must be received no later than 60 days after the date on the determination letter. The first premium payment and applicable premium surcharges are due to HCA no later than 45 days after the election period ends. An eligible survivor of an emergency service personnel killed in the line of duty must submit a PEBB Retiree Election Form (form A) along with any other required forms and supporting documents to the PEBB Program. They must be received no later than 180 days after the later of: • The date on the letter from the Department of Retirement Systems or the Board for Volunteer Firefighters and Reserve Officers that informs the survivor that they are determined to be an eligible survivor; • The date of the emergency service worker’s death; or • The last day the survivor was covered under any health plan through the emergency service worker’s employer or COBRA coverage from the emergency service worker’s employer. A retiree or a survivor who deferred enrollment and is enrolling in a PEBB retiree health plan, must enroll using Benefits 24/7, the online enrollment system (once available), or submit a PEBB Retiree Election Form (form A) along with any other required forms, supporting documents, and evidence of continuous enrollment to the PEBB Program. The online enrollment must be completed or the forms must be received no later than 60 days after a loss of other qualifying coverage. The first premium payment and applicable premium surcharges are due to HCA no later than 45 days after the election period ends. See “Enrollment following deferral” for additional enrollment timelines. Note: Enrollment in the PEBB Program’s Medicare Advantage Prescription Drug (MAPD) plan may not be retroactive. If a subscriber elects an MAPD plan and the online enrollment or the required forms are received by the PEBB Program after the date PEBB retiree insurance coverage is to begin, the subscriber and their enrolled dependents will be enrolled in the Uniform Medical Plan Classic during the gap month(s) prior to when the MAPD plan begins. Dependent enrollment To enroll an eligible dependent, the subscriber must include the dependent’s information online using Benefits 24/7 (once available) or on the applicable enrollment form and provide the required document(s) as proof of the dependent’s eligibility. The dependent will not be enrolled in PEBB health plan coverage if the PEBB Program is unable to verify their eligibility within the PEBB Program enrollment timelines. Dependents who are enrolled in medical coverage must be enrolled in the same PEBB medical plan as the retiree or survivor. Exception: If a retiree or a survivor selects a Medicare Supplement Plan or a Medicare Advantage Prescription Drug plan, non-Medicare enrollees will be enrolled in the Uniform Medical Plan Classic. A retiree or a survivor may also enroll an eligible dependent during the PEBB Program’s annual open enrollment or during a special open enrollment. See “Making changes.” Medicare eligibility and enrollment Medicare Part A and Part B If a subscriber or their enrolled dependent becomes eligible for Medicare, they should contact the Social Security Administration to ask about Medicare enrollment. Any enrollee who is eligible for Medicare must enroll and stay enrolled in Medicare Part A and Part B to continue enrollment in a PEBB retiree health plan. In most cases, Medicare will become the primary insurance coverage and the PEBB retiree medical plan will become the secondary insurance coverage. 2024 UMP Plus–UW Medicine ACN (PEBB) Certificate of Coverage 159