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

Marriage or registering a domestic partnership (for definition, see related laws and rules).

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 or adoption, including assuming a legal responsibility for support ahead 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 26 C.F.R. 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 in residence

You or your dependent change your residence and it affects health plan availability. Note: A dental plan is considered available if your new residence is located within 50 miles of a provider.

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 insurance coverage for an eligible dependent.

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 subsidy for PEBB health plan coverage from Medicaid or CHIP

You or a dependent become eligible for a state premium assistance subsidy for PEBB health plan coverage from Medicaid or CHIP.

Action	Allowed?
Add dependents	Yes
Change health plan	Yes

Documents to submit

• Eligibility letter from Medicaid or CHIP

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

You or your dependent have a change in enrollment under another employer-based group health insurance 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

Your dependent moves from another country to the U.S. or from the U.S. to another country

Your dependent's change in residence results in 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).

Medical plan becomes unavailable

Your current medical plan becoming unavailable because the you or your dependent is 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 experience a disruption of care for active and ongoing treatment that could function as a reduction in benefits. 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

Gain or lose eligibility for Medicare, or enroll or cancel enrollment in Medicare Advantage Prescription Drug plan or a Medicare Part D plan

You or your dependent enroll in Medicare or loses eligibility under Medicare; or enrolls (or terminates enrollment) in a Medicare Advantage Prescription Drug plan or a Medicare Part D plan.

Action	Allowed?
Add dependents	Yes
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

How do I make changes?

To take advantage of special open enrollments, you must use Benefits 24/7 or submit the following forms and documentation to the PEBB Program no later than 60 days after the event.

• Proof of the event
• Retiree Change Form (form E)

See PEBB Program Administrative 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 Benefits 24/7 change request or the Retiree Change Form (form E) and the Group Medicare Supplement Enrollment Application (form B) 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

Medicare Advantage with Part D plans: Kaiser Permanente NW Senior Advantage with Part D, Kaiser Permanente WA Medicare Advantage with Part D, UMP Classic Medicare with Part D (PDP), UnitedHealthcare PEBB Balance, and UnitedHealthcare PEBB Complete

If you are changing your medical plan to a Medicare Advantage with Part D plan, 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 Benefits 24/7 change request or the Retiree Change Form (form E) no later than the last day of the month before the month you or your dependent enroll in the MAPD or UMP Classic Medicare with Part D (PDP) plan.

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

If you are changing from a Medicare Advantage with Part D plan, use Benefits 24/7 or include a Medicare Plan Disenrollment form (Form D). To disenroll from a Medicare Advantage plan the change must be allowed under the Internal Revenue Code and Treasury regulations.

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, your payroll or benefits office 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 more details, see PEBB Program Administrative Policy Addendum 45-2A and refer to the following Washington Administrative Code (WAC) sections:

• WAC 182-08-198: When may a subscriber change health plans?
• WAC 182-12-205: May a retiree or survivor defer enrollment or voluntarily terminate enrollment under PEBB retiree insurance coverage?
• WAC 182-12-262: When may subscribers enroll or remove eligible dependents?