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 (206) 630-0107 in the Seattle area, or toll-free in Washington, 1-866-648-1928. G. General provisions for eligibility and enrollment 1. Payment of premiums during a labor dispute Any employee or dependent whose monthly premiums are paid in full or in part by the employing agency may pay premiums directly to HCA if the employee’s compensation is suspended or terminated directly or indirectly because of a strike, lockout, or any other labor dispute, for a period not to exceed six months. When the employee’s compensation is suspended or terminated, HCA will notify the employee immediately, by mail at the last address of record, that the employee may pay premiums as they become due. If coverage is no longer available to the employee under this certificate of coverage, then the employee may be eligible to purchase an individual medical plan from this plan consistent with premium rates filed with the Washington State Office of the Insurance Commissioner. 2. Termination for just cause The purpose of this provision is to allow for a fair and consistent method to process the plan-designated provider’s request to terminate coverage from this plan for just cause. An eligible dependent may have coverage terminated by HCA for the following reasons: • Failure to comply with the PEBB Program’s procedural requirements, including failure to provide information or documentation requested by the due date in written requests from the PEBB Program • Knowingly providing false information • Failure to pay the monthly premium and applicable premium surcharges when due • Misconduct. Examples of such termination include, but are not limited to the following: o Fraud, intentional misrepresentation or withholding of information the subscriber knew or should have known was material or necessary to accurately determine eligibility or the correct premium o Abusive or threatening conduct repeatedly directed to an HCA employee, a health plan, or other HCA-contracted vendor providing PEBB insurance coverage on behalf of HCA, its employees, or other persons The PEBB Program will enroll an employee and their eligible dependents in another PEBB medical plan upon termination from this plan. H. Appeal rights Any current or former employee of a state agency or their dependent may appeal a decision made by the state agency regarding PEBB eligibility, enrollment, or premium surcharges to the state agency. Any current or former employee of an employer group, such as a county, city, port, water district, etc., that contracts with HCA for PEBB benefits, or their dependent may appeal a decision made by an employer group regarding PEBB eligibility, enrollment, or premium surcharges to the employer group. Any enrollee may appeal a decision made by the PEBB Program regarding PEBB eligibility, enrollment, premium payments, or premium surcharges to the PEBB Appeals Unit. PEBB_CA_2024 61