4. Enrollment following deferral A retiree or a survivor who defers enrollment in PEBB retiree insurance coverage: • While enrolled in employer-based group medical or such coverage under COBRA coverage or continuation coverage may enroll in a PEBB medical plan during the PEBB Program’s annual open enrollment period, or no later than 60 days after the date their enrollment in employer-based group medical coverage or such coverage under COBRA coverage or continuation coverage ends. • While enrolled in a federal retiree medical plan as a retiree or dependent will have a one-time opportunity to enroll in a PEBB medical plan during the PEBB Program’s annual open enrollment period, or no later than 60 days after their enrollment in a federal retiree medical plan ends. • While enrolled in Medicare Parts A and B and a Medicaid program that provides creditable coverage may enroll in a PEBB medical plan during the PEBB Program’s annual open enrollment period, or no later than 60 days after their Medicaid coverage ends, or no later than the end of the calendar year when their Medicaid coverage ends if they were also enrolled in a subsidized Medicare Part D plan. • While enrolled in qualified health plan coverage through a health benefit exchange developed under the Affordable Care Act will have a one-time opportunity to enroll or reenroll in a PEBB medical plan during the PEBB Program’s annual open enrollment period, or no later than 60 days after exchange coverage ends. • While enrolled in CHAMPVA will have a one-time opportunity to enroll in a PEBB medical plan during the PEBB Program’s annual open enrollment period, or no later than 60 days after their enrollment in a CHAMPVA medical plan ends. • While enrolled as a dependent in a medical plan sponsored by PEBB or SEBB, including coverage under COBRA or continuation coverage, may enroll in a PEBB medical plan during the PEBB Program’s annual open enrollment period, or no later than 60 days after the enrollment in a medical plan sponsored by PEBB or SEBB ends, or such coverage under COBRA or continuation coverage ends. The evidence of continuous enrollment required to enroll as described below may include a health plan sponsored by a Washington State educational service district if enrollment was deferred prior to January 1, 2024. Note: Enrollment in the Kaiser Permanente WA Medicare Advantage (MA) plan may not be retroactive. If a subscriber is eligible for and elects this plan and the online enrollment or the required forms are received by the PEBB Program after the date PEBB retiree insurance coverage is to begin, the subscriber and their enrolled dependents will be enrolled in another Kaiser Permanente WA plan during the gap month(s) prior to when the Kaiser Permanente WA MA plan begins. For a retiree or a survivor to enroll in a PEBB medical plan, the enrollment must be completed online using Benefits 24/7 (once available) or the PEBB Program must receive a PEBB Retiree Election Form (form A), any other required forms, supporting documents, and evidence of continuous enrollment in one or more qualifying coverages during the timelines described in this section. A gap in coverage of 31 days or less is allowed between the date PEBB retiree insurance coverage is deferred and the start date of a qualifying coverage, and between each period of enrollment in qualifying coverages during the deferral period. A retiree or a survivor who deferred their enrollment in PEBB retiree insurance coverage while enrolled in qualifying coverage as described above may also enroll in a PEBB medical plan if they receive formal notice that HCA has determined it is more cost-effective to enroll in a PEBB medical plan than a medical assistance program. A retiree or a survivor should contact the PEBB Program or visit hca.wa.gov/pebb-retirees to get the required forms, information on premiums, and a list of available medical plans. PEBB_CRCOB_2024 53