• Subscriber or their dependent enrolls in coverage under Medicaid or a state Children’s Health Insurance Program (CHIP) or the subscriber or their dependent loses eligibility for coverage under Medicaid or CHIP. • Subscriber or their dependent becomes eligible for a state premium assistance subsidy for PEBB health plan coverage from Medicaid or CHIP. • Subscriber’s dependent enrolls in Medicare or loses eligibility for Medicare. F. When medical coverage ends 1. Termination dates Medical coverage ends on the following dates: • On the last day of the month when any enrollee ceases to be eligible. • On the date a medical plan terminates due to a change in contracted service area or when the group policy ends. If that should occur, the subscriber will have the opportunity to enroll in another PEBB medical plan. • On the last day of the month in which the monthly premium and applicable premium surcharges were paid. When a subscriber is enrolled in a Medicare Advantage (MA) or a Medicare Advantage Prescription Drug (MAPD) plan, medical coverage ends at the end of the month after a termination notice is sent. • The first of the month following the date the election is received online using Benefits 24/7 (once available) or the required forms are received by the PEBB Program when an enrolled retiree or survivor requests to defer enrollment in PEBB retiree insurance coverage. If the forms are received on the first day of the month, enrollment will be deferred effective that day. When a retiree, a survivor, or their dependent is enrolled in a Medicare Advantage plan, medical plan enrollment will be deferred the first of the month following the date the Medicare Advantage Plan Disenrollment Form (form D) is received. • The last day of the month in which the request is received online using Benefits 24/7 (once available) or the PEBB Program receives a written request and all required forms requesting to voluntarily terminate enrollment in a medical plan. If a future date is specified, medical coverage terminates the last day of the month specified. If the termination request is received on the first day of the month, medical plan enrollment will be terminated on the last day of the previous month. When a retiree, a survivor, or their dependent is enrolled in an MA or MAPD plan, medical plan enrollment will be terminated on the last day of the month when the PEBB Medicare Advantage Plan Disenrollment Form (form D) is received. A subscriber will be responsible for payment of any services received after the date medical coverage ends, as described above. 2. Final premium payments The subscriber is responsible for timely payment of premiums and applicable premium surcharges. Premium payments and applicable premium surcharges are not prorated during any month, for any reason, even if an enrollee dies or asks to terminate their medical plan before the end of the month. If the monthly premium or applicable premium surcharges remain unpaid for 30 days, it will be considered delinquent. A subscriber is allowed a grace period of 30 days from the date the monthly premium or applicable premium surcharges become delinquent to pay the unpaid premium balance or applicable premium surcharges. If the subscriber’s premium balance or applicable premium surcharges remain unpaid for 60 days from the original due date, coverage will be terminated retroactive to the last day of the month for which the monthly premium and any applicable premium surcharges were paid. PEBB_CRCOB_2024 57