Change your coverage

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

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Before you make a change

Before you make a change it is important to:

How to make changes

To make a change during the PEBB Program’s annual open enrollment from November 1 through 30:
The PEBB Program must receive the required Retiree forms  no later than November 30. You may also make some changes using PEBB PEBB My Account. The forms for open enrollment are available November 1. The enrollment change will become effective January 1 of the following year.

To make a change when a special open enrollment event occurs:
The PEBB Program must receive the  PEBB Retiree Coverage Change Form (form E) and any other required form(s) along with proof of the event that created the special open enrollment  no later than 60 days after the event that created the special open enrollment. However, if adding a newborn, newly adopted child, or child for whom the employee has assumed a legal obligation for total or partial support in anticipation of adoption, the subscriber should submit the required forms to the PEBB Program as soon as possible.  If adding the child increases your premium, the PEBB Program must receive this form no later than 60 days after the date of birth,  adoption, or the date the legal obligation is assumed for total or partial support in anticipation of adoption. If you are changing your medical plan to Premera Blue Cross Medicare Supplement Plan G due to you or your dependent becoming entitled to Medicare Part A and Part B, the PEBB Program must receive the required forms no later than six months after you or your dependent enroll in Medicare Part B.  If you are changing from a Medicare Advantage Plan, also include a Medicare Advantage Plan Disenrollment form (Form D).

See PEBB Program Administrative Policy Addendum 45-2A for a list of special open enrollment events.

In most cases, the change will occur the first day of the month after the date of the event or the date the PEBB Program receives your required, completed enrollment form(s), whichever is later. If that day is the first of the month, the enrollment change begins on that date. One exception is Medicare Advantage plans, which start the first of the month after the PEBB Program receives your required forms, per federal regulations. Other exceptions apply.

Note: Retiree subscribers may voluntarily remove an eligible dependent from insurance coverage any time during the year.

Changes you can make any time

There are some changes you can make any time during the year outside of the PEBB Program’s annual open enrollment and without a special open enrollment event.

  • Change your name and/or address. Use the Retiree Coverage Change Form (form E). You can also mail, the PEBB Program a written request with your new name or address, or call the PEBB Program at 1-800-200-1004 and select menu option 5.
  • Remove a covered dependent from your PEBB retiree insurance coverage.  Use the Retiree Coverage Change Form (form E) and any other required forms required.
  • Remove dependent(s) from coverage due to loss of eligibility (required) due to divorce, annulment, dissolution, or a qualifying event of a dependent ceasing to be eligible as a dependent child. The PEBB Program must receive the Retiree Coverage Change Form (form E) and any other required forms within 60 days of the last day of the month the dependent loses eligibility for health plan coverage.
  • Cancel (terminate) or defer (postpone) your PEBB retiree health plan coverage. Use the Retiree Coverage Change Form (form E) and any other required forms.
  • Change your life insurance beneficiary information. Use the MetLife Beneficiary Designation form, or contact MetLife at 1-866-548-7139.
  • Apply for, cancel (terminate), or change auto or home insurance coverage. See the Auto and home insurance page for details.
  • Start, stop, or change your contribution to your health savings account (HSA). Contact HealthEquity toll-free at 1-877-873-8823 to do this.
  • Change your HSA beneficiary information. Use the Health Savings Account Beneficiary Designation form.
  • Change your or a dependent's tobacco use premium surcharge attestation.  Use the PEBB Premium Surcharge Attestation Change form or log into PEBB My Account.

Plan change requirements

  • You can only change medical or dental plans during the PEBB Program's annual open enrollment (November 1–30) of if you have a special open enrollment event.
  • All eligible dependents must enroll in the same health plan, with some exceptions. (Dependents can have different providers.)
  • If you have a provider you want to stay with, contact the new plan or check the plan’s provider directory to make sure your provider is in the plan’s network.
  • You cannot be enrolled on two PEBB accounts at the same time. 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 coverage as an employee). Enrolled dependents will be listed on one account, not both.

Special open enrollment

The PEBB Program allows changes outside of the PEBB Program’s annual open enrollment when certain events create a special open enrollment. The change must be consistent with and correspond to the event that affects eligibility for coverage. You must provide proof of the event that created the special open enrollment (for example, a marriage or birth certificate).

Changes that may be allowed as a special open enrollment

If this event happens... Add dependent Change medical plan Change dental plan
Marriage, registering a state-registered domestic partnership, birth, adoption, including assuming a legal obligation for support in anticipation of adoption. Yes Yes Yes
Child becomes eligible as an extended dependent through legal custody or legal guardianship. Yes Yes Yes
Subscriber or 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). Yes Yes Yes
Subscriber has a change in employment status that affects their eligibility for the employer contribution under their employer-based group health plan. Yes Yes Yes
Subscriber's dependent has a change in their own 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.) Yes Yes Yes
A court order requires the subscriber or any other individual to provide insurance coverage for an eligible dependent of the subscriber. Yes Yes Yes
Subscriber or a subscriber’s dependent becomes entitled to coverage or loses eligibility for Medicaid or a state Children’s Health Insurance Program (CHIP). Yes Yes Yes
Subscriber or a dependent becomes eligible for a state premium assistance subsidy for PEBB Program health plan coverage from Medicaid or CHIP. Yes Yes Yes
Subscriber's 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. Yes No No
Subscriber’s dependent moves from outside the United States to live within the United States, or from within the United States to live outside of the United States, and that change in residence resulted in the dependent losing their health insurance. Yes No No
Subscriber or dependent has a change in residence that affects health plan availability. No Yes Yes
Subscriber or dependent experiences 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) No Yes Yes
Subscriber or dependent becomes entitled to Medicare or loses eligibility under Medicare; or enrolling (or cancelling enrollment) in a Medicare Part D plan. No Yes No
Subscriber’s or dependent’s current health plan becomes unavailable because the subscriber or subscriber’s dependent is no longer eligible for a health savings account (HSA) No Yes Yes

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

The PEBB Program's annual open enrollment

From November 1–30 each year, you can make changes to your PEBB account that will take effect January 1 of the following year.

During open enrollment you can:

  • Change medical and/or dental plans.
  • Add dental coverage. (If you enroll in a dental plan, you must stay enrolled for two years.)
  • Enroll or remove eligible dependents.
  • Defer your PEBB retiree insurance coverage.
  • Enroll in a health plan if you previously deferred (postponed) PEBB retiree health plan coverage for other qualifying medical coverage. Note:  You will need to provide proof of continuous enrollment in other qualifying medical coverage. You cannot enroll if there has been a gap in coverage.

Changes you can make online

During the PEBB Program’s 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/or dental plan(s).
  • 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 a 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.

Forms and publications

PDF icon Retiree coverage change form (form E) 2019
PDF icon Retiree enrollment guide 2019

Related links

Completing the retiree forms
File an appeal
Medical benefits comparison tool