Continuation Coverage (Unpaid Leave) Election/Change form (as appropriate) and any supporting documents to the PEBB Program. • A retired employee of a former employer group must make the change online using Benefits 24/7 (once available) or submit the required PEBB Continuation Coverage (Employer Group Ended Participation) Election/Change form and any supporting documents to the PEBB Program. The change must be completed online, or the forms must be received, no later than 60 days after the event that creates the special open enrollment. In addition, the PEBB Program or the employing agency will require the subscriber to provide proof of a dependent’s eligibility, evidence of the event that created the special open enrollment, or both. Exceptions: • If a subscriber wants to enroll a newborn or child whom the subscriber has adopted or has assumed a legal obligation for total or partial support in anticipation of adoption in PEBB health plan coverage, the subscriber should complete the request online or notify their employing agency or the PEBB Program by submitting the required forms as soon as possible to ensure timely payment of claims. If adding the child increases the premium, the request must be received online, or the required forms must be received, no later than 60 days after the date of the birth, adoption, or the date the legal obligation is assumed for total or partial support in anticipation of adoption. A continuation coverage subscriber or a retired employee of a former employer group: • 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 using Benefits 24/7 (once available) 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 they or their dependent is enrolled in a Medicare Advantage (MA) or Medicare Advantage Prescription Drug (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. • 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. They 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 in Benefits 24/7 (once available), or the forms must be received by the PEBB Program, no later than the last day of the month prior to the month they or their dependent enrolls in the MA or MAPD plan. Special open enrollment events that allow for a change in health plans A subscriber may not change their health plan during a special open enrollment if their state-registered domestic partner or state-registered domestic partner’s child is not a tax dependent. Any of the following events may create a special open enrollment: • Subscriber gains a new dependent due to: ▪ Marriage or registering a state-registered domestic partnership. ▪ Birth, adoption, or assuming a legal obligation for total or partial support in anticipation of adoption. ▪ A child becoming eligible as an extended dependent through legal custody or legal guardianship. • Subscriber or their dependent loses other coverage under a group health plan or through health insurance coverage, as defined by the Health Insurance Portability and Accountability Act (HIPAA). 148 2024 UMP Plus–PSHVN (PEBB) Certificate of Coverage