Below is a brief overview of eligibility for employees, spouses and children. You can find a full description of eligibility rules in the Plan of Benefits.
Eligible employees are those who:
- Work for the state, a higher education institution, a public school district or another entity allowed by law to participate, like a county government or municipality, in an insurance-eligible position; and
- Receive compensation from the state, a higher education institution, a public school district or other entity allowed by law to participate.
Eligible employees also include clerical and administrative employees of the S.C. General Assembly; judges in the state courts; and General Assembly members. Permanent part-time teachers, working between 15 and 30 hours a week, qualify for state health, vision and dental insurance. However, teachers working between 15 and 30 hours each week are not eligible for other PEBA benefits, such as life and disability insurance.
Elected members of participating county and city councils whose members are eligible to participate in one of the retirement systems PEBA administers are considered full-time employees. Generally, members of other governing boards are not eligible for coverage. If you work for more than one participating group, contact your benefits administrator for more information.
Types of employees
Employees fall into these categories:
- New full-time employees who are expected by their employer to work at least 30 hours a week. They are eligible for coverage within 31 days of their hire date.
- New variable-hour, part-time or seasonal employees whom their employer does not expect to average 30 hours a week during the first 12 months they are employed. Because their employer cannot determine their eligibility, they may not enroll in benefits immediately. Their employer must measure their hours to determine whether these employees work an average of 30 hours a week during the 12 months beginning the first of the month after the employee is hired. If the employee works an average of 30 hours a week during this period, the employee is eligible for coverage during the 12-month period that follows.
- Ongoing employees who have completed their initial measurement period (October 4 of one year to October 3 of the following year). If an ongoing employee worked an average of 30 hours a week during this 12-month period, the employee is eligible for coverage during the calendar year that follows, even if the employee’s hours decrease during that next calendar year. If an ongoing employee worked an average of less than 30 hours a week during this period, he is not eligible for coverage during the next calendar year, unless the employee gains coverage through some other provision of the Plan.
An eligible spouse is one recognized by South Carolina law. A spouse eligible for coverage as an employee of any participating group, including an optional employer, cannot be covered as a spouse under any plan. A spouse who is a permanent, part-time teacher may be covered either as an employee or as a spouse, but not as both. In addition, a spouse who is eligible for retiree coverage and receives full funding of the employer premium from the South Carolina Retiree Health Insurance Trust Fund cannot be covered as a spouse under any plan. A spouse who is eligible for retiree coverage but receives no funding or only partial funding of employer premiums from the Retiree Health Insurance Trust Fund may be covered as either a retiree or as a spouse, but not as both.
An eligible child must be:
- Younger than age 26; and
- The subscriber’s natural child, adopted child (including child placed for legal adoption), stepchild, foster child1, a child of whom the subscriber has legal custody or a child the subscriber is required to cover due to a court order.2
If both parents are eligible for coverage, only one parent can cover the children under any one plan. For example, if one parent covers the children under health and dental, the other parent cannot cover the children under either health or dental. One parent can cover the children under health, and the other can cover the children under dental.
For more information about a child’s eligibility for benefits, review the Insurance Benefits Guide. Topics include a child age 19 to age 25, an incapacitated child and coverage under Dependent Life-Child insurance.
Special eligibility situations
A special eligibility situation is an event that allows you, as an eligible employee, to enroll in or drop coverage for yourself or eligible family members outside of an open enrollment period.3
You can make changes using MyBenefits if you have a special eligibility situation, such as adding a newborn, marriage, divorce or adoption. MyBenefits will display the documentation required for each change. The required documents can be uploaded through MyBenefits.
To make a change through your benefits administrator, you will need to:
- Contact your benefits administrator;
- Complete a Notice of Election form within 31 days4 of the event; and
- Upload documentation to MyBenefits or give documentation to your benefits administrator.
If you are an active employee and are eligible to change your health, dental, State Vision Plan or Optional Life insurance coverage due to a special eligibility situation, you also may enroll in or drop the Pretax Group Insurance Premium feature.
More details about special eligibility situations are available in the Insurance Benefits Guide.
1 A foster child is a child placed with the subscriber by an authorized placement agency. The subscriber must be a licensed foster parent.
2 A child for whom the subscriber has legal custody is a child for whom the subscriber has guardianship responsibility, not just financial responsibility, according to a court order or other document filed with the courts.
3 A salary increase or decrease, or transfer does not create a special eligibility situation.
4 Changes related to Medicaid or the Children’s Health Insurance Program (CHIP) must be made within 60 days.