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

Receive email alerts as soon as relevant payer policies are published or updated.

This policy governs how the School Employees Benefits Board (SEBB) Program verifies, enrolls, continues, and recertifies coverage for a subscriber’s dependent child who is age 26 or older and has a disability.

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 ActionComplete the SEBB Certification of a Child with a Disability form and submit it with supporting documentation to the appropriate medical plan or SEBB Program.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

Age 26+Dependent child age addressed by the policy

60 daysCommon enrollment or continuation submission deadline

31 daysDeadline for a new school employee to enroll a dependent child

AnnuallyMaximum verification frequency after the two-year period following the child’s 26th birthday

OpenPayer is powered by Trek Health's payer performance platform. Trek continuously ingests, validates, and normalizes Transparency in Coverage data alongside payer policies and other commercial payer data to create a structured payer intelligence foundation. OpenPayer uses this foundation to deliver personalized search results, dynamically generated policy pages, and tailored policy monitoring based on each user's payers, specialties, billing codes, and areas of interest. The same intelligence powers broader payer performance workflows, including reimbursement benchmarking, contract evaluation, payer negotiations, and financial decision-making.

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

Receive email alerts as soon as relevant payer policies are published or updated.

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 ActionComplete the SEBB Certification of a Child with a Disability form and submit it with supporting documentation to the appropriate medical plan or SEBB Program.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

Age 26+Dependent child age addressed by the policy

60 daysCommon enrollment or continuation submission deadline

31 daysDeadline for a new school employee to enroll a dependent child

AnnuallyMaximum verification frequency after the two-year period following the child’s 26th birthday

30 daysTime allowed to correct an incomplete certification submission after notice

Eligibility, Enrollment, and Effective Dates

Base eligibility and procedural requirements

A dependent child age 26 or older may qualify for SEBB enrollment when all eligibility and procedural requirements are met.

ALL of the following

The dependent 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 evidence supporting the dependent's eligibility.
The enrollment or certification form is submitted within the applicable timeframe.

Enrollment and recertification deadlines

The required submission route and deadline depend on the enrollment event and the type of coverage requested. For medical enrollment, submit the certification materials to the subscriber's medical plan; for dental-only, vision-only, or combined dental and vision enrollment, submit them to the SEBB Program.

ANY of the following

For a new school employee, submit no later than 31 days after becoming eligible.
For medical enrollment, submit to the subscriber's medical plan; for dental-only, vision-only, or combined dental and vision enrollment, submit to the SEBB Program.
For a newly enrolling elected or appointed school board member, submit no later than 60 days from the beginning of the term, following loss of other group coverage, or by the last day of annual open enrollment, as applicable.
Submit to the subscriber's medical plan for medical enrollment or to the SEBB Program for dental-only, vision-only, or combined dental and vision enrollment.
For a current subscriber continuing coverage when the dependent turns age 26, submit no later than 60 days after the birthday.
Submit to the subscriber's medical plan for medical enrollment or to the SEBB Program for dental-only, vision-only, or combined dental and vision enrollment.

Coverage effective dates

When the subscriber satisfies the eligibility and procedural requirements, the coverage effective date depends on the enrollment pathway.

ANY of the following

When the subscriber first becomes eligible and enrolls in SEBB benefits, coverage begins on the subscriber's effective date.
For annual open enrollment, coverage begins January 1 of the following year.
For a special open enrollment event, coverage begins the first day of the month following the later of the event date or eligibility certification.
For a National Medical Support Notice, coverage begins the first day of the month following receipt, or on the receipt date if received on the first day of the month.
When continuing coverage after the dependent turns age 26, enrollment continues the first day of the month following the month of the birthday.

Eligibility Attributes and Verification Parameters

Disability onset

RequirementThe dependent must have a developmental or physical disability that was present before age 26.

Disability typeThe qualifying condition may be developmental or physical.

Age thresholdThe condition must have occurred before the dependent's 26th birthday.

Employment capacity

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

Employment standardThe dependent must be unable to maintain self-sustaining employment because of the disability.

Eligibility effect

Certification, Submission, and Review Responsibilities

Documentation Required

Complete the Disability Certification Documentation

The subscriber and the dependent child’s medical provider must complete the applicable sections of the SEBB Certification of a Child with a Disability form. The medical provider’s sections must be completed no more than six months before the form’s due date; the SEBB Program may receive clinical-review input from the subscriber’s medical plan.

For a newly enrolled dependent age 26 or older, the subscriber must submit the completed form and documentation supporting the request to add the dependent.
Supporting documentation must establish that the dependent has a developmental or physical disability that began before age 26, is incapable of self-sustaining employment, and is chiefly dependent on the subscriber for support and maintenance.

Note

Submit to the Appropriate Organization

Submit the completed certification and any required supporting documentation to the organization responsible for the dependent’s coverage, within the applicable Table 36-1 deadline.

For medical enrollment, send the form to the subscriber’s medical plan.

Key Policy Terms

Health plan

DefinitionA health plan is a plan offering medical, vision, dental, or any combination of these coverages.

Plan developmentThe plan is developed by the School Employees Benefits Board.

Plan administrationThe plan is provided by a contracted vendor or consists of self-insured plans administered by the HCA.

Eligibility certification

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

Information includedThe required information includes input from the medical plans.

Determination date

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 ActionComplete the SEBB Certification of a Child with a Disability form and submit it with supporting documentation to the appropriate medical plan or SEBB Program.

SourceLink

On This Page

For annual open enrollment, submit by the last day of the annual open enrollment period.

Submit to the subscriber's medical plan for medical enrollment or to the SEBB Program for dental-only, vision-only, or combined dental and vision enrollment.

For a special open enrollment event, submit no later than 60 days after the event.

Submit to the subscriber's medical plan for medical enrollment or to the SEBB Program for dental-only, vision-only, or combined dental and vision enrollment.

For recertification, submit by the last day of the month in which the current certification ends.

Submit to the subscriber's medical plan for medical enrollment or to the SEBB Program for dental-only, vision-only, or combined dental and vision enrollment.

Inability to achieve self-sustaining employment is part of the eligibility determination for a dependent child age 26 or older.

Dependency

RequirementThe dependent must be chiefly dependent on the subscriber for support and maintenance.

Primary supportThe subscriber must provide the dependent's chief source of support and maintenance.

Eligibility effectChief dependency on the subscriber is part of the eligibility determination for continued or new enrollment.

Provider form completion

Required formThe dependent child's medical provider must complete the provider sections of the SEBB Certification of a Child with a Disability form.

Timing limitThe medical provider sections must be completed no more than six months before the form is due.

Other completion responsibilityThe subscriber completes the subscriber portions of the form.

Verification frequency

Verification frequencyThe SEBB Program may verify eligibility periodically, but no more frequently than annually after the two-year period following the child's 26th birthday.

Two-year periodThe annual frequency limit applies after the two-year period following the child's 26th birthday.

Renewed proofVerification requires renewed proof of disability and dependence from the subscriber.

For dental or vision enrollment only, or both, send the form to the SEBB Program.

For a dependent already enrolled who is turning age 26, ensure the completed form is received by the applicable deadline.

For a newly enrolled dependent age 26 or older, submit the completed form and supporting documentation by the applicable deadline.

Note

Recertify After Account or Plan Changes

Recertification is required when the dependent moves between subscriber accounts or when a plan change affects administration of the coverage. The dependent must be recertified by the SEBB Program to continue enrollment in the circumstances below.

Recertify when the dependent moves from one subscriber account to another.
Recertify when the subscriber changes health plans and the new plan is administered by a different contracted vendor.
If the subscriber waives medical coverage and the dependent remains enrolled in dental or vision coverage, recertification is still required.
Recertification is not required for a dependent currently certified and enrolled through PEBB when moving to SEBB until the current PEBB certification expires.
An exception applies when the dependent was recertified within the prior 12 months, after the two-year period following the dependent’s 26th birthday.

Prior Authorization

Verify Eligibility and Meet Submission Deadlines

The SEBB Program reviews the enrollment request and certification evidence to verify that the dependent meets eligibility and procedural requirements. The subscriber must provide the required evidence and submit the enrollment form within the applicable Table 36-1 timeframe.

Eligibility requires a developmental or physical disability that was present before age 26 and renders the dependent incapable of self-sustaining employment.
The dependent must be chiefly dependent on the subscriber for support and maintenance.
New school employees must submit no later than 31 days after becoming eligible.
Newly enrolling elected or appointed school board members must submit no later than 60 days from the beginning of the term or following loss of other group coverage, or by the last day of the annual open enrollment period, as applicable.
A new continuation-coverage subscriber must submit no later than 60 days from the date SEBB coverage ended or the postmark date on the SEBB election notice, whichever is later.
A current subscriber requesting continued enrollment when the dependent turns age 26 must submit no later than 60 days after the dependent turns 26.
Requests during annual open enrollment are due by the last day of the annual open enrollment period; requests during a special open enrollment are due no later than 60 days after the event creating the special open enrollment.
Recertification submissions are due by the last day of the month in which the SEBB certification is scheduled to end.

Unsupported block type: denial_risk

It also includes the date the determination notice is provided to the SEBB Program to certify.