Special Eligibility

Special Eligibility Situations Quick Reference

The quick reference describes changes subscribers can make when a special eligibility situation occurs. Unless otherwise noted, all changes must be made within 30 days of the event. 

Marriage

If you, as a covered subscriber, wish to add a spouse because you marry, you can do so by completing an NOE and submitting a copy of your marriage license within 30 days of the date of your marriage. You may enroll yourself and your spouse and eligible children/stepchildren to your health, dental, vision and life insurance by submitting a completed Notice of Election form and proper documentation of dependent eligibility to your benefits office. You may also enroll in or increase your Optional Life by up to $50,000 and enroll in or change contributions to Medical or Dependent Care Spending accounts.

A subscriber can enroll his spouse, without medical evidence, in $10,000 or $20,000 in Dependent Life-Spouse coverage with 30 days of the marriage. Subscribers can also enroll eligible dependent children in Dependent Life-Child coverage within 30 days of the marriage.

Legal Separation

If you and your covered spouse separate, your spouse may remain on your health, Dental/Dental Plus, State Vision Plan and Dependent Life-Spouse coverage until the divorce is final.

If you do not participate in the MoneyPlus pretax premium feature, you can remove your spouse from your coverage when you separate. If you remove your spouse from one of these programs: health, dental or vision coverage, you must also remove him from the other two programs.

Divorce

If you divorce, you must remove your spouse and former stepchildren from your coverage by completing an NOE and submitting a complete copy of the divorce decree within 30 days of the date stamped on the divorce decree. Coverage for your divorced spouse and former stepchildren will end the last day of the month after the divorce decree is stamped. If you fail to drop your divorced spouse or former stepchildren within 30 days of the date the court order or divorce decree is stamped by the court, the change in coverage is effective the first of the month after your signature on the NOE dropping your former dependents.

Adding Children

Eligible children may be added by completing an NOE within 30 days of the qualifying event.

• Date of birth (effective on date of birth).
• Marriage of the subscriber to the child’s parent (effective on the date the marriage).
• Adoption or placement for adoption (effective on the date of adoption or placement for adoption).
• Placement of a foster child(effective on the date of placement)
• Loss of other coverage (effective on the date of loss of coverage).
• Notice of HIPAA Special Enrollment Rights. The Health Insurance Portability and Accountability Act (“HIPAA”) requires PEBA Insurance Benefits to notify you of a very important provision in its health insurance plan. You have the right to enroll in PEBA Insurance Benefits’ health insurance plans under its “special enrollment provision” if you acquire a new dependent or if you decline coverage under PEBA Insurance Benefits’ health insurance plans for yourself or an eligible dependent while other coverage is in effect and later lose that other coverage for certain qualifying reasons. 

The newly eligible child must be offered health, Dental/Dental Plus and State Vision Plan Coverage. The subscriber and all other previously enrolled family members may change health plans. A child, who is eligible, but not newly eligible, cannot be added at this time. However, a spouse may be added.

PEBA requires all employees adding dependents to provide documentation that verifies the dependent is eligible for coverage. The most common documentation required for enrollment is a marriage license for a spouse or a birth certificate for a child(ren). For complete information contact the Benefits Department at [email protected] or PEBA at 1-888-260-9430.

APPEALS: If you are dissatisfied after an eligibility determination has been made, you may ask PEBA Insurance Benefits to review the decision.

• If you are an employee, a Request for Review should be submitted through your benefits office. Your BA may write a letter or use the Request for Review form, which is available online at the PEBA Insurance Benefits website.
• If the request for review is denied, you may appeal by writing to the PEBA Insurance Benefits Appeals Committee within 90 days of notice of the decision. If the PEBA Insurance Benefits Appeals Committee denies your appeal, you have 30 days to seek judicial review as provided by Sections 1-11-710 and 1-23-380 of the S.C. Code of Laws, as amended.