5. Making changes during annual open enrollment and special open enrollment A subscriber may make certain changes to their enrollment during the annual open enrollment and if a specific life event creates a special open enrollment period. 6. Annual open enrollment changes A subscriber may make the following changes to their enrollment during the PEBB Program’s annual open enrollment period: • Enroll in a medical plan following a deferral • Defer or terminate their enrollment in a medical plan • Enroll or remove eligible dependents • Change their medical plan A subscriber must submit the election change online using PEBB My Account or Benefits 24/7 (once available) or submit the required PEBB Retiree Election Form (form A-OE) along with any other required forms, and any supporting documents to the PEBB Program. The change must be completed online or the forms must be received no later than the last day of the annual open enrollment period and will be effective January 1 of the following year. 7. Special open enrollment changes A subscriber may change their enrollment outside of the annual open enrollment period if a qualifying event creates a special open enrollment period. However, the change in enrollment must be allowable under Internal Revenue Code (IRC) and Treasury Regulations and correspond to and be consistent with the event that creates the special open enrollment for the subscriber, their dependent, or both. The subscriber must provide evidence of the event that created the special open enrollment. To disenroll from a Medicare Advantage (MA) plan or Medicare Advantage-Prescription Drug (MAPD) plan, the change in enrollment must be allowable under federal regulations. To make an enrollment change, the subscriber must submit the change online using Benefits 24/7 (once available) or submit the required PEBB Retiree Change Form (form E) along with any other required forms to the PEBB Program. The change must be completed online or the PEBB Program must receive the forms no later than 60 days after the event that creates the special open enrollment. In addition, the PEBB Program will require the subscriber to provide proof of the dependent’s eligibility, evidence of the event that created the special open enrollment, or both. Exceptions: • A subscriber enrolled in PEBB retiree insurance coverage has six months from the date of their or their dependent’s enrollment in Medicare Part B to change their enrollment to a PEBB Medicare Supplement Plan. The change must be made online or the PEBB Program must receive the required form(s) no later than six months after the enrollment in Medicare Part B for either the subscriber or their dependent. • When a subscriber or their dependent is enrolled in an MA or MAPD plan, they may disenroll during a special enrollment period as allowed under federal regulations. The new medical plan coverage will begin the first day of the month following the date the PEBB Medicare Advantage Plan Disenrollment Form (form D) is received. • A subscriber enrolled in PEBB retiree insurance coverage has seven months to enroll in an MA or MAPD plan that begins three months before they or their dependent first enrolled in both Medicare Part A and Part B and ends three months after the month of Medicare eligibility. A subscriber may also enroll themselves or their dependent in an MA or MAPD plan before their last day of the Medicare Part B initial enrollment period. The change must be made online or the forms must be received by the PEBB Program no later than the last day of the month prior to the month the subscriber or their dependent enrolls in the MA or MAPD plan. PEBB_CRCOB_2024 54