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 within 60 days of the last day of the month the dependent no longer meets the eligibility criteria. • An employee must notify their employing agency. • A retiree, a survivor, or continuation coverage subscriber must notify the PEBB Program. 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 dental coverage under one of the continuation coverage options described in “Options for continuing PEBB dental coverage.” • The subscriber may be billed for claims paid by the dental 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 dental plan coverage after the dependent lost eligibility. Voluntary termination for a retiree, a survivor, or a continuation coverage subscriber A retiree, a survivor, or a continuation coverage subscriber may voluntarily terminate enrollment in a dental plan at any time by submitting a request in writing to the PEBB Program. Enrollment in the dental plan will be terminated the last day of the month in which the PEBB Program receives the request 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, dental plan enrollment will be terminated on the last day of the previous month. A retiree or a survivor who voluntarily terminates their enrollment in a dental plan also terminates dental enrollment for all eligible dependents. 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. Annual open enrollment changes An employee may make the following changes to their enrollment during the PEBB Program’s annual open enrollment period: • Enroll or remove eligible dependents • Change their dental plan An employee must submit the election change online in PEBB My Account or return the required PEBB Employee Enrollment/Change form and any supporting documents to their employing agency. The change must be completed in PEBB My Account or the forms received no later than the last day of the annual open enrollment period and will be effective January 1 of the following year. A retiree, a survivor, or continuation coverage subscriber may make the following changes to their enrollment during the PEBB Program’s annual open enrollment period: • Enroll in or terminate enrollment in a dental plan • Enroll or remove eligible dependents • Change their dental plan A retiree, a survivor or continuation coverage subscriber must submit the election change online in PEBB My Account or return the required PEBB Retiree Change Form (form A-OE), PEBB Continuation Coverage (COBRA) 2024-01-03000-BB 24 LG PPOL 20240101