• For a continuation coverage subscriber or a retired employee of a former employer group who submits a request to terminate medical coverage, enrollment in medical coverage will be terminated the last day of the month in which the request was received online using Benefits 24/7 (once available) or by the PEBB Program, or on the last day of the month specified in the termination request, whichever is later. If the request is received on the first day of the month, medical coverage will be terminated on the last day of the previous month. Exception: When a subscriber or their dependent is enrolled in a Medicare Advantage or Medicare Advantage Prescription Drug plan, the medical plan enrollment will terminate on the last day of the month when the PEBB Medicare Advantage Plan Disenrollment form (form D) is received. A subscriber will be responsible for payment of any services received after the date medical coverage ends as described above. Final premium payments Premium payments and applicable premium surcharges are not prorated during any month, for any reason, even if an enrollee dies or asks to terminate their medical plan before the end of the month. If the monthly premium or applicable premium surcharges remain unpaid for 30 days, the account will be considered delinquent. A subscriber is allowed a grace period of 30 days from the date the monthly premiums or applicable premium surcharges become delinquent to pay the unpaid premium balance and applicable premium surcharges. If the subscriber’s premium balance or applicable premium surcharges remain unpaid for 60 days from the original due date, the subscriber’s medical coverage (including enrolled dependents) will be terminated retroactive to the last day of the month for which the monthly premiums and any applicable premium surcharges were paid. For a subscriber enrolled in a Medicare Advantage or a Medicare Advantage-Prescription Drug plan, a notice will be sent notifying them that they are delinquent on their monthly premium and that the enrollment will be terminated prospectively to the end of the month after the notice is sent. If an enrollee is hospitalized An enrollee who is receiving covered services in a hospital on the date medical coverage ends will continue to be eligible for covered services while an inpatient for the condition which the enrollee was hospitalized, until one of the following events occur: • According to this plan’s clinical criteria, it is no longer medically necessary for the enrollee to be an inpatient at the facility. • The remaining benefits available for the hospitalization are exhausted, regardless of whether a new calendar year begins. • The enrollee becomes covered under another agreement with a group health plan that provides benefits for the hospitalization. • The enrollee becomes enrolled under an agreement with another carrier that provides benefits for the hospitalization. This provision will not apply if the enrollee is covered under another agreement that provides benefits for the hospitalization at the time medical coverage ends, except as set forth in this section, or if the enrollee is eligible for PEBB Continuation Coverage as described in “Options for continuing PEBB medical coverage.” Options for continuing PEBB medical coverage When medical coverage ends, the subscriber and their dependents covered by this medical plan may be eligible to continue PEBB medical coverage during temporary or permanent loss of eligibility. 152 2024 UMP Plus–UW Medicine ACN (PEBB) Certificate of Coverage