PEBB Retiree Insurance Coverage The following are eligible to continue enrollment or defer enrollment in PEBB retiree insurance coverage if they meet procedural and substantive eligibility requirements:  Retiring employee  Retiring school employee  Eligible elected or full-time appointed official of the legislative or executive branch of state government leaving public office  Dependent becoming eligible as a survivor  Retiree or survivor enrolled in PEBB retiree insurance coverage For details, see the PEBB Retiree Enrollment Guide. Family and Medical Leave Act of 1993 An employee on approved leave under the federal Family and Medical Leave Act (FMLA) may continue to receive the employer contribution toward PEBB benefits in accordance with the federal FMLA. The Employing Agency determines if the employee is eligible for leave and the duration of the leave under FMLA. The employee must continue to pay their monthly premium contribution and applicable premium surcharges during this period to maintain eligibility. If an employee exhausts the period of leave approved under FMLA, they may continue PEBB insurance coverage by self-paying the monthly premium and applicable premium surcharges set by HCA, with no contribution from the Employing Agency. See “Options for Continuing PEBB Medical Coverage.” Paid Family and Medical Leave Act An employee on approved leave under the Washington State Paid Family and Medical Leave (PFML) Program may continue to receive the employer contribution toward PEBB benefits. The Employment Security Department determines if the employee is eligible for leave under PFML. The employee must continue to pay their monthly premium contribution and applicable premium surcharges during this period to maintain eligibility. If an employee exhausts the period of leave approved under PFML, they may continue PEBB insurance coverage by self-paying the monthly premium and applicable premium surcharges set by HCA, with no contribution from the Employing Agency. See “Options for continuing PEBB Medical Coverage.” Conversion of Coverage An Enrollee (including a Spouse or Dependent of a Subscriber terminated for cause) has the right to switch from PEBB group medical to an individual conversion plan offered by this Plan when they are no longer eligible to continue the PEBB group medical plan and are not eligible for Medicare or covered under another group insurance coverage that provides benefits for hospital or medical care. An Enrollee must apply for conversion coverage and pay the first month’s premium no later than 31 days after their group medical plan ends or within 31 days from the date the notice of termination of coverage is received, whichever is later. Evidence of insurability (proof of good health) is not required to obtain the conversion coverage. Rates, coverage, and eligibility requirements of this conversion plan differ from those of the Enrollee’s current group medical plan. To receive detailed information on conversion options under this medical plan, call us at 1-800-200-1004. EWCLGDED1983ACT0124 28 WAPEBB-CL-ACT