Premiums and applicable premium surcharges associated with continuing PEBB medical must be made directly to HCA. The first premium payment and applicable premium surcharges are due to HCA no later than 45 days after the election period ends as described above. For more information, see “Options for Continuing PEBB Medical Coverage” and the PEBB Continuation Coverage Election Notice. Retired employee of a former employer group enrollment A retired employee or a retired school employee of a former employer group may enroll and self-pay premiums using Benefits 24/7, the online enrollment system (once available), or by submitting the PEBB Continuation Coverage (Employer Group Ended Participation) Election/Change form and any supporting documents to the PEBB Program. The online enrollment must be completed or the PEBB Program must receive the required form no later than 60 days after the employer group ended their participation. Premiums and applicable premium surcharges associated with continuing PEBB medical must be made directly to HCA. The first premium payment and applicable premium surcharges are due to HCA no later than 45 days after the election period ends as described above. Enrollment in the Kaiser Permanente NW Senior Advantage 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 health plan coverage is to begin, the subscriber and their enrolled dependents will be enrolled in another Kaiser Permanente NW plan during the gap month(s) prior to when the Kaiser Permanente NW Senior Advantage plan begins. Dependent Enrollment To enroll an eligible Dependent, the Subscriber must include the Dependent’s information online using Benefits 24/7 (once available) on the applicable enrollment form and provide the required document(s) as proof of the Dependent’s eligibility. The Dependent will not be enrolled in PEBB health plan coverage if the PEBB Program or the Employing Agency is unable to verify their eligibility within the PEBB Program enrollment timelines. National Medical Support Notice (NMSN) When a National Medical Support Notice (NMSN) requires a Subscriber to provide health plan coverage for a Dependent child, the following provisions apply: The Subscriber may enroll their Dependent child and request changes to their health plan coverage as described under “Changes to health plan coverage or enrollment are allowed as directed by the NMSN,” below.  An employee must use Benefits 24/7 (once available) or submit the required form(s) to their Employing Agency.  Any other Subscriber must use Benefits 24/7 (once available) or submit the required form(s) to the PEBB Program. If the Subscriber fails to request enrollment or health plan coverage changes as directed by the NMSN, the Employing Agency or the PEBB Program may make enrollment or health plan coverage changes according to “Changes to health plan coverage or enrollment are allowed as directed by the NMSN,” below, upon request of:  The child’s other parent.  A child support enforcement program. Changes to health plan coverage or enrollment are allowed as directed by the NMSN:  The Dependent will be enrolled under the Subscriber’s health plan coverage as directed by the NMSN. EWCLGDED1983ACT0124 17 WAPEBB-CL-ACT