OAR 101-015-0045: Eligibility Verifications and Reviews

(1) PEBB shall plan and conduct eligibility verifications and reviews to monitor compliance with PEBB administrative rules. Reviews shall include, but are not limited to the following: (a) Dependent eligibility; (b) Employee eligibility; (c) Election change limitations; and (d) Plan enrollment limitations. (2) Employee eligibility, election change and plan enrollment reviews may occur on a random basis throughout the year, or if anomalies in data warrant a formal review. The Eligible Employee is responsible to submit documentation upon request. (3) Dependent eligibility reviews shall be completed as needed. The Eligible Employee, Retiree, Self-Pay or COBRA participant is responsible to submit documentation upon request. In the event the required documentation is not provided to sufficiently prove the dependent meets eligibility requirements, or the documentation provided is insufficient, the dependent’s coverage will be terminated prospectively. Retroactive terminations may occur if the documentation provided shows the dependent was not eligible for coverage and the member misrepresented the dependent as being an eligible dependent as defined by OAR 101-010-0005. (4) If an Eligible Employee does not complete the dependent eligibility review and moves to a different Agency under PEBB, their terminated dependent records may be locked in the PEBB benefit management system. The Eligible Employee must submit documentation to PEBB to be verified before the dependent records are unlocked. (5) An Eligible Employee adding a new or previous dependent to enrollments after failing to verify dependent eligibility will be required to provide DEV documentation along with the enrollment form to PEBB. Enrollments will not take effect until the verification of eligibility. The effective date of coverage is the first of the month following receipt of the form and all appropriate verification documents by PEBB.