WSR 02-08-047

PERMANENT RULES

HEALTH CARE AUTHORITY


[ Order 01-09 -- Filed March 29, 2002, 3:21 p.m. ]

Date of Adoption: March 28, 2002.

Purpose: Adds a new section WAC 182-12-230 which defines the process for collection of premium due and termination of coverage procedures for employer groups with a delinquent account.

Citation of Existing Rules Affected by this Order: Adds a new section WAC 182-12-230.

Statutory Authority for Adoption: RCW 41.05.160, 41.05.021 (1)(h).

Adopted under notice filed as WSR 02-05-078 on February 20, 2002.

Changes Other than Editing from Proposed to Adopted Version: Included "employee organizations representing state civil service employees" to the definition of "employer groups." This group had not been included in the definition in error.

Number of Sections Adopted in Order to Comply with Federal Statute: New 0, Amended 0, Repealed 0; Federal Rules or Standards: New 0, Amended 0, Repealed 0; or Recently Enacted State Statutes: New 0, Amended 0, Repealed 0.

Number of Sections Adopted at Request of a Nongovernmental Entity: New 0, Amended 0, Repealed 0.

Number of Sections Adopted on the Agency's Own Initiative: New 1, Amended 0, Repealed 0.

Number of Sections Adopted in Order to Clarify, Streamline, or Reform Agency Procedures: New 1, Amended 0, Repealed 0.

Number of Sections Adopted Using Negotiated Rule Making: New 0, Amended 0, Repealed 0; Pilot Rule Making: New 0, Amended 0, Repealed 0; or Other Alternative Rule Making: New 1, Amended 0, Repealed 0.
Effective Date of Rule: Thirty-one days after filing.

March 29, 2002

Melodie Bankers

Rules Coordinator

OTS-5472.2


NEW SECTION
WAC 182-12-230   Employer groups.   This section applies to all employer groups participating in PEBB insurance programs.

(1) For purposes of this section, "employer group" means those employee organizations representing state civil service employees, K-12 school districts, educational service districts, county, municipality, and political subdivisions that meet the participation requirements of WAC 182-12-111 (2), (3) and (4) and that participate in PEBB insurance programs.

(2)(a) Each employer group shall determine an employee's eligibility for PEBB insurance coverage in accordance with the applicable sections of this chapter (chapter 182-12 WAC) and chapter 41.05 RCW.

(b) Each employer group applying for participation in PEBB insurance programs shall submit required documentation and meet all participation requirements set forth in the then-current PEBB Coverage K-12 and Political Subdivisions booklet(s).

(3)(a) Each employer group applying for participation in PEBB insurance programs shall sign an interlocal agreement with the health care authority.

(b) Each employer group already participating in PEBB insurance programs as of the effective date of this section shall sign an interlocal agreement with the health care authority no later than June 30, 2002. Failure to sign such an agreement by that date will result in termination of the employer group's participation in PEBB insurance programs effective as of the end of the month of the last full premium payment, and disenrollment of all employees of the employer group. Termination and disenrollment are subject to subsections (8) and (9) of this section.

(c) Each interlocal agreement shall be renewed no less frequently than once in every two-year period.

(4) At least twenty days prior to the premium due date, the health care authority shall cause each employer group to be sent a monthly billing statement. The statement of premium due will be based upon the enrollment information provided by the employer group.

(a) Changes in enrollment status shall be submitted to the health care authority prior to the twentieth day of the month during which the change occurs. Changes submitted after the twentieth day of each month may not be reflected on the billing statement until the following month.

(b) Changes submitted more than one month late shall be accompanied by a full explanation of the circumstances of the late notification.

(5) Beginning with the July 2002 premium (billed to employer groups no later than June 26, 2002, and due not later than July 20, 2002), an employer group shall remit the monthly premium as billed or as reconciled by it.

(a) If an employer group determines that the invoiced amount requires one or more changes, the employer group may adjust its remittance only if an insurance eligibility adjustment form detailing the adjustment accompanies the remittance. The proper form for reporting adjustments will be attached to the interlocal agreement as Exhibit A.

(b) Each employer group is solely responsible for the accuracy of the amount remitted and the completeness and accuracy of the insurance eligibility adjustment form.

(6) Each employer group shall remit the entire monthly premium due including the employee share, if any. The employer group is solely responsible for the collection of any employee share of the premium. The employer shall not withhold portions of the monthly premium due because it has failed to collect the entire employee share.

(7) Nonpayment of the full premium when due will subject the employer group to disenrollment and termination of each employee of the group.

(a) Prior to termination for nonpayment of premium, the health care authority shall cause a notice of overdue premium to be sent to the employer group, which notice will provide a one-month grace period for payment of all overdue premium.

(b) An employer group that does not remit the entirety of its overdue premium no later than the last day of the grace period will be disenrolled effective the last day of the last month for which premium has been paid in full.

(c) Upon disenrollment, notification will be sent to both the employer group and each affected employee.

(d) Employer groups disenrolled due to nonpayment of premium shall have the right to a dispute resolution hearing in accordance with the terms of the interlocal agreement.

(e) Employees terminated due to the nonpayment of premium by the employer group are not eligible for continuation of group health plan coverage according to the terms of the Consolidated Omnibus Budget Reconciliation Act (COBRA). Terminated employees shall have conversion rights to an individual insurance policy as provided for by the employer group.

(f) Claims incurred by terminated employees of a disenrolled group after the effective date of disenrollment will not be covered.

(g) The employer group is solely responsible for refunding any employee share paid by the employee to the employer group and not remitted to the health care authority.

(8) A disenrolled employer group may apply for reinstatement in PEBB insurance programs under the following conditions:

(a) Reinstatement must be requested and all delinquent premium paid in full no later than ninety days after the date the premium was first due, as well as a reinstatement fee of one thousand dollars.

(b) Reinstatement requested more than ninety days after the effective date of disenrollment will be denied.

(c) Employer groups may be reinstated only once in any two-year period and will be subject to immediate disenrollment if, after the effective date of any such reinstatement, subsequent premiums become more than thirty days delinquent.

(9) Upon written petition by the employer group, disenrollment of an employer group or denial of reinstatement may be waived by the administrator upon a showing of good cause.

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Washington State Code Reviser's Office