What is special open enrollment?

What changes can I make? 

Based on the event, the following changes may be allowed as a special open enrollment. See the special open enrollment matrix for details.

My special open enrollment event is ...

Marriage or registering a domestic partnership

As defined by Washington Administrative Code 182-12-109.

Action	Allowed?
Add dependents	Yes
Change health plan	Yes (A health plan change is not allowed when adding a SRDP or their child if they are not a tax dependent.)

Documents to submit 

• Marriage certificate
• Certificate of state-registered domestic partnership or legal union

Birth or adoption

Birth, adoption, or assuming a legal obligation for support in anticipation of adoption.

Action	Allowed?
Add dependents	Yes
Change health plan	Yes

Documents to submit

• Birth certificate (or hospital certificate with child's footprints)
• Certificate or decree of adoption
• Placement letter from adoption agency

All valid documents for proof of this event must show the name of the parent who is the subscriber, subscriber's spouse, or the subscriber's state-registered domestic partner.

Newly eligible extended dependent

Child becomes eligible as an extended dependent through legal custody or legal guardianship. 

Action	Allowed?
Add dependents	Yes
Change health plan	Yes

Documents to submit 

• Valid court order showing legal custody, guardianship, or temporary guardianship, signed by a judge or officer of the court and a signed PEBB Extended Dependent Certification.

Loss of other coverage

You or your dependent loses eligibility for other coverage under a group health plan or through health insurance, as defined by the Health Insurance Portability and Accountability Act (HIPAA).

Action	Allowed?
Add dependents	Yes
Change health plan	Yes

Documents to submit 

• Certificate of creditable coverage
• Letter of termination of coverage from health plan or payroll or benefits office
• COBRA election notice

Subscriber has a change in employment status

Your change in employment status affects your eligibility for the employer contribution toward your employer-based group health plan.

Action	Allowed?
Add dependents	Yes
Change health plan	Yes

Documents to submit 

• Employee hire letter from employer that contains information about benefits eligibility
• Employment contract
• Termination letter
• Letter of resignation
• Statement of insurance
• Certificate of coverage

Subscriber's dependent has a change in their employment status

The change 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 Treasury Regulation 54.9801-6.

Action	Allowed?
Add dependents	Yes
Change health plan	Yes

Documents to submit 

• Employee hire letter from their employer that contains information about benefits eligibility
• Employment contract
• Termination letter
• Letter of resignation
• Statement of insurance
• Certificate of coverage

Change under other employer-based group health plan's open enrollment

You or your dependent has a change in enrollment under another employer-based group health plan during its annual open enrollment that does not align with the PEBB Program's annual open enrollment.

Action	Allowed?
Add dependents	Yes
Change health plan	No

Documents to submit 

• Certificate of credible coverage
• Letter of enrollment or termination of coverage from the health plan
• Letter of enrollment or termination of coverage from the employer's payroll or benefits office
• Proof of waiver

Subscriber's dependent moves from another county to the U.S. or from the U.S. to another country

Your dependent's change in residence results in the loss of their health insurance.

Action	Allowed?
Add dependents	Yes
Change health plan	No

 Documents to submit

• Visa or passport with date of entry
• Proof of former and current residence (e.g., utility bill)
• Letter or document showing coverage was lost (e.g., certificate of credible coverage).

Change in residence

You or your dependent has a change in residence that affects health plan availability.

Action	Allowed?
Add dependents	No
Change health plan	Yes

Documents to submit 

• Proof of former and current residence (e.g., utility bill)
• Certificate of credible coverage

Court order

 A court order requires you or your dependent to provide a health plan for an eligible child of the subscriber.

Action	Allowed?
Add dependents	Yes
Change health plan	Yes

Documents to submit 

•  Valid court order

Gain or lose eligibility for Medicaid or CHIP

You or your dependent enrolls in or loses eligibility for Medicaid or a state Children's Health Insurance Program (CHIP). 

Action	Allowed?
Add dependents	Yes
Change health plan	Yes

Documents to submit 

• Enrollment or termination letter from Medicaid or CHIP reflecting the date you or your dependent enrolled in or lost eligibility for Medicaid or CHIP.

Become eligible for state premium assistance subsidy for PEBB medical plan coverage from Medicaid or CHIP

You or a dependent becomes eligible for a state premium assistance subsidy for PEBB medical plan from Medicaid or a state CHIP.

Action	Allowed?
Add dependents	Yes
Change health plan	Yes

Documents to submit 

• Eligibility letter from Medicaid or CHIP.

Enroll in or lose eligibility for Medicare

You or your dependent loses eligibility for Medicare or enrolls in or terminates enrollment in a Medicare Advantage plan or Medicare Part D plan. 

Action	Allowed?
Add dependents	Yes (The subscriber may enroll a dependent who lost eligibility for coverage under Medicare. Existing uncovered dependents who did not lose Medicare eligibility may not be enrolled.)
Change medical plan	Yes
Change dental or vision plan	No

Documents to submit 

• Medicare benefit verification letter
• Copy of Medicare card
• Notice of denial of Medicare coverage
• Social Security denial letter
• Medicare entitlement or cessation of disability form

Medical plan becomes unavailable

You or your dependent's current health plan becomes unavailable because they are no longer eligible for a health savings account (HSA). 

Action	Allowed?
Add dependents	No
Change health plan	Yes

Documents to submit 

• Cancellation letter from the health plan
• Coverage confirmation in a new health plan
• Medicare entitlement letter
• Copy of current tax return claiming you as a dependent

Continuity of care

You or your dependent experiences a disruption of care for active and ongoing treatment that could function as a reduction in benefits for the employee or their dependent. Requires approval by the PEBB Program. 

Action	Allowed?
Add dependents	No
Change health plan	Yes

Documents to submit

• Submit request for a plan change to:
  Health Care Authority
  PEBB Program
  PO Box 42684
  Olympia, WA 98504-5502

How do I make changes? 

To take advantage of special open enrollments, you must submit the following forms and documentation to the PEBB Program no later than 60 days after the event.

• Proof of the event
• Use Benefits 24/7 or the appropriate form:
  • PEBB Continuation Coverage (COBRA) Election/Change
  • PEBB Continuation Coverage (Unpaid Leave) Election/Change
  • PEBB Continuation Coverage (Employer Group Ended Participation) Election/Change

(See PEBB Program Policy Addendum 45-2A for a list of valid documents.)

If you are changing to Plan G

If you are changing your medical plan to Premera Blue Cross Medicare Supplement Plan G, the PEBB Program must receive your request in Benefits 24/7 or the following forms:

• PEBB Continuation Coverage (COBRA) Election/Change
• Group Medicare Supplement Enrollment Application (form B)

By when?

No later than six months after you or your dependent enroll in Medicare Part B.

If you are changing to a Medicare Advantage with Part D plan

If you are changing your medical plan to a Medicare Advantage with Part D, you have seven months to enroll.

The seven-month period begins three months before you or your dependent first enrolled in both Medicare Part A and Part B. It ends three months after the month of Medicare eligibility, or before their last day of the Medicare Part B initial enrollment period.

The PEBB Program must receive your request in Benefits 24/7 or the PEBB Continuation Coverage (COBRA) Election/Change.

By when?

No later than the last day of the month before the month you or your dependent enroll in the Medicare Advantage with Part D plan.

If you are changing from a Medicare Advantage with Part D plan

If you are changing from a Medicare Advantage Plan with Part D, the PEBB Program must receive your request in Benefits 24/7 or the following forms:

• PEBB Continuation Coverage (COBRA) Election/Change
• Medicare Advantage Plan Disenrollment form (Form D)

When to submit

You may want to submit your request sooner to avoid a delay in the enrollment or change, and to ensure timely payment of claims.

When to submit when adding a child

When the special open enrollment is for birth, adoption, or assuming legal obligation for support ahead of adoption, submit the required forms and proof of your dependent's eligibility and the event as soon as possible.

If adding the child increases the premium, the PEBB Program must receive the required forms and proof no later than 60 days after the date of the birth, adoption, or when you assumed legal obligation.

Related laws and rules

For details on changes you can make

See PEBB Program Policy Addendum 45-2A.

For subscribers

• WAC 182-08-198: When may a subscriber change health plans?
• WAC 182-08-199: When may subscribers enroll or remove eligible dependents?

To disenroll from Medicare Advantage plan

To disenroll from a Medicare Advantage plan the change must be allowed under 42 C.F.R Secs. 422.62(b) and 423.38(c).