Election/Change, or PEBB Continuation Coverage (Unpaid Leave) Election/Change form (as appropriate) and any supporting documents to the PEBB Program. The change must be completed in PEBB My Account or the forms received no later than the last day of the annual open enrollment period and will be effective January 1 of the following year. Special open enrollment changes A subscriber may change their enrollment outside of the annual open enrollment period if a qualifying event creates a special open enrollment period. However, the change in enrollment must be allowable under Internal Revenue Code (IRC) and Treasury Regulations and correspond to and be consistent with the event that creates the special open enrollment for the subscriber, their dependent, or both. A special open enrollment event must be other than an employee gaining initial eligibility or regaining eligibility for PEBB benefits. The subscriber must provide evidence of the event that created the special open enrollment. A special open enrollment may allow a subscriber to make the following changes: • Enroll in or change their dental plan • Enroll or remove eligible dependents To request a special open enrollment: • An employee must submit the required PEBB Employee Enrollment/Change form and any supporting documents to their employing agency. • A retiree, a survivor, or continuation coverage subscriber must submit the required PEBB Retiree Change Form (form E), PEBB Continuation Coverage (COBRA) Election/Change, or PEBB Continuation Coverage (Unpaid Leave) Election/Change form (as appropriate) and any supporting documents to the PEBB Program. The forms must be received no later than 60 days after the event that creates the special open enrollment. In addition, the PEBB Program or the employing agency will require the subscriber to provide proof of a dependent’s eligibility, evidence of the event that created the special open enrollment, or both. Note: If a subscriber wants to enroll a newborn or child whom the subscriber has adopted or has assumed a legal obligation for total or partial support in anticipation of adoption in PEBB health plan coverage, the subscriber should notify their employing agency or the PEBB Program by submitting the required forms as soon as possible to ensure timely payment of claims. If adding the child increases the premium, the required forms must be received no later than 60 days after the date of the birth, adoption, or the date the legal obligation is assumed for total or partial support in anticipation of adoption. Special open enrollment events that allow for a change in health plans A subscriber may not change their health plan if their state-registered domestic partner or state-registered domestic partner’s child is not a tax 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 assuming 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. “Employer contribution” means contributions made by the dependent’s current or former employer toward health coverage as described in the Treasury Regulation. 2024-01-03000-BB 25 LG PPOL 20240101