HCA’s lobby is now open for walk-in customer service. Learn about customer service options.

Special open enrollment

Some life events (marriage, birth of a child, etc.) qualify you to make changes to your benefits outside of our annual open enrollment. We call these events and the time period you have to make changes (60 days) a "special open enrollment."

What changes can I make?

Based on the event, the following changes may be allowed as 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:

  • 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?

How to 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.

(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 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 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 the Retiree Change Form (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.

If you are 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).

Things to know

  • 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.
  • 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.

Note: 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.

Contact

The PEBB Program
Phone: 1-800-200-1004 
(TRS: 711)
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.