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Change your coverage

Learn the requirements to make changes to your PEBB retiree insurance coverage.

Before you make a change

Before you make a change it is important to:

Plan change requirements

  • You can only change medical or dental plans during the annual open enrollment if you have a special open enrollment event that allows a health plan change.
  • All eligible dependents must enroll in the same plan, with some exceptions. Dependents can have different providers.
  • You may be enrolled in only one PEBB medical or dental plan. If you and your spouse or state-registered domestic partner are both eligible subscribers, you need to choose which of you will cover yourselves and your eligible children (including adult children who are also eligible for PEBB benefits as an employee). Enrolled dependents will be listed on one account, not both.

How do I change my address?

  • Send us a secure message. You need to set up an account to protect your privacy and sensitive health information. By using our secure messaging system we can ensure that your data is safeguarded.
  • Use the Retiree Change Form (form E).
  • Fax to 1-360-725-0771.
  • Mail us a written request with your new name or address.
  • Call us at 1-800-200-1004 (TRS: 711).

What changes can I make any time?

Below are the changes you can make anytime during the year. You can use the Retiree Change Form (form E) to report the change, unless otherwise noted.

What is a special open enrollment?

The PEBB Program allows changes outside of annual open enrollment when certain events create a special open enrollment.

The change in enrollment must be allowable under the Internal Revenue Code and Treasury Regulations, and correspond to and be consistent with the event that creates the special open enrollment for you, your dependents, or both. You must provide proof of the event that created the special open enrollment (for example, a marriage or birth certificate).

What changes can I make during a special open enrollment?

Marriage or registering a domestic partnership (as defined by WAC 182-12-109).

Action

Allowed?

Add dependents

Yes

Change medical plan

Yes
(A health plan change is not allowed when adding a SRDP or their child if they are not a tax dependent.)

Change dental 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.
  • Also provide evidence the marriage/partnership is still valid (e.g., a utility bill or bank statement) dated within the past six months showing both names.

Birth or adoption, including assuming a legal responsibility for support ahead of adoption

Action

Allowed?

Add dependents

Yes

Change medical plan

Yes

Change dental 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.

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

Action

Allowed?

Add dependents

Yes

Change medical plan

Yes

Change dental plan Yes

Documents to submit

Subscriber or dependent losing 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 medical plan

Yes

Change dental 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 having a change in employment status that affects the subscriber’s eligibility for the employer contribution toward their employer-based group health plan.

Action

Allowed?

Add dependents

Yes

Change medical plan

Yes

Change dental 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 that affects their 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 medical plan

Yes

Change dental 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.

Subscriber or dependent having a change in residence that affects health plan availability

Action

Allowed?

Add dependents

No

Change medical plan

Yes

Change dental plan Yes

Documents to submit

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

A court order requires the subscriber or any other individual to provide insurance coverage for an eligible dependent

Action

Allowed?

Add dependents

Yes

Change medical plan

Yes

Change dental plan Yes

Documents to submit

  • Valid court order.

Subscriber or a subscriber’s dependent enrolls in coverage under Medicaid or a state Children’s Health Insurance Program (CHIP), or loses eligibility for coverage under Medicaid or CHIP.

Action

Allowed?

Add dependents

Yes

Change medical plan

Yes

Change dental plan Yes

Documents to submit

Enrollment or termination letter from Medicaid or CHIP reflecting the date the subscriber or subscriber’s dependent enrolled in Medicaid or CHIP or the date at which the subscriber or subscriber’s dependent lost eligibility for Medicaid or CHIP.

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

Action

Allowed?

Add dependents

Yes

Change medical plan

Yes

Change dental plan Yes

Documents to submit

  • Eligibility letter from Medicaid or CHIP.

 

Subscriber's dependent enrolls in Medicare or loses eligibility for Medicare.

Action

Allowed?

Add dependents

Yes

Change medical plan

No

Change dental 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.

Subscriber or dependent having 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 medical plan

No

Change dental 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 moving from another country to live within the United States, or from the United States to another country, and that change in residence resulted in the dependent losing their health insurance.

Action

Allowed?

Add dependents

Yes

Change medical plan

No

Change dental 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).

Subscriber’s current medical plan becoming unavailable because the subscriber or subscriber’s dependent is no longer eligible for a health savings account (HSA).

Action

Allowed?

Add dependents

No

Change medical plan

Yes

Change dental 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.

Subscriber or dependent experiencing a disruption of care for active and ongoing treatment that could function as a reduction in benefits for the subscriber or their dependent (requires approval by the PEBB Program).

Action

Allowed?

Add dependents

No

Change medical plan

Yes

Change dental plan Yes

Documents to submit

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

Subscriber or dependent enrolls 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

No

Change medical plan

Yes

Change dental 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.

For more details, see PEBB Program Administrative Policy Addendum 45-2A and refer to Washington Administrative Code (WAC) sections:

How do I make a change when a special open enrollment event occurs?

Submit the Retiree Change Form (form E) and any other forms or documents. The PEBB Program must receive them no later than 60 days after the event that created the special open enrollment.

Changing to Plan G

If you are changing your medical plan to Premera Blue Cross Medicare Supplement Plan G, the PEBB Program must receive 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.

Changing to a Medicare Advantage plan

If you are changing your medical plan to a Medicare Advantage or Medicare Advantage-Prescription Drug (MAPD) 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 Form E and the Medicare Advantage Plan Election Form (form C) no later than the last day of the month before the month you or your dependent enrolls in the Medicare Advantage or MAPD plan.

Changing from a Medicare Advantage plan

If you are changing from a Medicare Advantage Plan, also include a Medicare Advantage Plan Disenrollment form (Form D). 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).

When are changes effective?

In most cases, the change will occur the first day of the month after the date of the event or the date the we receive your forms, whichever is later. If that day is the first of the month, the enrollment change begins on that day.

Exceptions

  • Medicare Advantage plans. Start the first of the month after we receive your forms, per federal rules.
  • Arrival of a child (a newborn, adopted child, or a child you are legally required to support ahead of adoption). PEBB benefits will start or end as follows:
    • A newborn child, PEBB health plan coverage will start on the date of birth.
    • A newly adopted child, PEBB health plan coverage will start on the date of placement or the date you assume legal responsibility for their support ahead of adoption, whichever is earlier.
    • Enrolling a spouse or SRDP because of a birth or adoption, PEBB health plan coverage will start the first day of the month in which the event occurs. The spouse or partner will be removed from health plan coverage the last day of the month in which the event occurred.
    • If the special open enrollment is due to a child becoming eligible as an extended dependent or a dependent child with a disability, PEBB health plan coverage will start the first day of the month following either the event date or the date we confirm their eligibility, whichever is later.

What changes can I make during annual open enrollment?

The open enrollment is held in the fall. To make any of the changes below, we must receive the required forms no later than the last day of open enrollment. The change will become effective January 1 of the next year.

To make a change during annual open enrollment

We must receive the required forms no later than November 30. You may also make some changes using PEBB My Account. The forms for open enrollment are available November 1. The enrollment change will become effective January 1 of the following year.

What changes can I make using PEBB My Account?

During annual open enrollment you can make some changes online using PEBB My Account. If you cannot make changes online, PEBB My Account will direct you to the correct forms. You can:

  • Change your medical and dental plans.
  • Reattest to the spouse or state-registered domestic partner coverage premium surcharge.

Please print or save your confirmation page when you’ve completed your changes. Check back in two business days to verify the coverage you selected and your spousal or state-registered domestic partner coverage premium surcharge attestation is correct.

When you submit an online plan change, please wait two business days to make any additional online plan changes.