An employee of an employer group (such as a county, city, port, water district, etc.) that contracts with HCA for PEBB benefits should contact their payroll or benefits office for eligibility criteria. Employees have the right to appeal eligibility and enrollment decisions. Information about appeals can be found under “Appeal rights.” Continuation coverage eligibility The PEBB Program determines whether subscribers are eligible for continuation coverage (COBRA or Unpaid Leave) upon receipt of a PEBB Continuation Coverage (COBRA) Election/Change or PEBB Continuation Coverage (Unpaid Leave) Election/Change form. If the subscriber requests to enroll in and is not eligible for continuation coverage, the PEBB Program will notify them of their right to appeal. Information about appeals can be found under “Appeal rights.” Retiree and survivor eligibility Retiree: The PEBB Program determines if a retiring employee or retiring school employee is eligible to enroll in PEBB retiree insurance coverage upon receipt of a completed PEBB Retiree Election Form (form A). If the retiring employee or retiring school employee does not have substantive eligibility or does not meet the procedural requirements for enrollment in PEBB retiree insurance coverage, the PEBB Program will notify them of their right to appeal eligibility decisions. Information about appeals can be found under “Appeal rights.” Survivor: The PEBB Program determines whether a dependent is eligible to enroll or continue enrollment in PEBB retiree insurance coverage as a survivor upon receipt of a completed PEBB Retiree Election Form (form A). If the survivor does not meet the eligibility and procedural requirements for enrollment in PEBB retiree insurance coverage, the PEBB Program will notify them of their right to appeal. Information about appeals can be found under “Appeal rights.” Dependent eligibility The following are eligible dependents: • Legal spouse • State-registered domestic partner and substantially equivalent legal unions from jurisdictions as defined in Washington State statute. Individuals in a state-registered domestic partnership are treated the same as a legal spouse except when in conflict with federal law. • Children, through the last day of the month in which their 26th birthday occurred regardless of marital status, student status, or eligibility for coverage under another plan. It also includes children age 26 or older with a disability as described below in “Children of any age with a developmental or physical disability.” Children are defined as the subscriber’s: o Children based on establishment of a parent-child relationship, as described in Washington State statutes, except when parental rights have been terminated. o Children of the subscriber’s spouse, based on the spouse’s establishment of a parent-child relationship, except when parental rights have been terminated. The stepchild’s relationship to the subscriber (and eligibility as a dependent) ends on the same date the marriage with the spouse ends through divorce, annulment, dissolution, termination, or death. o Children for whom the subscriber has assumed a legal obligation for total or partial support in anticipation of adoption of the child. o Children of the subscriber’s state-registered domestic partner, based on the state-registered domestic partner’s establishment of a parent-child relationship, except when parental rights have been terminated. The child’s relationship to the subscriber (and eligibility as a dependent) ends on the same date the subscriber’s legal relationship with the state-registered domestic partner ends through divorce, annulment, dissolution, termination, or death. o Children specified in a court order or divorce decree for whom the subscriber has a legal obligation to provide support or health care coverage. o Extended dependents in the legal custody or legal guardianship of the subscriber, the subscriber’s spouse, or the subscriber’s state-registered domestic partner. The legal responsibility is demonstrated by a valid court order and the child’s official residence with the 2024-01-03000-BB 19 LG PPOL 20240101