThe developmental or physical disability must be present before age 26.

Employment capacityThe disability must render the dependent incapable of self-sustaining employment.

Age for coverageThe eligibility standard applies to a dependent child age 26 or older.

Provider certification recency

Required formThe subscriber and the dependent child’s medical provider must complete the PEBB Certification of a Child with a Disability form.

Provider sectionsThe dependent child’s medical provider must complete the provider sections.

Required Certification and Enrollment Actions

Documentation Required

Obtain Disability Certification

Obtain the PEBB Certification of a Child with a Disability form when enrolling or continuing coverage for a dependent child age 26 or older with a disability. The subscriber must complete the subscriber sections, and the dependent child’s medical provider must complete the medical sections no more than six months before the form is due.

Use the form to document the dependent child’s disability and dependence.
The PEBB Program may receive clinical-review input from the subscriber’s or dependent child’s medical plan.

Note

Route Certification Materials

Route the completed certification form and supporting documentation according to the enrollment type and plan vendor. Materials must be received within the applicable Table 36-1 deadline.

For dental or vision-only enrollment, or enrollment in a UnitedHealthcare plan, send the materials to the PEBB Program.
For all other medical enrollment, send the materials to the subscriber’s or dependent child’s medical plan.

Key Policy Terms

Health plan

Medical coverageA health plan may offer medical coverage.

Dental or vision coverageA health plan may offer dental coverage, vision coverage, or both.

Combined coverageA health plan may offer any combination of medical, dental, and vision coverage and is provided by a contracted vendor or a self-insured plan administered by HCA.

Eligibility certification

DefinitionEligibility certification is the date the PEBB Program receives all required information to make a determination.

Medical-plan inputRequired information includes input from the medical plans.

Denial Risk

Meet Table 36-1 Deadlines

Submit the completed certification form and required documentation by the deadline that applies to the enrollment event in Table 36-1. Missing the applicable time limit may prevent enrollment or continued coverage.

New employee: no later than 31 days after becoming eligible.
New continuation-coverage subscriber: no later than 60 days after the employee’s PEBB coverage ends or the postmark date on the PEBB election notice, whichever applies.
New retiree: no later than 60 days after the employee’s employer-paid, COBRA, or continuation coverage ends.
New survivor of an eligible employee or school employee: no later than 60 days after the later of the employee’s death or the applicable eligibility date; new survivor of an eligible retiree: no later than 60 days after the retiree’s death.
Current subscriber continuing coverage when the dependent turns age 26: no later than 60 days after the dependent’s birthday.
Annual open enrollment: by the last day of the annual open enrollment period.
Special open enrollment: no later than 60 days after the event creating the special open enrollment.
Recertification: by the last day of the month in which the child’s PEBB certification is scheduled to end.
Retired or school employee enrolling after the employer group ends: no later than 60 days after the employer group terminates.
A dependent currently certified and enrolled through SEBB does not require a new PEBB form or recertification until the current SEBB certification expires.

Documentation Required

Recertify When Circumstances Require

Recertify the dependent child when the applicable account, vendor, or coverage circumstances require it. The PEBB Program periodically verifies eligibility and may require renewed proof of disability and dependence, but verification occurs no more frequently than annually after the two-year period following the child’s 26th birthday.

Recertification is required when the dependent moves from one subscriber account to another.
Recertification is required when the subscriber changes health plans and the new plan is administered by a different contracted vendor.
Recertification is required when the subscriber waives medical coverage and the child remains enrolled in dental or vision coverage.
An exception applies when the child was recertified within the preceding 12 months after the two-year period following the child’s 26th birthday.
For an existing PEBB certification, submit the form by the last day of the month in which the certification is scheduled to end.
A subscriber moving from SEBB coverage to PEBB coverage does not need to recertify until the current SEBB certification expires.

Billing Rule

Apply Effective-Date Rules

Apply the effective-date rule that matches the enrollment pathway after the subscriber satisfies the eligibility and procedural requirements. For special open enrollment, eligibility certification means the date the PEBB Program receives all required information, including medical-plan input, and the determination notice is provided to the PEBB Program to certify.

Initial enrollment with the subscriber’s PEBB eligibility: the dependent’s coverage begins on the same effective date as the subscriber’s coverage.
Annual open enrollment: coverage begins January 1 of the following year.
Special open enrollment: coverage begins the first day of the month following the later of the event date or eligibility certification.
National Medical Support Notice (NMSN): coverage begins the first day of the month following receipt of the NMSN by the employing agency or PEBB Program; if received on the first day of the month, coverage begins that day.
Continued enrollment when the dependent turns age 26: coverage continues beginning the first day of the month following the month of the child’s 26th birthday.