Subscribers may change health plans at the following times:
(1)
During annual open enrollment: Subscribers may change health plans during the annual open enrollment. The subscriber must submit the appropriate enrollment forms to change health plan no later than the end of the annual open enrollment. Enrollment in the new health plan will begin January 1st of the following year.
(2)
During a special open enrollment: Subscribers may change health plans outside of the annual open enrollment if a special open enrollment event occurs. The change in enrollment must be allowable under Internal Revenue Code (IRC) and correspond to the event that creates the special open enrollment for either the subscriber or the subscriber's dependents or both. To make a health plan change, the subscriber must submit the appropriate enrollment forms (and a completed disenrollment form, if required) no later than sixty days after the event occurs. Employees submit the enrollment forms to their employing agency. All other subscribers, including retirees, COBRA, and other self-pay subscribers, submit the enrollment forms to the PEBB program. Insurance coverage in the new health plan will begin the first day of the month following the event that created the special open enrollment; or in cases where the event occurs on the first day of the month, insurance coverage will begin on that date. If the special open enrollment is due to the birth, adoption, or assumption of legal obligation for total or partial support in anticipation of adoption of a child, insurance coverage will begin the month in which the event occurs. The following events create a special open enrollment:
(a) Subscriber acquires a new eligible dependent through marriage, registering a domestic partnership with Washington state, birth, adoption or when the subscriber has assumed a legal obligation for total or partial support in anticipation of adoption, legal custody or legal guardianship;
(b) Subscriber's dependent child becomes eligible by fulfilling PEBB dependent eligibility criteria;
(c) Subscriber loses an eligible dependent or a dependent no longer meets PEBB eligibility criteria;
(d) Subscriber has a change in marital status or Washington state registered domestic partnership status, including legal separation documented by a court order;
(e) Subscriber or a dependent loses comprehensive group health coverage;
(f) Subscriber or a dependent has a change in employment status that affects the subscriber's or a dependent's eligibility, level of benefits, or cost of insurance coverage;
(g) Subscriber or a dependent has a change in residence that affects health plan availability, benefits, or cost of insurance coverage. If the subscriber moves and the subscriber's current health plan is not available in the new location but the subscriber does not select a new health plan, the PEBB program may enroll the subscriber in the Uniform Medical Plan or Uniform Dental Plan;
(h) Subscriber receives a court order or medical support order requiring the subscriber, the subscriber's spouse, or the subscriber's Washington state registered domestic partner to provide insurance coverage for an eligible dependent;
(i) Subscriber or a dependent becomes eligible for a medical assistance program under the department of social and health services, including medicaid or the children's health insurance program (CHIP), or the subscriber or a dependent loses eligibility in such a medical assistance program;
(j) A dependent dies;
(k) Seasonal employees whose off-season occurs during the annual open enrollment. They may select a new health plan upon their return to work;
(l) Subscriber or an eligible dependent becomes entitled to medicare, enrolls in or disenrolls from a medicare Part D plan;
(m) Subscriber experiences a disruption that could function as a reduction in benefits for the subscriber or the subscriber's dependent(s) due to a specific condition or ongoing course of treatment. A subscriber may not change their health plan if the subscriber's or an enrolled dependent's physician stops participation with the subscriber's health plan unless the PEBB program determines that a continuity of care issue exists. The PEBB program criteria used will include, but is not limited to, the following in determining if a continuity of care issue exists:
(i) Active cancer treatment; or
(ii) Recent transplant (within the last twelve months); or
(iii) Scheduled surgery within the next sixty days; or
(iv) Major surgery within the previous sixty days; or
(v) Third trimester of pregnancy; or
(vi) Language barrier.
If the employee is having premiums taken from payroll on a pretax basis, a plan change will not be approved if it would conflict with provisions of the salary reduction plan authorized under RCW
41.05.300.
[Statutory Authority: RCW 41.05.160. 09-23-102 (Order 09-02), § 182-08-198, filed 11/17/09, effective 1/1/10; 08-20-128 (Order 08-03), § 182-08-198, filed 10/1/08, effective 1/1/09; 08-09-027 (Order 08-01), § 182-08-198, filed 4/8/08, effective 4/9/08; 07-20-129 (Order 07-01), § 182-08-198, filed 10/3/07, effective 11/3/07. Statutory Authority: RCW 41.05.160 and 41.05.068. 06-23-165 (Order 06-09), § 182-08-198, filed 11/22/06, effective 12/23/06. Statutory Authority: RCW 41.05.160, 41.05.350, and 41.05.165. 05-16-046 (Order 05-01), § 182-08-198, filed 7/27/05, effective 8/27/05.]