retiree, a survivor, or their dependent is enrolled in an MA or MAPD plan, medical plan enrollment will be terminated 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 The subscriber is responsible for timely payment of premiums and applicable premium surcharges. 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, it will be considered delinquent. A subscriber is allowed a grace period of 30 days from the date the monthly premium or applicable premium surcharges become delinquent to pay the unpaid premium balance or applicable premium surcharges. If the subscriber’s premium balance or applicable premium surcharges remain unpaid for 60 days from the original due date, coverage will be terminated retroactive to the last day of the month for which the monthly premium and any applicable premium surcharges were paid. For a subscriber enrolled in a Medicare Advantage or Medicare Advantage Prescription Drug plan, a notice will be sent to them notifying them that they are delinquent on their monthly premiums 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 A subscriber and their dependents covered by this medical plan may be eligible to continue enrollment under PEBB Continuation Coverage (COBRA) if they lose eligibility. PEBB Continuation Coverage (COBRA) temporarily extends group insurance coverage if certain circumstances occur that would otherwise end the subscriber or their dependent’s PEBB medical coverage. PEBB Continuation Coverage (COBRA) includes eligibility and administrative requirements under federal COBRA laws and regulations and also includes coverage for some enrollees who are not qualified beneficiaries under federal COBRA continuation coverage. Refer to the PEBB Continuation Coverage Election Notice for details. 170 2024 UMP Select (PEBB) Certificate of Coverage