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Special Eligibility Situations


If You and Your Spouse are Both Public Employees

Two public employees who are married to each other and who are both eligible for benefits under PEIA may elect to enroll as follows:
  • as Family with Employee Spouse in any plan
  • as “Employee Only” and “Employee and Child(ren)” in two different plans
  • as “Employee Only” and “Employee and Child(ren)” in the PPB Plan
  • as “Employee Only” and “Employee and Child(ren)” in the same managed care plan
All children must be enrolled under the same policyholder. If no children are to be covered, you may enroll as “Family with Employee Spouse” or as separate “Employee Only” plans. Both employees are eligible to enroll for the basic life policy, as well as optional and dependent life insurance.

To qualify for the Family with Employee Spouse premium, both employees MUST have basic life insurance. For active employees, the premium for Family with Employee Spouse coverage is based on the average of the two employees’ salaries. The Family with Employee Spouse discount is also offered when the ‘employee spouse’ is a retired public employee; the premium for this coverage is based on the active employee’s salary.

Generally, since both spouses, as policyholders, are eligible to make independent benefit elections, both spouses receive the Shopper’s Guide, Summary Plan Description, and other relevant benefit information.

If the employee spouse on an active employee’s plan is retired and Medicare-eligible, that employee spouse may want to consider becoming a “policyholder only” in PEIA’s Medicare Advantage plan. Doing so could reduce your total premium and cost-sharing, depending on your situation.

In the event of the death of the employee spouse who is the policyholder in the PEIA Plan, when the surviving dependent is also an active or retired public employee who is benefit-eligible in his or her own right, the surviving dependent has a choice to make. He or she must choose whether to enroll in the PEIA plan as a surviving dependent of the policyholder, or as an active or retired employee.

If you enroll as a surviving dependent before July 1, 2015, premiums will be based on the Medicare or non-Medicare (depending on the survivor’s age) retiree premium with 25 or more years of service, but the surviving dependent is not eligible for life insurance. If you enroll as a surviving dependent on or after July 1, 2015, premiums will be based on the Medicare or non-Medicare (depending on the survivor’s age) retiree premium and the years of service earned by the deceased policyholder, but the surviving dependent is not eligible for life insurance. If enrolled as an active or retired employee, premiums will be based on the appropriate active employee premium chart or if retired, the surviving employee’s own years of service, and he or she will be eligible for life insurance.

If you need help evaluating which would be better, please contact PEIA’s customer service unit at 1-888-680-7342.

Transfer from One Participating Agency to Another

If you transfer from one participating agency to another in the middle of a plan year without a lapse in coverage, that transfer does not constitute a qualifying event to change coverage. You can only change plans if the transfer moves you out of the enrollment area of a plan so that accessing care is unreasonable. Since the PEIA PPB Plans A, B and C have an unlimited enrollment area, you will not be permitted to transfer out of them during the plan year, even if you move. PEIA PPB Plan D is available only to WV residents, so if you move outside the state, you will be required to change plans.

When an employee transfers from one participating State agency to another, PEIA will collect updated salary information, and the premium at the new agency will be based on the salary at the new agency, whether it is a salary increase or a decrease. In this case, a plan change may be permitted, if the transfer creates a qualifying change in family status under the Premium Conversion Plan. Other transfers may permit a change in coverage based on documented financial hardship.

Disabled Child

Your dependent child may continue to be covered after reaching age 26 if he or she is incapable of self-support because of mental or physical disability. To be eligible:
  • the disabling condition must have begun before age 26
  • the child must have been covered by PEIA upon reaching age 26 and
  • the child must be incapable of self-sustaining employment and chiefly dependent on you for support and maintenance. To continue this coverage, the WV PEIA Disabled Dependent Disability Application must be obtained from PEIA, completed by a licensed physician, and returned to PEIA with all supporting medical records, between 2-3 months prior to the dependent’s 26th birthday, to prevent a potential lapse in coverage.

Court-Ordered Dependent (COD)

If a PEIA policyholder and his or her spouse divorce, and the policyholder is not the custodial parent for the dependent child(ren), the employee may continue to provide medical benefits for the child(ren) through the PEIA plan. If the non- custodial parent is ordered by the court to provide medical benefits for the child(ren), the custodial parent may submit medical claims for the court-ordered dependent(s), and benefits may be paid directly to the custodial parent. Special claim forms are required. The custodial parent will also receive Explanations of Benefits (EOBs) for the CODs as claims are processed. Contact PEIA to discuss this benefit.

Medicare and Active Employees

If an active employee or the dependent of an active employee becomes eligible for Medicare and has no other insurance, the PEIA PPB Plan remains the primary insurer, except if the policyholder or dependent attains Medicare eligibility due to End Stage Renal Disease (ESRD). As long as you are an active employee, you and your Medicare- eligible dependents are not required to sign up for Medicare Part B and pay the premium. When you prepare to retire, you and your Medicare- eligible dependents must enroll for Medicare Part B. If you do not enroll in Medicare Parts A & B, your coverage may be terminated.

For PEIA PPB Plan active employees who are also eligible for Medicare, and Medicare is the primary payor (as in the case of ESRD), PEIA will use the traditional method of coordinating benefits, which means that once Medicare has paid, PEIA will pay the balance up to 100% of Medicare’s allowed amount.

When you or your dependent become eligible for Medicare, please send a copy of the Medicare card to PEIA.

Medicare-eligible Members Who Reside Outside the U.S.

Medicare-eligible retirees who reside outside the United States will have benefits through PEIA’s Special Medicare Plan. Medical claims will be processed by HealthSmart, and PEIA will pay only the amount we would have paid if Medicare had processed your claim and made a payment. Prescription drug claims will be processed by CVS Caremark.