General provisions for eligibility and enrollment Payment of premiums during a labor dispute Any employee or dependent whose monthly premiums are paid in full or in part by the employing agency may pay premiums directly to HCA if the employee’s compensation is suspended or terminated directly or indirectly because of a strike, lockout, or any other labor dispute, for a period not to exceed six months. When the employee’s compensation is suspended or terminated, HCA will notify the employee immediately (by mail at the last address of record) that the employee may pay premiums as they become due. If coverage is no longer available to the employee under this certificate of coverage, then the employee may be eligible to purchase an individual dental plan from this plan consistent with premium rates filed with the Washington State Office of the Insurance Commissioner. Termination for just cause The purpose of this provision is to allow for a fair and consistent method to process the plan-designated provider’s request to terminate an enrollee’s coverage from this plan for just cause. A retiree or eligible dependent may have coverage terminated by HCA for the following reasons: • Failure to comply with the PEBB Program’s procedural requirements, including failure to provide information or documentation requested by the due date in written requests from the PEBB Program • Knowingly providing false information • Failure to pay the monthly premium and applicable premium surcharges when due • Misconduct. Examples of such termination include, but are not limited to the following: o Fraud, intentional misrepresentation or withholding of information the subscriber knew or should have known was material or necessary to accurately determine eligibility or the correct premium o Abusive or threatening conduct repeatedly directed to an HCA employee, a health plan, or other HCA-contracted vendor providing PEBB insurance coverage on behalf of HCA, its employees, or other persons If a retiree’s PEBB insurance coverage is terminated by HCA for the above reasons, PEBB insurance coverage for all of the retiree’s eligible dependents is also terminated. The PEBB Program will enroll an employee and their eligible dependents in another PEBB dental plan upon termination from this plan. Appeal rights Any current or former employee of a state agency or their dependent may appeal a decision made by the state agency regarding PEBB eligibility, enrollment, or premium surcharges to the state agency. Any current or former employee of an employer group, such as a county, city, port, water district, etc., that contracts with HCA for PEBB benefits, or their dependent may appeal a decision made by an employer group regarding PEBB eligibility, enrollment, or premium surcharges to the employer group. Any enrollee may appeal a decision made by the PEBB Program regarding PEBB eligibility, enrollment, premium payments, or premium surcharges to the PEBB Appeals Unit. Any enrollee may appeal a decision regarding the administration of a PEBB dental plan by following the appeal provisions of the plan, except when regarding eligibility, enrollment, and premium payment decisions. Learn more at hca.wa.gov/pebb-appeals. Relationship to law and regulations Any provision of this certificate of coverage that is in conflict with any governing law or regulation of Washington State is hereby amended to comply with the minimum requirements of such law or regulation. Release of Information 2024-01-03000-BB 29 LG PPOL 20240101