PEIA Divorce Eligibility Audit
All state employee PEIA or Health Plan policyholders should be advised
that the West Virginia Public Employees Insurance Agency (PEIA) is conducting an
ongoing dependent eligibility audit.
It is important to note that if an employee policyholder has not been divorced there is nothing the employee needs to do.
In September of 2015 the Social Security Administration released their marriage and
divorce records to PEIA. PEIA is comparing those records to their
records, court records, and information from the Bureau for Vital Statistics.
PEIA UPDATE (October 2016)
PEIA has notified all state agencies that they cannot and will not tolerate acts of fraud being committed against the State of WV. There is no amnesty and there will be zero tolerance shown to violators. If these audits find that an employee policyholder is divorced but has not removed their ex-spouse (or step-children) from the policy, PEIA will explore every legal remedy to recover cost[s] incurred by the fraudulent acts.
Please NOTE: Even if a policyholder self-reports, they may still be responsible for reimbursing PEIA for any and/or all medical or prescription claims paid on behalf of the ineligible dependent, and/or West Virginia University for the difference in premium(s) that the employer paid.
Click to read the details in PEIA’s March 2016 Letter to state employees:
PEIA UPDATE (August 2018)
- Divorces and/or other events which impact the eligibility of the member and/or dependents must be reported immediately.
- Members cannot “ Agree” to keep their ex-spouse on their insurance(s) as part of a divorce. Members do not have the authority to bind the State and/or their participating public agency to the terms and/or conditions of a divorce.
- The divorce ends the eligibility of the spouse and/or step-children. A re-marriage does not automatically re-establish eligibility and/or negate the period(s) of ineligibility between the divorce and the re-marriage. Eligibility must be re-applied for via a Change In Status form submitted with a copy of the marriage certificate.
- Family Courts cannot bind a participating agency and/or PEIA to provide coverage(s) for ex-spouses and/or step-children.
- Member cannot keep step-children on their coverage(s) after a divorce – the divorce nullifies the eligibility of step-children.
- Adding dependents requires “ LEGAL” documentation to be submitted along with the Change In Status form(s), e.g. birth certificate, marriage certificate, Court Ordered Guardianship, legal adoption paperwork (not private adoption ‘contracts’), visas, etc. A notary seal/signature does not make a document a “LEGAL” document, it only means that an official witnessed the signature(s).
- In the case of foreign adoptions, marriages, and/or births, with documents, all documents must be independently translated into English with a certification and/or attestation of the translation.
- PEIA is not responsible for the translation of documents and we must comply with any and/or all applicable State and/or federal laws, e.g. the Hague Convention rule(s); The Illegal Immigration Reform and Immigrant Responsibility Act of 1996, Division C of Pub.L. 104–208, 110 Stat. 3009-546; etc.
- If a Surviving Spouse re-marries, they are no longer eligible for PEIA Survivor benefits. If the Surviving spouse divorces after a re-marriage, they cannot return to PEIA coverage(s) as a Surviving Dependent.
- Per West Virginia Code §5-16-12 and §5-16-12a, members can be held fully liable for any and/or all medical and/or pharmaceutical claims paid on behalf of an ineligible dependent. PEIA can and will seek recovery. Publicly funded agencies would also have a fiduciary responsibility to collect premium(s) paid for ineligible ex-spouses and/or dependents.
- Knowingly and/or willingly submitting false information to PEIA by an Employee and/or an Employer about eligibility status, tobacco use, or other information, “…requested by the Director…” may constitute fraud and be subject to prosecution. THESE ARE NOT “ NO HARM-NO FOUL” MATTERS!-!-! Both the agency and the member are responsible for the accuracy and truthfulness of information provided.
- PEIA will be conducting on-going audits to verify information that affects eligibility and/or premium(s).
Any questions, comments, and/or concerns may be directed to Thomas Miller, Privacy Officer for the WV Department of Administration and PEIA at 304-558-7850 ext. 52663 or email firstname.lastname@example.org.
How To Report Ineligible Dependents
Policyholders may report their divorce or ineligible dependents directly to WVU Benefits Administration. See Life/Qualifying Events for instructions on how to report.