WSR 03-17-031

PERMANENT RULES

HEALTH CARE AUTHORITY


(Public Employees Benefits Board)

[ Order 02-07 -- Filed August 14, 2003, 8:12 a.m. ]

Date of Adoption: August 14, 2003.

Purpose: The Health Care Authority (HCA) reviewed chapters 182-08 and 182-12 WAC and is adopting amendments to those chapters to clarify the eligibility and administrative rules affecting PEBB-sponsored insurance coverages for active and retired public employees and to streamline administration of the PEBB program.

Citation of Existing Rules Affected by this Order: Repealing WAC 182-08-020; and amending WAC 182-08-015, 182-08-095, 182-08-120, 182-08-125, 182-08-175, 182-08-180, 182-08-190, 182-08-210, 182-08-220, 182-12-111, 182-12-115, 182-12-117, 182-12-119, 182-12-132, 182-12-145, and 182-12-220.

Statutory Authority for Adoption: RCW 41.05.160 and 41.05.165.

Adopted under notice filed as WSR 03-16-033 on July 29, 2003.

Changes Other than Editing from Proposed to Adopted Version: In addition to editing proposed rules, HCA adopted new WAC 182-12-124. This new rule permits persons to apply for PEBB retiree medical and dental coverages within sixty days after Department of Retirement Services makes a retroactive determination of eligibility for state pension benefits.

Number of Sections Adopted in Order to Comply with Federal Statute: New 0, Amended 0, Repealed 0; Federal Rules or Standards: New 0, Amended 0, Repealed 0; or Recently Enacted State Statutes: New 0, Amended 1, Repealed 0.

Number of Sections Adopted at Request of a Nongovernmental Entity: New 0, Amended 0, Repealed 0.

Number of Sections Adopted on the Agency's Own Initiative: New 2, Amended 16, Repealed 1.

Number of Sections Adopted in Order to Clarify, Streamline, or Reform Agency Procedures: New 2, Amended 16, Repealed 1.

Number of Sections Adopted Using Negotiated Rule Making: New 0, Amended 0, Repealed 0; Pilot Rule Making: New 0, Amended 0, Repealed 0; or Other Alternative Rule Making: New 2, Amended 16, Repealed 1.
Effective Date of Rule: Thirty-one days after filing.

August 14, 2003

Melodie Bankers, Director

Legal and Contract Services

OTS-6406.3


AMENDATORY SECTION(Amending WSR 96-08-042, filed 3/29/96, effective 4/29/96)

WAC 182-08-015   Definitions.   The following definitions apply throughout ((these rules)) this Title 182 WAC unless the context clearly indicates other meaning:

(1) "Administrator" means the administrator of the HCA or designee.

(2) (("Public employees benefits board" (PEBB).)) "Board" means the public employees benefits board established under provisions of ((chapter 41.05 RCW)) RCW 41.05.055. The ((PEBB)) board is created within the HCA and the administrator of the HCA shall serve as the chair of the board.

(3) "Open enrollment" means a time period designated by the administrator during which enrollees may apply to transfer their enrollment from one health plan to another, enroll in a medical plan if the enrollee had previously waived coverage or add dependents.

(4) "Enrollee" means a person who meets all eligibility requirements defined in chapter 182-12 WAC, who is enrolled in a PEBB plan, and for whom applicable premium payments have been made.

(5) "Subscriber" or "insured" means the enrollee who has been designated by the HCA as the individual to whom the HCA and the health plan will issue all notices, information, requests and premium bills on behalf of all enrolled family members.

(6) "Effective date of enrollment" means the first date((, as established by the PEBB)) on which an enrollee is entitled to receive covered services ((from the enrollee's respective health plan system)).

(7) "PEBB plan" means one or more insurance programs established by the public employees benefits board for eligible enrollees and their dependents.

[Statutory Authority: Chapter 41.05 RCW. 96-08-042, 182-08-015, filed 3/29/96, effective 4/29/96.]


AMENDATORY SECTION(Amending Order 01-05, filed 11/29/01, effective 12/30/01)

WAC 182-08-095   Waiver of coverage for active employees.   (1) Active employees eligible for PEBB health care coverage have the option of waiving medical coverage for themselves and any or all dependents if they are covered by another medical plan. In order to waive medical coverage, the employee must complete an enrollment form that identifies the individuals for whom coverage is being waived. If an employee waives medical coverage for him/herself, coverage is automatically waived for all eligible dependents. An employee may choose to enroll only him/herself, and waive medical coverage for any or all dependents.

(2) Employees whose medical coverage is waived ((will)) must remain enrolled in a PEBB dental plan. Employees ((will)) must also remain enrolled in PEBB life and long term disability coverage.

(3) If PEBB medical coverage is waived, an otherwise eligible person may not enroll in a PEBB plan until the next open enrollment period, or within 31 days of loss of other medical coverage. Proof of other medical coverage ((is required to)) during the period of waived coverage must demonstrate that:

((1))) (a) Medical coverage was continuous from the date PEBB coverage was waived; and

((2))) (b) The period between loss of coverage and application for PEBB coverage is 31 days or less. The employee and dependents may have an additional opportunity to enroll ((in the event)) only as a result of acquisition of a new dependent ((as a result of)) due to marriage, birth, adoption, or placement for adoption, provided that enrollment is requested within 31 days of marriage or within 60 days of birth, adoption or placement for adoption of a child.

[Statutory Authority: RCW 41.05.160 and 41.05.065. 01-24-048 (Order 01-05), 182-08-095, filed 11/29/01, effective 12/30/01. Statutory Authority: RCW 41.05.160. 99-19-029 (Order 99-03), 182-08-095, filed 9/8/99, effective 10/9/99; 97-21-126, 182-08-095, filed 10/21/97, effective 11/21/97. Statutory Authority: Chapter 41.05 RCW. 96-08-042, 182-08-095, filed 3/29/96, effective 4/29/96.]


AMENDATORY SECTION(Amending WSR 96-08-042, filed 3/29/96, effective 4/29/96)

WAC 182-08-120   Employer contribution.   The ((PEBB has utilized the)) employers' contribution must be used to provide coverage for the basic life insurance benefit, a basic long term disability benefit, medical coverage, and dental coverage, and to establish a reserve for any remaining balance. There is no employer contribution available for any other insurance coverages.

[Statutory Authority: Chapter 41.05 RCW. 96-08-042, 182-08-120, filed 3/29/96, effective 4/29/96; 86-16-061 (Resolution No. 86-3), 182-08-120, filed 8/5/86; 83-22-042 (Resolution No. 6-83), 182-08-120, filed 10/28/83; Order 3-77, 182-08-120, filed 11/17/77; Order 7228, 182-08-120, filed 12/8/76.]


AMENDATORY SECTION(Amending Order 01-05, filed 11/29/01, effective 12/30/01)

WAC 182-08-125   PEBB-sponsored medical and dental benefit is limited to one enrollment per individual member.   (1) Effective January 1, 2002, individuals that have more than one source of eligibility for enrollment in PEBB((-sponsored)) medical and dental benefits (called "dual eligibility") are limited to one enrollment.

(2) One insurance-eligible employee may waive medical coverage for him/herself and enroll as a spouse or dependent on the coverage of his/her eligible spouse. This waiver option is not available for other insurance coverages.

(3) The following ((three)) examples describe typical situations of dual eligibility. These are not the only situations where dual eligibility may arise ((and)). These examples are provided as illustrations only.

(a) A husband and wife who are both insurance-eligible and employed by PEBB-participating employers, such as state agencies, may enroll only in medical or dental as an employee ((and)) but not also as a dependent. That is, the husband may enroll only under his employing agency and the wife may enroll only under her employing agency but not also as dependents of each other. In the alternative, one spouse may waive medical coverage as an employee and enroll as a dependent on the medical coverage of the other spouse.

(b) A dependent child that is eligible for coverage under two or more parents or stepparents who are employed by PEBB-participating employers, may be enrolled as a dependent under the coverage of one parent or stepparent, but not more than one.

(c) An employee employed in an insurance-eligible position by more than one PEBB-participating employer may enroll only under one employer. The employee may choose to enroll in insurance under the employer that:

(i) Offers the most favorable cost-sharing arrangement; or

(ii) Employed the employee for the longer period of time.

[Statutory Authority: RCW 41.05.160 and 41.05.065. 01-24-048 (Order 01-05), 182-08-125, filed 11/29/01, effective 12/30/01.]


AMENDATORY SECTION(Amending WSR 97-21-126, filed 10/21/97, effective 11/21/97)

WAC 182-08-175   Group coverage while on family and medical leave.   Employees on leave under the federal Family and Medical Leave Act of 1993, and regulations implementing that act, ((shall)) may continue to receive up to twelve weeks of employer-paid group medical, dental, basic life, and basic long-term disability insurance while on family and medical leave and may ((self-pay their)) also continue current optional life and long-term disability on a self-pay basis. All premiums that come due during the period of family and medical leave shall be paid monthly as they become due. If premiums are more than sixty days delinquent, coverage will be terminated as of the last day of the month of fully paid coverage. If an employee fails to return to work after expiration of family and medical leave for a reason other than the continuation, recurrence, or onset of a serious health condition or other circumstance beyond the control of the employee, the employer may recover the premiums paid to maintain the employee's insurance coverage from the employee.

[Statutory Authority: RCW 41.05.160. 97-21-126, 182-08-175, filed 10/21/97, effective 11/21/97. Statutory Authority: Chapter 41.05 RCW. 93-23-065, 182-08-175, filed 11/16/93, effective 12/17/93.]


AMENDATORY SECTION(Amending WSR 96-08-042, filed 3/29/96, effective 4/29/96)

WAC 182-08-180   ((Reimbursement payment of miscalculated premiums.)) Premium payments and refunds.   (1) Within ninety days after an event affecting eligibility, the subscriber or a dependent or beneficiary of a subscriber must notify HCA of any change in eligibility status, such as for example: Death, divorce, or when no longer a dependent as defined at WAC 182-12-119. Premium paid after such an event will be refunded in accordance with subsection (4) of this section.

(2) Premiums miscalculated will be adjusted by returning the excess charged premium, if any, to the employer ((or)), subscriber, or beneficiary, as appropriate. Errors producing an underpayment ((will)) must be reimbursed by the employer or subscriber((.)) to the HCA. Upon request of an employer, subscriber, or beneficiary, as appropriate, the HCA will develop a repayment plan ((that will)) designed not to create undue hardship on the employer or subscriber.

(3) Premium is due for the entire month of coverage and will not be prorated during the month of death or loss of eligibility of the enrollee.

(4) Premium refunds requested by a subscriber or a dependent or beneficiary must be presented to HCA within ninety days of the event. Refunds will not be made for more than three months of premium. Examples of such events include, but are not limited to, divorce, death of an employee or retiree, or death of a dependent of an employee or retiree, or situations where premium was paid on behalf of enrollees or dependents.

[Statutory Authority: Chapter 41.05 RCW. 96-08-042, 182-08-180, filed 3/29/96, effective 4/29/96; Order 01-77, 182-08-180, filed 8/26/77.]


AMENDATORY SECTION(Amending Order 02-03, filed 9/3/02, effective 10/4/02)

WAC 182-08-190   Employer contribution.   (1) Every department, division, or agency of state government, and such county, municipal or other political subdivisions as are covered under the PEBB plans, shall ((provide)) pay premium contributions to the HCA for insurance benefits for all of its insurance-eligible employees and their dependents.

((State)) (a) Employer contributions shall be set by the HCA and are subject to the approval of the governor.

(b) Employer contributions shall include an amount determined by the HCA to pay administrative costs to administer the plans for employees of these groups.

(c) Each eligible ((state)) employee in pay status for eight or more hours during a calendar month or for each eligible employee on family and medical leave shall be eligible for the employer contribution. The entire employer contribution is due and payable to HCA even if medical coverage is waived.

(d) Coverage for any county, municipality or other political subdivision or any K-12 school district may be terminated by HCA if the premium contributions are delinquent more than ninety days.

(2) For the period of July 1, 2002, to June 30, 2003, eligible state employees placed on temporary unpaid leave in order to implement the 2002 supplemental appropriations act are not required to have eight hours of pay status in order to maintain eligibility for the employer contribution for each month that they are on mandatory leave.

[Statutory Authority: RCW 41.05.160. 02-18-088 (Order 02-03), 182-08-190, filed 9/3/02, effective 10/4/02. Statutory Authority: Chapter 41.05 RCW. 96-08-042, 182-08-190, filed 3/29/96, effective 4/29/96; 93-23-065, 182-08-190, filed 11/16/93, effective 12/17/93; 78-02-015 (Order 2-78), 182-08-190, filed 1/10/78; Order 3-77, 182-08-190, filed 11/17/77.]


NEW SECTION
WAC 182-08-196   Health plan no longer available.   Active employees and retirees for whom the chosen health plan becomes unavailable must select a new health plan within thirty-one days after notification by HCA. Any person that fails to select a new plan within the prescribed time period will be enrolled in the Uniform Medical Plan by default. Any person defaulted to the Uniform Medical Plan may not change health plans until the next open enrollment.

[]


AMENDATORY SECTION(Amending WSR 96-08-042, filed 3/29/96, effective 4/29/96)

WAC 182-08-210   Termination of employer paid insurance benefit programs.   Coverage for a terminated employee, spouse ((and)) or dependent ((children)) child under the PEBB ((coverage)) medical, dental, and life insurance coverages ceases at 12:00 midnight, the last day of the month in which the employee is in pay status. Basic long term disability coverage ceases at 12:00 midnight the date ((your)) employment terminates or immediately upon the death of the employee.

[Statutory Authority: Chapter 41.05 RCW. 96-08-042, 182-08-210, filed 3/29/96, effective 4/29/96; Order 3-77, 182-08-210, filed 11/17/77.]


AMENDATORY SECTION(Amending WSR 96-08-042, filed 3/29/96, effective 4/29/96)

WAC 182-08-220   Advertising or promotion of PEBB sponsored benefit plans.   (1) In order to assure equal and unbiased representation of PEBB ((sponsored or approved benefit)) plans, any promotion of these plans shall comply with all of the following:

(((1))) (a) All materials describing PEBB plan benefits ((are to)) shall be prepared by or approved by the HCA prior to use.

(((2))) (b) Distribution or mailing of all plan benefit descriptions ((is to)) shall be performed by or under the direction of the HCA.

(((3))) (c) All media announcements or advertising by a carrier which include any mention of the "Public Employees Benefits Board," "health care authority" or any reference to coverage for "state employees or retirees" or any group of employees covered by PEBB plans, must receive the advance written approval of the HCA.

(2) Failure to comply with any or all of these requirements by a PEBB contracted ((plan)) carrier or ((plan)) subcontractor may result in contract termination by the HCA ((and/or HCA)), refusal to ((consider continued or renewed contracting)) continue or renew a contract with the noncomplying party, or both.

[Statutory Authority: Chapter 41.05 RCW. 96-08-042, 182-08-220, filed 3/29/96, effective 4/29/96; 91-20-163, 182-08-220, filed 10/2/91, effective 11/2/91; 86-16-061 (Resolution No. 86-3), 182-08-220, filed 8/5/86.]


REPEALER

     The following section of the Washington Administrative Code is repealed:
WAC 182-08-020 Duties and responsibilities.

OTS-6407.4


AMENDATORY SECTION(Amending Order 02-02, filed 9/3/02, effective 10/4/02)

WAC 182-12-111   Eligible entities and individuals.   The following entities and individuals shall be eligible to participate in PEBB insurance plans subject to the terms and conditions set forth below:

(1) State agencies. Every department, division, or separate agency of state government, including all state higher education institutions, ((including)) the higher education coordinating board, and the state board for community and technical colleges is ((eligible and)) required to participate in all PEBB approved plans. Insurance and health care contributions for ferry employees shall be governed by RCW 47.64.270.

(a) Employees of technical colleges previously enrolled in a benefits trust may terminate PEBB coverage by January 1, 1996, or the expiration of the current collective bargaining agreements, whichever is later. Employees electing to terminate PEBB coverage have a one-time re-enrollment option after a five year wait. Employees of a bargaining unit may terminate PEBB participation only as an entire bargaining unit. All administrative or managerial employees may terminate PEBB participation only as an entire unit.

(b) Technical colleges with employees enrolled in a benefits trust shall remit to the HCA a retiree remittance as specified in the omnibus appropriations act, for each full-time employee equivalent. The remittance may be prorated for employees receiving a prorated portion of benefits.

(2) Employee organizations. Employee organizations representing state civil service employees, and, effective October 1, 1995, employees of employee organizations currently pooled with employees of school districts for the purpose of purchasing insurance benefits, may participate in PEBB-sponsored benefits at the option of each employee organization provided all of the following requirements are met:

(a) All eligible employees of the entity must transfer to PEBB plan coverage as a unit. If the group meets the minimum size standards established by HCA, bargaining units may elect to participate separately from the whole group, and the nonrepresented employees may elect to participate separately from the whole group provided all nonrepresented employees join as a group.

(b) The PEBB medical plans ((are)) must be the only employer sponsored medical plans available to ((all)) eligible employees.

(c) The legislative authority ((of the entity)) or the board of directors ((submits)) of the entity must submit to the HCA an application together with employee census data and, if available, prior claims experience of the entity ((to the HCA)). The application to participate in the PEBB plans is subject to the approval of the HCA.

(d) The legislative authority or the board of directors ((agrees to)) must maintain its PEBB plan participation for a minimum of one full year, and ((then through)) may terminate participation only at the end of ((the)) a plan year.

(e) The terms and conditions for the payment of the insurance premiums shall be set forth in the provisions of the bargaining agreement or terms of employment and shall comply with the employer contribution requirements specified in the appropriate governing statute. These provisions, including eligibility, shall be subject to review and approval by the HCA at the time of application for participation. Any substantive changes ((will)) must be submitted to HCA.

(f) The eligibility requirements for dependents ((shall)) must be the same as the requirements for dependents of the state employees and retirees as defined in WAC 182-12-119.

(g) The legislative authority or the board of directors shall provide the HCA with written notice of its intent to terminate PEBB plan participation no ((later)) fewer than thirty days prior to the effective date of termination. If the employee organization terminates coverage in PEBB insurance plans, retired and disabled employees who began participating after September 15, 1991, ((will no longer be)) are not eligible to participate in PEBB insurance plans beyond the mandatory extension requirements specified in WAC 182-12-215.

(3) Blind vendors as defined in RCW 74.18.200: Vendors actively operating a business enterprise program facility in the state of Washington and deemed eligible by the department of services for the blind may voluntarily participate in PEBB insurance programs.

(a) Vendors that do not enroll when first eligible may enroll only during the annual open enrollment period offered by the health care authority or the first day of the month following loss of other coverage.

(b) Department of services for the blind will notify eligible vendors of their eligibility in advance of the date that they are eligible to apply for enrollment in PEBB insurance programs.

(c) The eligibility requirements for dependents of blind vendors shall be the same as the requirements for dependents of the state employees and retirees as defined in WAC 182-12-119.

(4) Local governments: Employees of a county, municipality, or other political subdivision of the state may participate in PEBB insurance programs provided all of the following requirements are met:

(a) All eligible employees of the entity must transfer to PEBB plan coverage as a unit. If the employer group meets the minimum size standards established by HCA, bargaining units may elect to participate separately from the whole group, and the nonrepresented employees may elect to participate separately from the whole group provided all nonrepresented employees join as a group.

(b) The PEBB medical plans ((are)) must be the only employer sponsored medical plans available to ((all)) eligible employees.

(c) The legislative authority ((of the entity)) or the board of directors ((submits)) of the entity must submit to the HCA an application together with employee census data and, if available, prior claims experience of the entity ((to the HCA)). The application to participate in the PEBB plans is subject to the approval of the HCA.

(d) The legislative authority or the board of directors ((agrees to)) must maintain its PEBB plan participation for a minimum of one full year, and ((then through)) may terminate participation only at the end of the plan year.

(e) The terms and conditions for the payment of the insurance premiums ((shall)) must be set forth in the provisions of the bargaining agreement or terms of employment and shall comply with the employer contribution requirements specified in the appropriate governing statute. These provisions, including eligibility, shall be subject to review and approval by the HCA at the time of application for participation. Any substantive changes ((will)) must be submitted to HCA.

(f) The eligibility requirements for dependents of local government employees ((shall)) must be the same as the requirements for dependents of the state employees and retirees as defined in WAC 182-12-119.

(g) The legislative authority or the board of directors shall provide the HCA with written notice of its intent to terminate PEBB plan participation no ((later)) fewer than thirty days prior to the effective date of termination. If a county, municipality, or political subdivision terminates coverage in PEBB insurance plans, retired and disabled employees who began participating after September 15, 1991, ((will no longer be)) are not eligible to participate in PEBB insurance plans beyond the mandatory extension requirements specified in WAC 182-12-215.

(5) K-12 school districts and educational service districts: Employees of school districts or educational service districts may participate in PEBB insurance programs provided all of the following requirements are met:

(a) All eligible employees of the entity must transfer to PEBB plan coverage as a unit. If the K-12 school district or educational service district meets the minimum size standards established by HCA, bargaining units may elect to participate separately from the whole group. For the purpose of enrolling by bargaining unit, all nonrepresented employees will be considered a single bargaining unit.

(b) The school district or educational service district must submit an application together with employee census data and, if available, prior claims experience of the entity to the HCA. The application to participate in the PEBB plans is subject to the approval of the HCA.

(c) The school district or educational service district ((obligates itself)) must agree to participate in all PEBB insurance plans. The PEBB medical plans ((are)) must be the only employer sponsored medical plans available to ((all)) eligible employees.

(d) The school district or educational service district ((agrees to)) must maintain its PEBB plan participation for a minimum of one full year, and ((then through)) may terminate participation only at the end of the plan year.

(e) Beginning September 1, 2003, the health care authority will collect an amount equal to the composite rate charged to state agencies plus an amount equal to the employee premium by plan and family size as would be charged to state employees for each participating school district((s)) or educational service district((s that begin participation on or after September 1, 2002, will pay the same composite rate as state agencies. The premium charged to eligible employees will be the same as that charged to state employees)). Each participating school district or educational service district must agree to collect an employee premium by plan and family size that is not less than that paid by state employees. The eligibility requirements for employees will be the same as those for state employees as defined in WAC 182-12-115.

(f) The eligibility requirements for dependents of K-12 school district and educational service district employees ((shall)) must be the same as the requirements for dependents of the state employees and retirees as defined in WAC 182-12-119.

(g) The school district or educational district ((shall)) must provide the HCA with written notice of its intent to terminate PEBB plan participation no ((later)) fewer than thirty days prior to the effective date of termination, and may terminate participation only at the end of a plan year.

(6) Eligible nonemployees:

(a) Dislocated forest products workers enrolled in the employment and career orientation program pursuant to chapter 50.70 RCW shall be eligible for PEBB medical and dental plan coverage while enrolled in that program.

(b) School board members or students eligible to participate under RCW 28A.400.350 may participate as long as they remain eligible under that section.

[Statutory Authority: RCW 41.05.160. 02-18-087 (Order 02-02), 182-12-111, filed 9/3/02, effective 10/4/02; 99-19-028 (Order 99-04), 182-12-111, filed 9/8/99, effective 10/9/99; 97-21-127, 182-12-111, filed 10/21/97, effective 11/21/97. Statutory Authority: Chapter 41.05 RCW. 96-08-043, 182-12-111, filed 3/29/96, effective 4/29/96. Statutory Authority: RCW 41.04.205, 41.05.065, 41.05.011, 41.05.080 and chapter 41.05 RCW. 92-03-040, 182-12-111, filed 1/10/92, effective 1/10/92. Statutory Authority: Chapter 41.05 RCW. 78-02-015 (Order 2-78), 182-12-111, filed 1/10/78.]


AMENDATORY SECTION(Amending WSR 96-08-043, filed 3/29/96, effective 4/29/96)

WAC 182-12-115      Eligible employees. The following employees of state government, higher education, K-12 school districts, educational service districts, political subdivisions and employee organizations representing state civil service workers are eligible to apply for PEBB insurance coverage ((by PEBB plans)). For purposes of defining eligible employees of school districts((,)) and educational service districts, ((the)) a collective bargaining agreement will supersede all definitions provided under this ((rule)) chapter 182-12 WAC only if approved by the ((PEBB and/or)) the HCA.

(1) "Permanent employees." Those who work at least half-time per month and are expected to be employed for more than six months. Coverage begins on the first day of the month following the date of employment. If the date of employment is the first working day of a month, coverage begins on the date of employment.

(2) "Nonpermanent employees." Those who work at least half-time and are expected to be employed for no more than six months. Coverage begins on the first day of the seventh month following the date of employment.

(3) "Seasonal employees." Those who work at least half-time per month during a designated season for a minimum of three months but less than nine months per year and who have an understanding of continued employment season after season. Coverage begins on the first day of the month following the date of employment. If the date of employment is the first working day of a month, coverage begins on the date of employment. However, seasonal employees are not eligible for the employer contribution during the break between seasons of employment but may be eligible to continue coverage by self-paying premiums.

(4) "Career seasonal/instructional year employees." Employees who work half-time or more on an instructional year (school year) or equivalent nine-month seasonal basis. Coverage begins on the first day of the month following the date of employment. If the date of employment is the first working day of the month, coverage begins on the date of employment. These employees are eligible to receive the employer contribution for insurance during the off-season following each period of seasonal employment.

(5) "Part-time faculty." Faculty who are employed on a quarter/semester to quarter/semester basis ((become)) are eligible to apply for coverage beginning with the second consecutive quarter/semester of half-time or more employment at one or more state institutions of higher education. Coverage begins on the first day of the month following the beginning of the second quarter/semester of half-time or more employment. If the first day of the second consecutive quarter/semester is the first working day of the month, coverage begins at the beginning of the second consecutive quarter/semester.

Employers of part-time faculty must:

(a) Consider spring and fall as consecutive quarters/semesters when determining eligibility; and

(b) Determine "halftime or more employment" based on each institution's definition of "full-time"; and

(c) At the beginning of each quarter/semester notify, in writing, all current and newly hired part-time faculty of their potential right to benefits under this section. ((The employee shall have the responsibility, each quarter, to notify the employers))

(d) Part-time faculty members employed at more than one institution are responsible for notifying each employer quarterly, in writing, of the employee's multiple employment. In no case will ((there be a requirement for)) retroactive coverage be permitted or employer contribution paid to HCA if a part-time faculty member fails to inform all of his/her employing institutions about employment at all institutions within the current quarter; and

(((d))) (e) Where concurrent employment at more than one state higher education institution is used to determine total part-time faculty employment of half-time or more, the employing institutions will arrange to prorate the cost of the employer insurance contribution based on the employment at each institution. However, if the part-time faculty member would be eligible by virtue of employment at one institution, that institution will pay the entire cost of the employer contribution regardless of other higher education employment. In cases where the cost of the contribution is prorated between institutions, one institution will forward the entire contribution monthly to HCA; and

(((e))) (f) Once enrolled, if a part-time faculty member does not work at least a total of half-time in one or more state institutions of higher education, eligibility for the employer contribution ceases.

(6) "Appointed and elected officials." Legislators are eligible to apply for coverage on the date their term begins. All other elected and full-time appointed officials of the legislative and executive branches of state government are eligible to apply for coverage on the date their term begins or they take the oath of office, whichever occurs first. Coverage for legislators begins on the first day of the month following the date their term begins. If the term begins on the first working day of the month, coverage begins on the first day of their term. Coverage begins for all other elected and full-time appointed officials of the legislative and executive branches of state government on the first day of the month following the date their term begins, or the first day of the month following the date they take the oath of office, whichever occurs first. If the term begins, or oath of office is taken, on the first working day of the month, coverage begins on the date the term begins, or the oath of office is taken.

(7) "Judges." Justices of the supreme court and judges of ((the)) courts of appeals and the superior courts become eligible to apply for coverage on the date they take the oath of office. Coverage begins on the first day of the month following the date their term begins, or the first day of the month following the date they take oath of office, whichever occurs first. If the term begins, or oath of office is taken, on the first working day of a month, coverage begins on the date the term begins, or the oath of office is taken.

[Statutory Authority: Chapter 41.05 RCW. 96-08-043, 182-12-115, filed 3/29/96, effective 4/29/96; 92-08-003, 182-12-115, filed 3/18/92, effective 3/18/92; 91-14-084, 182-12-115, filed 7/1/91, effective 7/1/91. Statutory Authority: RCW 41.05.065(3). 90-12-037, 182-12-115, filed 5/31/90, effective 7/1/90. Statutory Authority: RCW 41.05.065. 89-12-045 (Resolution No. 89-2), 182-12-115, filed 6/2/89; 89-01-053 (Resolution No. 88-6), 182-12-115, filed 12/15/88. Statutory Authority: RCW 41.05.010. 88-19-078 (Resolution No. 88-4), 182-12-115, filed 9/19/88; 88-12-034 (Resolution No. 88-1), 182-12-115, filed 5/26/88, effective 7/1/88. Statutory Authority: Chapter 41.05 RCW. 86-21-042 (Resolution No. 86-6), 182-12-115, filed 10/10/86; 83-12-007 (Order 2-83), 182-12-115, filed 5/20/83; 80-05-016 (Order 2-80), 182-12-115, filed 4/10/80; 78-08-071 (Order 5-78), 182-12-115, filed 7/26/78; Order 5646, 182-12-115, filed 2/9/76.]


AMENDATORY SECTION(Amending Order 01-01, filed 8/9/01, effective 9/9/01)

WAC 182-12-117   Eligible retirees.   (1) Eligible employees who terminate state service after becoming vested in a Washington state sponsored retirement system are eligible for retiree medical and dental coverages provided all of the following requirements are met:

(a) If the retiree ((and)) or covered dependent(s) ((are eligible for)) is entitled to Medicare((, elects Medicare Parts A and B if)) and the retiree retired after July 1, 1991 the Medicare-entitled retiree or Medicare-entitled dependent must enroll in Medicare Parts A and B; and

(b) The person submits an application form to enroll or ((waive)) defer PEBB medical and dental coverage within sixty days after active employer or continuous Consolidated Omnibus Budget Reconciliation Act (COBRA) coverage ends and is eligible for retiree benefits under one or more of the programs described in (c), (d), (e), (f), or (g) of this subsection;

(c) Except as provided in (c)(vii) of this subsection, the person immediately begins receiving a monthly retirement income benefit from one or more of the following retirement systems:

(i) Law enforcement officers' and fire fighters' retirement system plan 1 or 2;

(ii) Public employees' retirement system plan 1 or 2;

(iii) School employees' retirement system plan 2;

(iv) State judges/judicial retirement system;

(v) Teachers' retirement system plan 1 or 2; or

(vi) Washington state patrol retirement system.

(vii) Provided, however, that a lump-sum payment may be received in lieu of a monthly retiree income benefit payment under RCW 41.26.425(1), 41.32.762(1), 41.32.870(1), 41.35.410(1), 41.35.670(1), 41.40.625(1) or 41.40.815(1).

(d) The person is at least fifty-five years of age with at least ten years service credit and a member of one of the following retirement systems:

(i) Public employees' retirement system plan 3;

(ii) School employees' retirement system plan 3; and

(iii) Teachers' retirement system plan 3.

(e) The person is a member of state of Washington higher education retirement plan, and is:

(i) At least fifty-five years of age with at least ten years service; or

(ii) At least sixty-two years of age; or

(iii) Immediately begins receiving a monthly retirement income benefit.

(f) If not retiring under the public employees' retirement system, the person would have been eligible for a monthly retirement income benefit because of age and years of service had the person been employed under the provisions of public employees retirement system 1 or 2 for the same period of employment.

(g) The person is an elected official as defined under WAC 182-12-115(6) who has voluntarily or involuntarily left a public office, whether or not they receive a benefit from a state retirement system.

(2) Eligible employees who participate in the public employees' benefits board (PEBB) sponsored life insurance as an active employee and meet qualifications for retiree medical benefits as provided in subsection (1) of this section are eligible for PEBB sponsored retiree life insurance if they apply to the health care authority within sixty days after the date their active PEBB life insurance terminates and their premium is not being waived for any PEBB life insurance plan at the time of application for retiree life insurance.

(3) The following retired and disabled school district and educational service district employees are eligible to participate in PEBB medical and dental plans only, provided they meet all of the enrollment criteria stated below and if ((eligible for)) they are entitled to Medicare, are also enrolled in Medicare Parts A and B:

(a) Persons receiving a retirement allowance under chapter 41.32, 41.35 or 41.40 RCW as of September 30, 1993, and who enroll in PEBB plans not later than the end of the open enrollment period established by the authority for the plan year beginning January 1, 1995;

(b) Persons who separate from employment with a school district or educational service district due to a total and permanent disability, and are eligible to receive a deferred retirement allowance under chapter 41.32, 41.35 or 41.40 RCW. Such persons must enroll in PEBB plans not later than the end of the open enrollment period established by the authority for the plan year beginning January 1, 1995, or sixty days following retirement, whichever is later.

(4) ((Employees who are permanently and totally disabled and eligible for a deferred monthly retirement income benefit are eligible for medical, dental and life insurance benefits as provided in subsection (2) of this section, provided they apply for retiree coverage before their PEBB active employee coverage ends.

(5))) With the exception of the Washington state patrol, retirees and disabled employees are not eligible for an employer premium contribution.

(((6))) (5) The Federal Civil Service Retirement System shall be considered a Washington state sponsored retirement system for Washington State University cooperative extension service employees who hold a federal civil service appointment and who are covered under the PEBB program at the time of retirement or disability.

(6) Employees who do not elect enrollment in PEBB retiree coverage within sixty days of retirement, or who terminate PEBB retiree coverage within sixty days of retirement, or who terminate PEBB retiree coverage after retirement, are not eligible to reenroll in PEBB retiree coverage, unless they retired and deferred PEBB retiree coverage pursuant to WAC 182-12-132 or retired and deferred PEBB retiree coverage pursuant to WAC 182-12-200.

(7) If a retiree's coverage terminates for any reason, coverage will not be reinstated at a later date. Examples of termination include, but are not limited to, any one or more of the following:

(a) Failure to continue to meet eligibility requirements;

(b) Failure to pay the premium when due;

(c) Fraud, intentional misrepresentation or withholding of information the enrollee knew or should have known was material or necessary to accurately determine eligibility or the correct premium;

(d) Failure to provide information requested by the due date or knowingly providing false information;

(e) Abusive or offensive conduct repeatedly directed to an HCA employee, a health plan or other HCA contractor providing coverage on behalf of the PEBB program, its employees, or other persons; or

(f) Intentional misconduct.

(8) Enrollees may not enroll in retiree PEBB dental coverage unless they also enroll in retiree PEBB medical coverage.

(9) In order to continue retiree term life coverage, an election must be made within sixty days of retirement and premiums must be paid whether or not the retiree is otherwise employed. Election of retiree term life coverage may not be waived or deferred during periods of other coverage or otherwise.

[Statutory Authority: RCW 41.05.160. 01-17-042 (Order 01-01), 182-12-117, filed 8/9/01, effective 9/9/01; 97-21-127, 182-12-117, filed 10/21/97, effective 11/21/97. Statutory Authority: Chapter 41.05 RCW. 96-08-043, 182-12-117, filed 3/29/96, effective 4/29/96.]


AMENDATORY SECTION(Amending Order 02-02, filed 9/3/02, effective 10/4/02)

WAC 182-12-119   Eligible dependents.   "Eligible dependents." The following are eligible as dependents under the PEBB eligibility rules:

(1) Lawful spouse or "qualified domestic partner" (same sex domestic partner qualified through the declaration certificate issued by the health care authority).

(2) Dependent children through age nineteen. The term "children" includes the subscriber's natural children, stepchildren, legally adopted children, children for whom the subscriber has assumed a legal obligation for total or partial support of a child in anticipation of adoption of the child, children of the subscriber's qualified domestic partner, or children specified in a court order or divorce decree. Married children who qualify as dependents of the subscriber under the Internal Revenue Code, and extended dependents approved by the HCA are included. To qualify for HCA approval, the subscriber must demonstrate legal custody for the child with a court order, and the child:

(a) Must be living with the subscriber in a parent-child relationship; and

(b) ((Be dependent upon the subscriber for financial support; and

(c))) Must not be a foster child for whom support payments are made to the subscriber through the state department of social and health services (DSHS) foster care program.

(3) Dependent children age twenty through age twenty-three ((who are dependent upon the employee/retiree for maintenance and support,)) and who are registered students ((in full-time attendance)) at an accredited secondary school, college, university, vocational school, or school of nursing. Dependent student eligibility continues year-round for those who attend three of the four school quarters or two semesters and ((for)) and continues during the ((quarter)) three-month period following graduation provided the employee/retiree is covered at the same time((;)), the dependent ((limiting age has not been exceeded;)) has not reached age twenty-four, and the dependent meets all other eligibility requirements.

(4) Dependent children of any age who are incapable of self-support due to developmental or physical disability, provided such condition occurs prior to age twenty or during the time the dependent was covered under a PEBB plan as a ((full-time)) registered student. Proof of such disability must be furnished prior to the dependent's attainment of age twenty or loss of eligibility for student coverage, and as periodically requested thereafter.

(5) Dependent parents.

(a) Dependent parents covered under a PEBB medical plan before July 1, 1990, may continue enrollment on a self-pay basis as long as:

(((a))) (i) The parent maintains continuous coverage in a PEBB-sponsored medical plan;

(((b))) (ii) The parent ((continues to qualify)) qualifies under the Internal Revenue Code as a dependent of an eligible subscriber;

(((c))) (iii) The subscriber who claimed the parent as a dependent continues enrollment in a PEBB program; and

(((d))) (iv) The parent is not covered by any other group medical insurance.

(b) Dependent parents may be enrolled in a different PEBB plan than that selected by the eligible subscriber; however, dependent parents may not add additional family members to their coverage.

(6) Surviving dependents.

(a) The following surviving dependents may continue their medical and dental coverages on a self-pay basis:

(i) If a dependent loses eligibility under a PEBB plan due to the death of the employee, the dependent(s) may continue coverage under a retiree plan provided the dependent(s) will immediately begin receiving a monthly benefit from any state of Washington-sponsored retirement system ((()). The Federal Civil Service Retirement System shall be considered a Washington sponsored retirement system for Washington State University cooperative extension service employees who held a federal civil service appointment and who were covered under the PEBB program at the time of death(())).

(ii) If a surviving dependent of a PEBB employee is not eligible for a monthly retirement income benefit, or lump-sum payment because the monthly pension payment would be less than (($50)) the minimum amount established by the department of retirement systems, the dependent may be eligible for continued coverage under COBRA.

(iii) Dependents of retirees enrolled in the retiree's PEBB plan or ((waiving)) that waived coverage under a PEBB plan while eligible for an employer sponsored medical plan at the time of the retiree's death are eligible to continue PEBB retiree coverage.

(iv) Surviving spouses and/or eligible dependent children of a deceased school district or educational service district employee who were not enrolled in a PEBB plan at the time of death may continue coverage provided the employee died on or after October 1, 1993 and the dependent(s) immediately began receiving a retirement benefit allowance under chapter 41.32 or 41.40 RCW.

(b) Application for surviving dependent(s) coverage must be made in writing on the enrollment form approved by the health care authority within ((sixty)) ninety days from the date of death of the employee or retiree. Coverage is retroactive to the date the employee or retiree coverage terminated subject to the payment of the premium. In order to avoid duplication of group medical coverage, surviving dependents may defer or waive their enrollment in the PEBB coverage each full calendar month in which they maintain coverage under ((an)) another employer sponsored medical plan. Notice of intent to waive PEBB coverage must be sent in writing to the Washington state health care authority within ninety days from date of death. When an employer sponsored medical plan ends, surviving dependent(s) must submit an application to enroll in a PEBB plan within sixty days of the last day of coverage under the employer sponsored medical plan. Satisfactory evidence of continuous enrollment in an employer sponsored medical plan will be required by the Washington state health care authority prior to enrollment in a PEBB plan. The employee's or retiree's spouse or qualified domestic partner may continue coverage indefinitely; other dependents may continue coverage only until they lose eligibility under PEBB rules.

[Statutory Authority: RCW 41.05.160. 02-18-087 (Order 02-02), 182-12-119, filed 9/3/02, effective 10/4/02; 01-01-126 (Order 00-02), 182-12-119, filed 12/19/00, effective 1/19/01; 99-19-028 (Order 99-04), 182-12-119, filed 9/8/99, effective 10/9/99; 97-21-127, 182-12-119, filed 10/21/97, effective 11/21/97. Statutory Authority: Chapter 41.05 RCW. 96-08-043, 182-12-119, filed 3/29/96, effective 4/29/96.]


NEW SECTION
WAC 182-12-124   Determination by department of retirement systems of retroactive eligibility for PEBB pension.   (1) When the Washington state department of retirement systems (DRS) makes a formal determination that a person is retroactively eligible for pension benefits, that person may apply for PEBB retiree medical and dental benefits only if application is made within sixty days after the date of notice from DRS.

(2) All premium due from the date of eligibility established by DRS, or the date of the DRS decision letter, at the option of the retiree, must be sent with the application to HCA.

(3) The administrator may make an exception to the date PEBB retiree benefits commence or payment of premiums; however, such requests must demonstrate extraordinary circumstances beyond the control of the retiree.

[]


AMENDATORY SECTION(Amending Order 02-02, filed 9/3/02, effective 10/4/02)

WAC 182-12-132   ((Waiving or)) Deferring coverage at or following retirement.   (1)(a) Beginning January 1, 2001, retirees may ((waive)) defer enrollment in PEBB medical and dental coverage for themselves and all dependents at or following retirement if they are covered under another comprehensive employer sponsored medical plan as an active employee or as the spouse or same sex domestic partner of an active employee, or as a retiree or dependent of the spouse's or employee's retirement coverage from a federal retiree plan. (((Other coverage may be attained through the retiree's reemployment or the spouse's employment.) In order to continue retiree term life coverage, coverage must be selected upon retirement and premiums must continue to be paid during reemployment status.))

(b) In order to ((waive)) defer medical and dental coverage, the retiree must submit to the health care authority a PEBB enrollment form indicating ((their)) a desire to ((waive)) defer coverage ((to the health care authority)). ((This)) The notice of deferral must be ((accomplished)) received by the HCA prior to the date coverage is ((waived)) deferred or within sixty days of the date ((they are)) the retiree is eligible to apply for PEBB sponsored retiree benefits.

(c) When the retiree again ceases active employment, the retiree may enroll in PEBB medical and dental coverage with satisfactory evidence of continuous comprehensive employer-sponsored coverage within sixty days ((of the loss of)) after the last day of the retiree's other coverage.

(d) PEBB coverage will become effective the first of the month following the date other coverage ended.

(2) Election of retiree term life coverage may not be deferred during periods of other coverage or otherwise.

(3) Retirees and their eligible dependents who defer PEBB medical and dental coverage while enrolled as a retiree or dependent in a federal retiree plan will have a one-time opportunity to reenroll in PEBB medical and dental coverage. To reenroll in PEBB medical and dental coverage, retirees or their surviving dependents, must submit an enrollment form and proof of continuous enrollment in a federal retiree medical plan to the HCA either: (a) During any open enrollment period determined by the HCA; or (b) within sixty days after the date their other coverage ends.

[Statutory Authority: RCW 41.05.160. 02-18-087 (Order 02-02), 182-12-132, filed 9/3/02, effective 10/4/02; 01-01-126 (Order 00-02), 182-12-132, filed 12/19/00, effective 1/19/01; 97-21-127, 182-12-132, filed 10/21/97, effective 11/21/97. Statutory Authority: Chapter 41.05 RCW. 96-08-043, 182-12-132, filed 3/29/96, effective 4/29/96; 80-05-016 (Order 2-80), 182-12-132, filed 4/10/80.]


AMENDATORY SECTION(Amending WSR 96-08-043, filed 3/29/96, effective 4/29/96)

WAC 182-12-145   Insurance eligibility for higher education.   For the purpose of insurance eligibility, the ((PEBB)) HCA considers the higher education personnel board, the council for post secondary education, and the state board for community colleges to be higher education agencies.

[Statutory Authority: Chapter 41.05 RCW. 96-08-043, 182-12-145, filed 3/29/96, effective 4/29/96; Order 5646, 182-12-145, filed 2/9/76.]


AMENDATORY SECTION(Amending Order 02-03, filed 9/3/02, effective 10/4/02)

WAC 182-12-220   Eligibility during appeal of dismissal.   (1) Employees awaiting hearing of a dismissal action before the personnel appeals board, higher education personnel board or court may continue their PEBB coverages by self-payment of premium on the same terms as an employee who is granted leave without pay.

(2) If the hearing board or court upholds the dismissal, all coverages shall terminate at the end of the month in which the board or court's decision is made or the date to which premiums have been paid, whichever is earlier.

(3)(a) If the hearing board or court sustains the employee in the appeal and directs reinstatement of employer paid coverages retroactively, the employer must forward to the HCA the full employer contribution for the period directed by the hearing board or court and collect from the employee the employee's share of premiums due, if any.

((PEBB)) (b) The HCA will refund to the employee any premiums the employee paid that will be provided for by the reinstatement of the employer contribution provided the employee makes retroactive payment of any employee contribution amounts associated with the coverage.

(c) All optional life and long term disability insurance which was in force at the time of dismissal shall be reinstated retroactively, provided the employee makes retroactive payment of premium for any such optional coverage which was not continued by self-payment during the appeal process. If the employee chooses not to pay the retroactive premium, evidence of insurability will be required to obtain such optional coverage.

[Statutory Authority: RCW 41.05.160. 02-18-088 (Order 02-03), 182-12-220, filed 9/3/02, effective 10/4/02. Statutory Authority: Chapter 41.05 RCW. 96-08-043, 182-12-220, filed 3/29/96, effective 4/29/96; 86-16-061 (Resolution No. 86-3), 182-12-220, filed 8/5/86.]

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