Group Ended Participation) Election/Change form and any supporting documents to the PEBB Program. The change must be completed online, 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. 5. Special Open Enrollment changes. A subscriber may change their enrollment outside of the annual open enrollment if a qualifying event creates a special open enrollment period. However, the change in enrollment must be allowable under Internal Revenue Code (IRC) and Treasury Regulations and correspond to and be consistent with the event that creates the special open enrollment for the subscriber, their dependent, or both. A special open enrollment may allow a subscriber to make the following changes: Enroll in or change their medical plan • Waive their medical plan enrollment • Enroll after waiving medical plan enrollment • Enroll or remove eligible dependents • To request a special open enrollment: • An employee must make the change online using Benefits 24/7 (once available) or submit the required PEBB Employee Enrollment/Change form and any supporting documents to their employing agency. • A continuation coverage subscriber must make the change online using Benefits 24/7 (once available) or submit the required PEBB Continuation Coverage (COBRA) Election/Change, or PEBB 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. PEBB HMOHSA 2024 55