• Subscriber or their dependent has a change in residence that affects health plan availability. If the subscriber moves and their current health plan is not available in the new location, the subscriber must select a new health plan, otherwise there will be limited accessibility to network providers and covered services. A dental plan is considered available if a provider is located within 50 miles of the subscriber’s new residence. • A court order requires the subscriber or any other individual to provide insurance coverage for an eligible dependent of the subscriber (a former spouse or former state-registered domestic partner is not an eligible dependent). • Subscriber or their dependent enrolls in coverage under Medicaid or a state Children’s Health Insurance Program (CHIP) or the subscriber or their dependent loses eligibility for coverage under Medicaid or CHIP. • Subscriber or their dependent becomes eligible for state premium assistance subsidy for PEBB health plan coverage from Medicaid or CHIP. • Subscriber or their dependent enrolls in coverage under Medicare, or the subscriber or their dependent loses eligibility for coverage under Medicare or enrolls in or terminates enrollment in a Medicare Advantage-Prescription Drug or a Part D plan. If the subscriber’s current medical plan becomes unavailable due to the subscriber or their dependent’s enrollment in Medicare, the subscriber must select a new medical plan. • Subscriber or their dependent’s current medical plan becomes unavailable because the subscriber or enrolled dependent is no longer eligible for a health savings account (HSA). • Subscriber or their dependent experiences a disruption of care for active and ongoing treatment that could function as a reduction in benefits for the subscriber or their dependent. The subscriber may not change their health plan election because the subscriber or dependent’s physician stops participation with the subscriber’s health plan unless the PEBB Program determines that a continuity of care issue exists. The PEBB Program will consider but not limit its consideration to the following: o Active cancer treatment, such as chemotherapy or radiation therapy o Treatment following a recent organ transplant o A scheduled surgery o Recent major surgery still within the postoperative period o Treatment for a high-risk pregnancy Note: The plan cannot guarantee that any physician, hospital, or other provider will be available or remain under contract with the plan. An enrollee may not change dental plans simply because their provider or health care facility discontinues participation with this dental plan until the PEBB Program’s next annual open enrollment or when another qualifying event creates a special open enrollment for changing health plans, unless the PEBB Program determines that a continuity of care issue exists. Special open enrollment events that allow adding or removing a dependent Any of the following events may create a special open enrollment: • Subscriber gains a new dependent due to: o Marriage or registering a state-registered domestic partnership. o Birth, adoption, or when the subscriber has assumed a legal obligation for total or partial support in anticipation of adoption. o A child becoming eligible as an extended dependent through legal custody or legal guardianship. • Subscriber or their dependent loses other coverage under a group health plan or through health insurance coverage, as defined by the Health Insurance Portability and Accountability Act (HIPAA). • Subscriber has a change in employment status that affects their eligibility for the employer contribution toward their employer-based group health plan. • Subscriber’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 health plan. 2024-01-03000-BB 26 LG PPOL 20240101