Government regulations generally require that your plan coverage remains in effect throughout the plan year, but you may be able to make changes during the year if it is determined that you have a qualifying status change.

When a qualifying status change occurs, you are responsible for notifying your agency representative (if you are an active employee) or the Public Employees’ Benefits Program.

HMO and PPO participants must submit a Benefit Enrollment and Change Form and any supporting documents within 60 days of the status change.

The following qualifying status changes are permitted under this plan:

Adding Dependents (effective the first day of the month following the date of the qualifying status change):

• Marriage: Copy of a certified Marriage Certificate or Passport.

• Birth, Adoption or Placement for Adoption: Copy of birth confirmation followed by a copy of certified birth certificate and social security number. Placement for Adoption and/or Adoption Decree signed by a Judge followed by Certified Birth Certificate.

• Legal Guardianship: Copy of Legal Guardianship Court Order signed by the Judge and copy of Certified Birth Certificate.

• Full-time student (child age 19 through age 23): Copy of certified Birth Certificate and a Full-time Student verification from the Registrar’s Office of an accredited institution, or a printout from the Student Clearinghouse for the appropriate quarter/semester.

• Involuntary loss of coverage for dependent(s): HIPAA Certificate of Creditable Coverage from previous employer and copies of certified Marriage and/or Birth Certificates (as applicable).

• Qualified Medical Child Support Order (QMCSO): Copy QMCSO and copy of certified Birth Certificate.

Deleting Dependents (coverage will end on the last day of the month in which the qualifying status change occurred):

• Death: Original Death Certificate.

• Divorce or Annulment: Copy of Divorce Decree dated and signed by Judge.

• Loss of dependent status for dependent age 19 through age 23: Written, signed, dated statement declaring the effective date of the loss of dependent status due to any of the following: marriage, loss of full-time student status, or entry into the military.

• Dependent obtains coverage through his/her employer: Letter or statement from the employer acknowledging effective date of that coverage and to include any covered dependents.

• Dependent(s) who become entitled to coverage under Medicare or Medicaid: Copy of Medicare Card or eligibility letter from Medicaid. Mail the original Benefit Enrollment and Change form, however, you may mail or fax supporting documentation to PEBP at 901 South Stewart Street, Suite 1001, Carson City, NV 89701, or fax to 775-684-7028. Please include the name of the primary insured or the account number on all documents mailed or faxed.

Note: When you have a qualifying status change it is also a good time to review your beneficiary(ies) you have named to receive benefits in the event of your death. Changes in your family situation do not automatically alter or revoke your previous designations. Prior designations remain valid until you complete a new designation form. A will does not supersede a beneficiary designation. You may name or change beneficiaries at any time online with Standard Insurance or by completing the appropriate forms and submitting them to the office listed on the form.