• Employee or their dependent loses other coverage under a group health plan or through health insurance coverage, as defined by the HIPAA. • Employee has a change in employment status that affects their eligibility for the employer contribution toward their employer-based group medical. • Employee’s dependent has a change in their own employment status that affects their eligibility or their dependent’s eligibility for the employer contribution under their employer-based group medical. “Employer contribution” means contributions made by the dependent’s current or former employer toward health coverage as described in the Treasury Regulation. • Employee or their dependent has a change in enrollment under an employer-based group medical plan during its annual open enrollment that does not align with the PEBB Program’s annual open enrollment. • Employee’s dependent has a change in residence from outside of the United States to within the United States, or from within the United States to outside of the United States and the change in residence resulted in the dependent losing their health insurance. • A court order requires the employee or any other individual to provide a health plan for an eligible dependent of the employee (a former spouse or former state-registered domestic partner is not an eligible dependent). • Employee or their dependent enrolls in coverage under Medicaid or a state Children’s Health Insurance Program (CHIP), or the employee or their dependent loses eligibility for coverage under Medicaid or CHIP. Note: An employee may only return from having waived PEBB medical for the events described in this paragraph. An employee may not waive their PEBB medical for the events described in this paragraph. • Employee or their dependent becomes eligible for a state premium assistance subsidy for PEBB health plan coverage from Medicaid or CHIP. • Employee or their dependent becomes eligible and enrolls in a TRICARE plan, or loses eligibility for a TRICARE plan. • Employee becomes eligible and enrolls in Medicare or loses eligibility for Medicare. When medical coverage ends Termination dates Medical coverage ends on the following dates: • On the last day of the month when any enrollee ceases to be eligible. • On the date a medical plan terminates due to a change in contracted service area or when the group policy ends. If that should occur, the subscriber will have the opportunity to enroll in another PEBB medical plan. • For an employee and their dependents, on the last day of the month the employment relationship is terminated. The employment relationship is considered terminated: ▪ On the date specified in an employee’s letter of resignation. ▪ On the date specified in any contract or hire letter. ▪ On the effective date of an employer-initiated termination notice. Note: If the employing agency deducted the employee’s premium for PEBB insurance coverage after the employee was no longer eligible for the employer contribution, medical coverage ends the last day of the month for which employee premiums were deducted. 2024 UMP Classic (PEBB) Certificate of Coverage 163