For a retiree, a survivor, or their eligible dependents enrolling during a special open enrollment, medical coverage begins the first of the month following the later of the event date or the date the online enrollment election using Benefits 24/7 (once available) or the required form is received. If that day is the first of the month, medical coverage begins on that day, except for a Medicare Advantage or Medicare Advantage Prescription Drug plan, which will begin the first day of the month following the date the enrollment election is received online or the required from is received by the PEBB Program. If the special open enrollment is due to the birth or adoption of a child, or when the subscriber has assumed a legal obligation for total or partial support in anticipation of adoption of a child, medical coverage will begin as follows: • For a newly born child, medical coverage will begin the date of birth; • For a newly adopted child, medical coverage will begin on the date of placement or the date a legal obligation is assumed in anticipation of adoption, whichever is earlier; or • For a spouse or state registered domestic partner of a subscriber, medical coverage will begin the first day of the month in which the event occurs. If the special open enrollment is due to the enrollment of an extended dependent or a dependent child with a disability, medical coverage will begin the first day of the month following the later of the event date or eligibility certification, whichever is later. Making changes Removing a dependent who is no longer eligible A subscriber must provide notice to remove a dependent who is no longer eligible due to divorce, annulment, dissolution, or a qualifying event of a dependent ceasing to be eligible as a dependent child, as described under “Dependent eligibility.” The notice must be received online using Benefits 24/7 (once available) or by written request to the PEBB Program within 60 days of the last day of the month the dependent no longer meets the eligibility criteria. Consequences for not submitting notice within the required 60 days may include, but are not limited to: • The dependent may lose eligibility to continue PEBB medical coverage under one of the continuation coverage options described in “Options for continuing PEBB medical coverage.” • The subscriber may be billed for claims paid by the medical plan for services that were rendered after the dependent lost eligibility. • The subscriber may not be able to recover subscriber-paid insurance premiums for the dependent that lost eligibility. • The subscriber may be responsible for premiums paid by the state for the dependent’s medical plan coverage after the dependent lost eligibility. Voluntary termination An enrolled retiree or survivor may voluntarily terminate enrollment in a medical plan at any time by submitting a request online using Benefits 24/7 (once available) or in writing to the PEBB Program. Enrollment in the medical plan will be terminated the last day of the month in which the request is received online or by the PEBB Program, or on the last day of the month specified in the termination request, whichever is later. If the 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 a Medicare Advantage or Medicare Advantage Prescription Drug 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. 2024 UMP Plus–UW Medicine ACN (PEBB) Certificate of Coverage 161