▪ 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 ▪ 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. 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. Any enrollee may appeal a decision regarding the administration of a PEBB medical plan by following the appeal provisions of the plan, except when regarding eligibility, enrollment, and premium payment decisions. Learn more at hca.wa.gov/pebb-appeals. Relationship to law and regulations Any provision of this certificate of coverage that is in conflict with any governing law or regulation of Washington State is hereby amended to comply with the minimum requirements of such law or regulation. Eligibility and enrollment for a retiree or survivor In these sections, the term “retiree” or “retiring employee” includes a retiring employee from a Public Employees Benefits Board (PEBB) employing agency or employer group, and an elected or full-time appointed official of the legislative and executive branch of state government eligible to continue enrollment in PEBB retiree insurance coverage. The term “retiree” or “retiring school employee” includes a retiring school employee from a School Employees Benefits Board (SEBB) organization or employer group. Additionally, “health plan” is used to refer to a plan offering medical or dental, or both, developed by PEBB and provided by a contracted vendor or self-insured plans administered by the Health Care Authority (HCA). Eligibility for subscribers and dependents Retiree eligibility The PEBB Program determines if a retiring employee or retiring school employee is eligible to enroll in PEBB retiree insurance coverage upon receipt of their election to enroll. If the retiring employee or retiring school employee does not have substantive eligibility or does not meet the procedural requirements for enrollment in PEBB retiree insurance coverage, the PEBB Program will notify them of their right to appeal eligibility decisions. Information about appeals can be found under “Appeal rights.” 2024 UMP CDHP (PEBB) Certificate of Coverage 155