• The last day the survivor was covered under any health plan through the emergency service worker’s employer or COBRA coverage from the emergency service worker’s employer. A retiree or a survivor who deferred enrollment and is enrolling in a PEBB retiree health plan, must submit a PEBB Retiree Election Form (form A) along with any other required forms, supporting documents, and evidence of continuous enrollment to the PEBB Program. They must be received no later than 60 days after a loss of other qualifying coverage. The first premium payment and applicable premium surcharges are due to HCA no later than 45 days after the election period ends. Dependent enrollment If a retiree or a survivor chooses to enroll in a dental plan under PEBB retiree insurance coverage, any dependents enrolled on the retiree or survivor’s account will also be enrolled in dental coverage. If a subscriber chooses to enroll an eligible dependent, the subscriber must include the dependent’s information on the applicable enrollment form and provide the required document(s) as proof of the dependent’s eligibility. The dependent will not be enrolled in PEBB health plan coverage if the PEBB Program or the employing agency is unable to verify their eligibility within the PEBB Program enrollment timelines. Dual enrollment A subscriber and their dependents may each be enrolled in only one PEBB dental plan. An employee or their dependent who is eligible to enroll in both the PEBB Program and the School Employees Benefits Board (SEBB) Program is limited to a single enrollment in either the PEBB or SEBB Program. For example: • A child who is an eligible dependent under two parents enrolled in PEBB Program benefits may be enrolled as a dependent under both parents but is limited to a single enrollment in PEBB dental. • A child who is an eligible dependent of an employee in the PEBB Program and a school employee in the SEBB Program may only be enrolled as a dependent under one parent in either the PEBB or SEBB Program. Medicare eligibility and enrollment Employee and dependent If an employee or their dependent becomes eligible for Medicare, they should contact the Social Security Administration to ask about the advantages of immediate or deferred Medicare enrollment. Continuation coverage subscriber and dependent If a continuation coverage subscriber or their dependent becomes eligible for Medicare, federal regulations allow enrollment in Medicare three months before they turn age 65. If they do not enroll within three months before the month they turn age 65, enrollment in Medicare may be delayed. If enrollment in Medicare does not occur when the subscriber or their dependent is first eligible, a late enrollment penalty may apply. Retiree or survivor and dependent If a retiree, a survivor, or their enrolled dependent becomes eligible for Medicare, they should contact the Social Security Administration to ask about Medicare enrollment. The Medicare eligible subscriber or their dependent must enroll and stay enrolled in Medicare Part A and Part B to keep PEBB retiree health plan coverage. If this procedural requirement is not met, eligibility will end as described in the termination notice sent by the PEBB Program. The only exception to this rule is for an employee or school employee who retired on or before July 1, 1991. When dental coverage begins Employees and dependents For a newly eligible employee and their eligible dependents, dental coverage begins the first day of the month following the date the employee becomes eligible. If the employee becomes eligible on the first working day of the month, then coverage begins on that date. If the eligible employee is a faculty member hired on a quarter-to-quarter or semester-to-semester basis, dental coverage begins the first day of the month following the beginning of the second consecutive quarter or semester. 2024-01-03100-BB 27 DCL 20240101