Integrated Service Center

Life Events

Changes Due to a Life Event

Certain life events allow you to change your medical and/or dental coverage. The Integrated Service Center (ISC) must receive your benefit elections within 60 days from the date of the event (your “special open enrollment” window), and any enrollment changes must correspond with your life event.

Qualified life events and how to submit your benefit elections are summarized below; for details about a life event, select it from the list in the left sidebar.

Life Event Workday Paper Form
Marriage and Start of a Domestic Partnership x  
Birth or Adoption within 60 days of the date of birth or adoption x  
Birth or Adoption after 60 days, and within 1 year, of the date of birth or adoption x
Loss of Other Coverage
Gain of Other Coverage x
Newly Eligible Disabled Dependent x
Newly Eligible Extended Dependent x
Dependent Loss of Eligibility x
Change in Employment Status x
Change in Residence x
Dependent Moves to or From USA x
Newly Eligible Dependent due to Court Order x
Health Plan Becomes Unavailable x
Medicaid, Medicare, CHIP, or TRICARE coverage changes x
Changes in Dependent Care x

Events that qualify are defined by the state in the Washington Administrative Code 182-08-198.

Marriage and Start of Domestic Partnership

You acquire a new dependent(s) due to marriage or start of a state-registered domestic partnership.

Enrollment changes you can make within 60 days of the life event: How to change your Election(s)
  • Add dependents
  • Enroll/change or waive medical/dental elections for you and your dependents
  • Enroll/increase/decrease Medical FSA and DCAP
  • Change Tobacco Use Attestation
  • Change Spousal Surcharge Attestation
  • To drop dependents, attach the completed 2017 Employee Enrollment Change form to your Marriage and Domestic Partnership Change Benefit Event. This must be entered by the ISC
  • To enroll/change your Premium Payment plan (e.g. the tax treatment of your health plan deductions), attach the completed Premium Payment Plan Election/Change form to your Marriage and Domestic Partnership Change Benefit Event. This must be entered by the ISC
Workday: Initiate a Marriage and Domestic Partnership Change Benefit Event

Proof of Event Required: Scan/attach proof of the event and any newly added dependents verification

  • Elect/increase optional life for you and your dependents through MetLife
Paper Form: Submit a completed Metlife enrollment form to MetLife

Birth or Adoption

You acquire a new dependent(s) due to birth, adoption or when you assume legal obligation for full or partial support prior to adoption.

Enrollment changes you can make within 60 days of the life event: How to change your Election(s)
  • Add newborn or newly adopted child(ren) to your health plan
  • To enroll/change your health plan election for you and your dependents ­­­­­­or to drop dependent(s) from your health plan, attach the completed 2017 Employee Enrollment Change form to your Birth or Adoption Change Benefit Event. This must be entered by the ISC.
  • To enroll/change your Premium Payment plan (e.g. the tax treatment of your health plan deductions), attach the completed Premium Payment Plan Election/Change form to your Birth or Adoption Change Benefit Event. Enrollment/changes to your Premium Payment plan must be entered by the ISC
Enrolling your newborn/newly adopted within 60 Days:

Workday: Initiate a Birth or Adoption Change Benefit Event

Proof of Event Required: Scan/attach proof of the event and any newly added dependents verification

After 60 Days and Within 1 Year OR Changing your Medical Plan within 60 days:

Paper form:  Drop off or mail a completed 2017 Employee Enrollment Change form to the ISC

  • Enroll/change Medical FSA
  • Enroll/change DCAP
Paper form:  Drop off or mail a completed 2017 Employee Enrollment Change form to the ISC

Proof of Event Required: Attach proof of the event and any newly added dependents verification

  • Elect/increase optional life for you and your dependents through MetLife
Paper Form: Submit a completed Metlife enrollment form to MetLife

Loss of Other Coverage

You or your dependent loses other coverage under a group health plan or through health insurance coverage, as defined by HIPAA.

Enrollment changes you can make within 60 days of the life event: How to change your Election(s)
  • Enroll in or change your health plan election
  • Add dependent(s) in health plan(s)
  • Enroll in or change spending accounts (FSA)
  • Change Tobacco Use Attestation
  • Change Spousal Surcharge Attestation
Workday: Initiate a Loss of Coverage Change Benefit Event

Proof of Event Documentation Required (provide one, must include start/end date of coverage and names of all covered dependents): 

  • Certificate of Creditable Coverage
  • Letter of enrollment or termination of coverage from the health plan
  • Letter of enrollment or termination of coverage from the employer’s personnel, payroll, or benefits office
  • Proof of Waiver

If your dependent has lost health coverage through UW, you do not need to provide documentation for proof of the event. You will need to indicate that your dependent has lost coverage through UW.

Proof of Dependent Documentation Required

  • Enroll/change Premium Payment Plan
Paper Form: Drop off or mail  a completed Premium Payment Plan Election/Change form  to the ISC

Gain of Other Coverage

You or your dependent gains other coverage under a group health plan where your dependent gained eligibility for the employer contribution.

Enrollment changes you can make within 60 days of the life event: How to change your Election(s)
  • Waive your health plan election
  • Remove dependent(s) from health plan(s)
  • Decrease or cease spending accounts (FSA)
  • Change Tobacco Use Attestation
  • Change Spousal Surcharge Attestation
Paper form:  Drop off or mail a completed 2017 Employee Enrollment Change form to the ISC

Proof of Event Documentation Required (provide one, must include start of coverage and names of all covered dependents you wish to remove):

  • Dependent’s hire letter from dependent’s employer
  • Employment Contract

If your dependent has lost health coverage through UW, you do not need to provide documentation for proof of the event. You will need to indicate that your dependent has lost coverage through UW.

  • Enroll/change Premium Payment Plan
Paper Form: Drop off or mail  a completed Premium Payment Plan Election/Change form  to the ISC

Newly Eligible Disabled Dependent

You are enrolling your new disabled dependent (disability must have occurred prior to age 26).

Enrollment changes you can make within 60 days of the life event: How to change your Election(s)
  • Enroll/drop/change your medical and dental plan election
  • Enroll/change spending accounts (FSA and DCAP)
  • Change Tobacco Use Attestation
  • Change Spousal Surcharge Attestation
Paper form:  Drop off or mail a completed 2017 Employee Enrollment Change form to the ISC

Proof Documentation Required:

  • Enroll/change Premium Payment Plan
Paper Form: Drop off or mail  a completed Premium Payment Plan Election/Change form  to the ISC

Newly Eligible Extended Dependent

You acquire a new dependent due to a child becoming eligible as an extended dependent through legal custody or legal guardianship

Enrollment changes you can make within 60 days of the life event: How to change your Election(s)
  • Enroll/drop/change your health plan election
  • Add/drop dependent(s) in health coverage
  • Enroll/change spending accounts (FSA and DCAP)
  • Change Tobacco Use Attestation
  • Change Spousal Surcharge Attestation
Paper form:  Drop off or mail a completed 2017 Employee Enrollment Change form to the ISC

Proof Documentation Required:

  • Enroll/change Premium Payment Plan
Paper Form: Drop off or mail  a completed Premium Payment Plan Election/Change form  to the ISC

Dependent Loss of Eligibility

Your dependent no longer meets PEBB eligibility criteria due to:

  • Divorce, annulment
  • Dissolution of state-registered domestic partnership (if state-registered domestic partner was your tax dependent)
  • Death
  • No longer meets the plan definition of dependent (e.g. reaches age 26, etc.)
Enrollment changes you can make within 60 days of the life event: How to change your Election(s)
  • Drop dependent(s) from health coverage
  • Enroll/change spending accounts (FSA and DCAP), effective first day of the month the later of date of loss or election
Paper form:  Drop off or mail a completed 2017 Employee Enrollment Change form to the ISC

Proof Documentation Required (provide one):

  • Petition for Dissolution of marriage (divorce)
  • Petition for Dissolution of state-registered domestic partnership
  • Copy of a death certificate
  • Enroll/change Premium Payment Plan
Paper Form: Drop off or mail  a completed Premium Payment Plan Election/Change form  to the ISC

Change in Employment Status

You have a change in employment status that affects your eligibility to receive the employer contribution toward your health plan.

Enrollment changes you can make within 60 days of the life event: How to change your Election(s)
  • Enroll/drop/change your health plan election
  • Add/drop dependent(s) from coverage
  • Enroll/change spending accounts (FSA and DCAP)
  • Change Tobacco Use Attestation
  • Change Spousal Surcharge Attestation
Paper form:  Drop off or mail a completed 2017 Employee Enrollment Change form to the ISC

Proof Documentation Required (provide one)

  • Hire letter on company letterhead with effective date on company letterhead
  • Employment contract
  • Termination letter on company letterhead
  • Letter of resignation
  • Enroll/change Premium Payment Plan
Paper Form: Drop off or mail  a completed Premium Payment Plan Election/Change form  to the ISC

Change in Residence

You or your dependent has a change in residence that affects health plan availability

Enrollment changes you can make within 60 days of the life event: How to change your Election(s)
  • Change your health plan election
Paper form:  Drop off or mail a completed 2017 Employee Enrollment Change form to the ISC

Proof Documentation Required (provide one)

  • Proof of former and current residence (e.g. utility bill)
  • Enroll/change Premium Payment Plan
Paper Form: Drop off or mail  a completed Premium Payment Plan Election/Change form  to the ISC

Dependent Moves to or From USA

Your dependent has moved to or from the USA

Enrollment changes you can make within 60 days of the life event: How to change your Election(s)
  • Waive if all dependents move from USA
  • Enroll if dependents who move to the USA are being enrolled in medical coverage
  • Add dependent(s) who move to the USA to coverage
  • Remove dependent(s) who move from the USA from coverage
  • Change Tobacco Use Attestation
  • Change Spousal Surcharge Attestation
Paper form:  Drop off or mail a completed 2017 Employee Enrollment Change form to the ISC

Proof Documentation Required (provide one)

  • Visa or Passport with date of entry (if dependent moves to USA or from USA)
  • Enroll/change Premium Payment Plan

Newly Eligible Dependent due to Court Order

A court ordered, legal guardianship, or national medical support notice requiring you to provide Insurance coverage.

Enrollment changes you can make within 60 days of the life event: How to change your Election(s)
  • Enroll/drop/change your health plan election
  • Add/drop dependent(s) from coverage
  • Enroll/change spending accounts (FSA and DCAP)
  • Change Tobacco Use Attestation
  • Change Spousal Surcharge Attestation
Paper form:  Drop off or mail a completed 2017 Employee Enrollment Change form to the ISC

Proof Documentation Required (provide one)

  • Valid court order; OR
  • National Medical Support Notice
  • Enroll/change Premium Payment Plan
Paper Form: Drop off or mail  a completed Premium Payment Plan Election/Change form  to the ISC

Health Plan Becomes Unavailable

You or your dependent’s current health plan becomes unavailable because the subscriber or enrolled dependent is no longer eligible for a health savings account (HSA). HCA may require evidence that the subscriber or the subscriber’s dependent is no longer eligible for an HSA.

Enrollment changes you can make within 60 days of the life event: How to change your Election(s)
  • Enroll/drop/change your health plan election
  • Add/drop dependent(s) from coverage
  • Enroll/change spending accounts (FSA and DCAP)
  • Change Tobacco Use Attestation
  • Change Spousal Surcharge Attestation
Paper form:  Drop off or mail a completed 2017 Employee Enrollment Change form to the ISC

Proof Documentation Required (provide one)

  • Cancellation letter from HDHP
  • Coverage confirmation In a new health plan
  • Medicare entitlement letter
  • Copy of current tax return claiming you as a dependent
  • Enroll/change Premium Payment Plan
Paper Form: Drop off or mail  a completed Premium Payment Plan Election/Change form  to the ISC

Medicaid, Medicare, CHIP, or TRICARE Coverage Changes

  • Gain or Lose Eligibility for Medicaid or Chip: You or your dependent becomes entitled to coverage under Medicaid or a state children’s health Insurance program (CHIP), or you or your dependent loses eligibility for coverage under Medicaid or CHIP
  • Become Eligible for State Premium Assistance Subsidy for PEBB Health Plan Coverage from Medicaid or Chip:  As required by HIPAA, you or your dependent becomes eligible for state premium assistance subsidy for PE8B health plan coverage from Medicaid or a state children’s health insurance program (CHIP).
  • Gain or Lose Eligibility for Medicare, or Enroll or Cancel Enrollment in Medicare Part D: You or your dependent:
    • Becomes entitled (enrolled) to Medicare, or
    • Loses eligibility for Medicare, or
    • Enrolls in or terminates enrollment in a Medicare Part D plan
  • Gain or Lose Eligibility for Tricare/Medicare: You or your dependent becomes eligible and enrolls in TRICARE/Medicare, or loses eligibility for TRICARE/Medicare.
Enrollment changes you can make within 60 days of the life event: How to change your Election(s)
  • Enroll/drop/change your health plan election
  • Add/drop dependent(s) from coverage
  • Enroll/change spending accounts (FSA and DCAP)
  • Change Tobacco Use Attestation
  • Change Spousal Surcharge Attestation
Paper form:  Drop off or mail a completed 2017 Employee Enrollment Change form to the ISC

Proof Documentation Required (provide one)

Gain or Lose Eligibility for Medicaid or Chip

  • Enrollment or Termination letter from Medicaid or CHIP reflecting the date that the subscriber or subscriber’s dependent became entitled to and enrolled In Medicaid or CHIP or the date at which the subscriber or subscriber’s dependent lost eligibility for Medicaid or CHIP

Become Eligible for State Premium Assistance Subsidy for PEBB Health Plan Coverage from Medicaid or Chip

  • Eligibility or loss of eligibility letter Allowed only if the from Medicaid or CHIP

Gain or Lose Eligibility for Medicare, or Enroll or Cancel Enrollment in Medicare Part D

  • Medicare Benefit Verification letter; or
  • Copy of Medicare card; or
  • Notice of Denial of Medicare Coverage; or
  • Social Security denial letter; or
  • Medicare Entitlement or Cessation of Disability form; or
  • Letter confirming enrollment or cancellation of Medicare Part D coverage; or
  • Letter of declination of Medicare Part D coverage
  • Enroll/change Premium Payment Plan
Paper Form: Drop off or mail  a completed Premium Payment Plan Election/Change form  to the ISC

Change in Dependent Care

  • Change Dependent Care Provider (with Increased or Decreased Cost): Your dependent care provider imposes a change in the cost of dependent care, provided the dependent care provider is not a relative as defined in Section 152 (a)(l) through (8), incorporating the rules of Section 152 (b)(l) and (2) of the IRC.
  • Change number of DCAP Qualifying Individuals: You or your spouse/partner experience a change in the number of qualifying individuals as defined In IRC Section 21 (b)(l).
Enrollment changes you can make within 60 days of the life event: How to change your Election(s)
  • Enroll in or Change DCAP
Workday: Initiate an FSA/DCAP Change Benefit Event

Proof Documentation Required (provide one):

  • Letter from both the current and new daycare providers stating the premium amount for qualifying Individuals and the due date;
  • Billing statement from both the current and new daycare providers stating the premium amount for qualifying individuals and the statement date.