WSR 06-06-079

PROPOSED RULES

HEALTH CARE AUTHORITY


(Public Employees' Benefits Board)

[ Order 06-02 -- Filed March 1, 2006, 7:50 a.m. ]

Original Notice.

Preproposal statement of inquiry was filed as WSR 06-02-091.

Title of Rule and Other Identifying Information: Sections in chapters 182-08 and 182-12 WAC that relate to employee health plan enrollment provisions, employee eligibility for the PEBB medical flexible spending account plan, and retiree eligibility.

Hearing Location(s): Health Care Authority, the Center Conference Room, 676 Woodland Square Loop S.E., Olympia, WA, on April 20, 2006, at 1:00 p.m.

Date of Intended Adoption: April 28, 2006.

Submit Written Comments to: Barbara Scott, 676 Woodland Square Loop S.E., P.O. Box 42684, Olympia, WA 98504-2684, e-mail bsco107@hca.wa.gov, fax (360) 923-2602, by April 20, 2006.

Assistance for Persons with Disabilities: Contact Nikki Johnson by April 12, 2006, TTY (888) 923-5622 or (360) 923-2805.

Purpose of the Proposal and Its Anticipated Effects, Including Any Changes in Existing Rules: The health care authority is proposing amendments to chapters 182-08 and 182-12 WAC to clarify the provision for an employee to postpone or interrupt the public employees' benefits board (PEBB) health plan enrollment for their self or a dependent; to clarify employee eligibility for participation in the PEBB medical flexible spending account plan; and to update PEBB retiree eligibility to include the new public safety employees' retirement system (PSERS). In addition WAC 182-12-133 is amended to replace the term "miliary service" with the broader term "uniformed service" as defined under the Uniformed Services Employment and Reemployment Act (USERRA). The use of the broader term will make it clearer that PEBB rules are compliant with the federal act. PEBB eligibility under the current rule extends continuation coverage to employees on any approved leave of absence for up to twenty-nine months which exceeds the minimum twenty-five month extension required by the federal act.

Reasons Supporting Proposal: These amendments are necessary to ensure that PEBB rules are clear and compliant with federal law.

Statutory Authority for Adoption: RCW 41.05.160.

Statute Being Implemented: RCW 41.05.065.

Rule is not necessitated by federal law, federal or state court decision.

Name of Proponent: Health care authority, governmental.

Name of Agency Personnel Responsible for Drafting and Implementation: Barbara Scott, 676 Woodland Square Loop, Lacey, WA, (360) 923-2642; and Enforcement: Mary Fliss, 676 Woodland Square Loop, Lacey, WA, (360) 923-2640.

No small business economic impact statement has been prepared under chapter 19.85 RCW. The joint administrative rules review committee has not requested the filing of a small business economic impact statement, and there will be no costs to small businesses.

A cost-benefit analysis is not required under RCW 34.05.328. RCW 34.05.328 does not apply to the health care authority rules unless requested by the joint administrative rules review committee or applied voluntarily.

March 1, 2006

Pete Cutler

Rules Coordinator

OTS-8647.1


AMENDATORY SECTION(Amending WSR 04-18-039, filed 8/26/04, effective 1/1/05)

WAC 182-08-015   Definitions.   The following definitions apply throughout this chapter unless the context clearly indicates other meaning:

"Administrator" means the administrator of the health care authority (HCA) or designee.

"Board" means the public employees' benefits board established under provisions of RCW 41.05.055.

"Decline" means to interrupt enrollment or postpone enrollment in a PEBB sponsored health plan by an employee (as defined in WAC 182-12-115) or a dependent who meets eligibility requirements set forth in WAC 182-12-260.

"Defer" means to postpone enrollment or interrupt enrollment in PEBB sponsored medical insurance by a retiree or surviving dependent.

"Dependent" means a person who meets eligibility requirements set forth in WAC 182-12-260.

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

"Effective date of enrollment" means the first date on which an enrollee is entitled to receive covered benefits.

"Extended dependent" means a dependent child who is not the child of an enrollee through birth, adoption, marriage, or a qualified same sex domestic partnership. Some examples of extended dependents include, but are not limited to, a grandchild or a niece or nephew for whom the enrollee is the legal guardian or the enrollee has legal custody.

"Health carrier" has the meaning set forth at RCW 48.43.005(18) for purposes of administering this Title 182 WAC only, it includes the uniform medical plan and uniform dental plan.

"Health plan" or "plan" means medical and dental coverage.

"Insurance coverage" means any health plan, life or long-term disability insurance plan administered as a PEBB benefit.

"LTD insurance" includes basic long-term disability insurance paid for by the employer and long-term disability insurance offered to employees on an optional basis.

"Life insurance" includes basic life insurance paid for by the employer and life insurance offered to employees on an optional basis.

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

"PEBB plan" or "PEBB benefits" means one or more insurance coverages approved by the public employees' benefits board for eligible enrollees and their dependents.

"Subscriber" or "insured" means the employee, retiree, COBRA beneficiary or surviving dependent who has been designated by the HCA as the individual to whom the HCA and the health carrier will issue all notices, information, requests and premium bills on behalf of enrolled dependents.

(("Waive" means to interrupt enrollment or postpone enrollment in a PEBB sponsored health plan by an employee (as defined in WAC 182-12-115) or a dependent who meets eligibility requirements set forth in WAC 182-12-260.))

[Statutory Authority: RCW 41.05.160 and 41.05.165. 04-18-039, 182-08-015, filed 8/26/04, effective 1/1/05; 03-17-031 (Order 02-07), 182-08-015, filed 8/14/03, effective 9/14/03. Statutory Authority: Chapter 41.05 RCW. 96-08-042, 182-08-015, filed 3/29/96, effective 4/29/96.]


AMENDATORY SECTION(Amending WSR 04-18-039, filed 8/26/04, effective 1/1/05)

WAC 182-08-190   The employer contribution shall be set by the HCA and paid to the HCA for all eligible employees.   Every department, division, or agency of state government, and such county, municipal or other political subdivision, K-12 school district or educational service district that are covered under PEBB insurance coverage, shall pay premium contributions to the HCA for insurance coverage for all eligible employees and their dependents.

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

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

(3) Each eligible employee in pay status eight or more hours during a calendar month or each eligible employee on leave under the federal Family and Medical Leave Act (FMLA) shall be eligible for the employer contribution. The entire employer contribution is due and payable to HCA even if medical coverage is ((waived)) declined.

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

[Statutory Authority: RCW 41.05.160 and 41.05.165. 04-18-039, 182-08-190, filed 8/26/04, effective 1/1/05; 03-17-031 (Order 02-07), 182-08-190, filed 8/14/03, effective 9/14/03. 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.]


AMENDATORY SECTION(Amending Order 05-01, filed 7/27/05, effective 8/27/05)

WAC 182-08-197   Newly eligible employees must select insurance coverages within thirty-one days of the date they become eligible to apply for coverage.   Newly eligible employees must select a medical and dental plan (if dental is available based on employer participation in PEBB insurance coverages) no later than thirty-one days after they become eligible to apply for coverage. Employees who do not select a medical and dental plan will be defaulted to Uniform Medical Plan Preferred Provider Organization and Uniform Dental Plan ((with existing dependent enrollment)).

[Statutory Authority: RCW 41.05.160, 41.05.350, and 41.05.165. 05-16-046 (Order 05-01), 182-08-197, filed 7/27/05, effective 8/27/05.]


AMENDATORY SECTION(Amending WSR 04-18-039, filed 8/26/04, effective 1/1/05)

WAC 182-08-230   Employer groups.   This section applies to all employer groups, K-12 school districts and educational service districts participating in PEBB insurance coverages.

(1) For purposes of this section, "employer group" means those employee organizations representing state civil service employees, blind vendors, 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 coverages.

(2)(a) Each employer group shall determine an employee's eligibility for PEBB insurance coverage in accordance with the applicable sections of chapter 182-12 WAC, RCW 41.04.205, and chapter 41.05 RCW.

(b) Each employer group, K-12 school district and educational service district applying for participation in PEBB insurance coverage shall submit required documentation and meet all participation requirements set forth in the then-current Introduction to PEBB Coverage K-12 and Employer Groups booklet(s).

(3)(a) Each employer group, K-12 school district or educational service district applying for participation in PEBB insurance coverage shall sign an interlocal agreement with the HCA.

(b) 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 HCA shall cause each employer group, K-12 school district or educational service district to be sent a monthly billing statement. The statement of premium due will be based upon the enrollment information provided by the employer group, K-12 school district or educational service district.

(a) Changes in enrollment status shall be submitted to the HCA 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) An employer group, K-12 school district or educational service district shall remit the monthly premium as billed or as reconciled by it.

(a) If an employer group, K-12 school district or educational service district determines that the invoiced amount requires one or more changes, they may adjust the 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, K-12 school district or educational service district 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, K-12 school district or educational service district shall remit the entire monthly premium due including the employee share, if any. The employer group, K-12 school district or educational service district 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, K-12 school district or educational service district to disenrollment and termination of each employee of the group.

(a) Prior to termination for nonpayment of premium, the HCA shall cause a notice of overdue premium to be sent to the employer group, K-12 school district or educational service district which notice will provide a one-month grace period for payment of all overdue premium.

(b) An employer group, K-12 school district or educational service district 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, K-12 school district or educational service district and each affected employee.

(d) Employer groups, K-12 school districts or educational service districts 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, K-12 school district or educational service district 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, K-12 school district or educational service district.

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

(g) The employer group, K-12 school district or educational service district is solely responsible for refunding any employee share paid by the employee to the employer group, K-12 school district or educational service district and not remitted to the HCA.

(8) A disenrolled employer group, K-12 school district or educational service district may apply for reinstatement in PEBB insurance coverages 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 delinquent 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, K-12 school districts or educational service districts 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, K-12 school district or educational service district disenrollment of an employer group, K-12 school district or educational service district or denial of reinstatement may be ((waived)) declined by the administrator upon a showing of good cause.

[Statutory Authority: RCW 41.05.160 and 41.05.165. 04-18-039, 182-08-230, filed 8/26/04, effective 1/1/05.]

OTS-8648.1


AMENDATORY SECTION(Amending WSR 04-18-039, filed 8/26/04, effective 1/1/05)

WAC 182-12-109   Definitions.   The following definitions apply throughout this chapter unless the context clearly indicates another meaning:

"Administrator" means the administrator of the HCA or designee.

"Board" means the public employees' benefits board established under provisions of RCW 41.05.055.

"Decline" means to interrupt enrollment or postpone enrollment in a PEBB sponsored health plan by an employee (as set forth in WAC 182-12-115) or a dependent who meets eligibility requirements set forth in WAC 182-12-260.

"Defer" means to postpone enrollment or interrupt enrollment in PEBB sponsored medical coverage by a retiree or surviving dependent.

"Dependent" means a person who meets eligibility requirements set forth in WAC 182-12-260.

"Effective date of enrollment" means the first date on which an enrollee is entitled to receive covered benefits.

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

"Extended dependent" means a dependent child who is not the child of an enrollee through birth, adoption, marriage, or a qualified same sex domestic partnership. Some examples of extended dependents include, but are not limited to, a grandchild or a niece or nephew for whom the enrollee is the legal guardian or the enrollee has legal custody.

"Health carrier" has the meaning set forth at RCW 43.43.005(18) for purposes of administering this Title 182 WAC only, it includes the uniform medical plan and the uniform dental plan.

"Health plan" or "plan" means medical and dental coverages.

"Insurance coverage" means any health plan, life, or long-term disability insurance plan administered as a PEBB benefit.

"LTD insurance" includes basic long-term disability insurance paid for by the employer and long-term disability insurance offered to employees on an optional basis.

"Life insurance" includes basic life insurance paid for by the employer and life insurance offered to employees on an optional basis.

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

"PEBB plan" or "PEBB benefits" means one or more insurance coverages approved by the public employees' benefits board for eligible enrollees and their dependents.

"Subscriber" or "insured" means the employee, retiree, COBRA beneficiary or surviving dependent who has been designated by the HCA as the individual to whom the HCA and the health carrier will issue all notices, information, requests and premium bills on behalf of enrolled dependents.

(("Waive" means to interrupt enrollment or postpone enrollment in a PEBB sponsored health plan by an employee (as set forth in WAC 182-12-115) or a dependent who meets eligibility requirements set forth in WAC 182-12-260.))

[Statutory Authority: RCW 41.05.160 and 41.05.165. 04-18-039, 182-12-109, filed 8/26/04, effective 1/1/05.]


AMENDATORY SECTION(Amending Order 05-01, filed 7/27/05, effective 8/27/05)

WAC 182-12-116   Who is eligible to participate in the PEBB flexible spending account ((program)) plan?   ((State agency employees, including those employed by)) Beginning January 1, 2006, all ((state)) employees of public four-year institutions of higher education ((institutions)), of the state community and technical colleges and of the ((higher education coordinating board, and the)) state board for community and technical colleges((,)) who are eligible for PEBB insurance benefits, as defined in WAC 182-12-115, are eligible to participate in the PEBB medical flexible spending account ((program)) plan. Beginning July 1, 2006, all employees of state agencies who are eligible for PEBB insurance benefits, are eligible to participate in the PEBB medical flexible spending account plan.

If an employee terminates employment after becoming a plan participant and later on in the same plan year is hired into a new position that is eligible for PEBB insurance benefits, the employee may not resume participation in the PEBB medical flexible spending account until the beginning of the next plan year.

[Statutory Authority: RCW 41.05.160, 41.05.350, and 41.05.165. 05-16-046 (Order 05-01), 182-12-116, filed 7/27/05, effective 8/27/05.]


AMENDATORY SECTION(Amending WSR 04-18-039, filed 8/26/04, effective 1/1/05)

WAC 182-12-123   Dual eligibility is prohibited.   Health plan coverage is limited to a single enrollment per individual.

(1) Effective January 1, 2002, individuals that have more than one source of eligibility for enrollment in PEBB health coverage (called "dual eligibility") are limited to one enrollment.

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

(3) The following examples describe typical situations of dual eligibility. These are not the only situations where dual eligibility may arise. 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 a health plan as an employee 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)) decline 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 health plan 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 a health plan 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 41.05.165. 04-18-039, 182-12-123, filed 8/26/04, effective 1/1/05.]


AMENDATORY SECTION(Amending WSR 04-18-039, filed 8/26/04, effective 1/1/05)

WAC 182-12-128   When may an employee ((waive enrollment in)) decline PEBB ((insurance)) coverage and later enroll?   (((1) Employees eligible for PEBB insurance coverage have the option of waiving health plan coverage if they are covered by other health plan coverage. If an employee waives health plan coverage, such coverage is automatically waived for all eligible dependents. An employee may choose to enroll only himself or herself, and waive either the medical or dental portion of the health plan coverage, or both, for any or all dependents. In order to waive enrollment, the employee must complete an enrollment form and list all enrollees for whom coverage is being waived.

(2) An employee may only waive the medical portion of health plan coverage. The employee must remain enrolled in the dental, life and LTD insurance coverages.

(3) If the medical portion of the health plan coverage is waived, an otherwise eligible enrollee may not rescind the waiver and reenroll in the medical portion of the health plan coverage except during the following times:

(a) The next open enrollment period; or

(b) Within sixty days of loss of other medical coverage if proof of enrollment in other comprehensive group medical coverage is submitted and demonstrates that:

(i) Enrollment in other medical coverage was continuous from the most recent open enrollment period for which PEBB medical coverage was waived; and

(ii) The period between loss of the other medical coverage and application for PEBB medical coverage is sixty days or less.

(4) If the dental portion of the health plan coverage is waived, an otherwise eligible dependent may not enroll in PEBB dental coverage except during the following times:

(a) The next open enrollment period; or

(b) Within sixty days after loss of other dental coverage if proof of enrollment in other dental coverage is submitted and demonstrates that:

(i) Enrollment in the other dental coverage was continuous from the most recent open enrollment period for which dental was waived; and

(ii) The period between loss of the other dental and application for PEBB dental coverage is sixty days or less.

(5) The employee and eligible dependents may have an additional opportunity to reenroll only as a result of addition of a new dependent due to marriage, birth, adoption, or placement for adoption, provided that advice of such enrollment is provided to HCA within thirty-one days after the marriage or within sixty days after the birth, adoption or placement for adoption of a child.)) (1) Employees may decline PEBB medical coverage if they have other comprehensive, group medical coverage. To decline medical coverage, the employee must complete an enrollment form. If an employee declines medical coverage, then medical coverage is automatically declined for all eligible dependents.

(2) An employee may only decline PEBB medical coverage. The employee must remain enrolled in dental, life, and long term disability.

(3) An employee can decline medical and/or dental coverage for any or all dependents.

(4) Once coverage is declined, enrollment is only allowed during the following times:

(a) The next open enrollment period; or

(b) After losing other coverage. The employee must submit proof:

(i) Coverage was comprehensive, group coverage;

(ii) Enrollment was continuous from the most recent PEBB open enrollment period; and

(iii) Of the date coverage was lost. Application to enroll in PEBB coverage must be made no later than sixty days after the date coverage was lost.

(c) As a result of addition of a new dependent due to marriage, birth, adoption, or placement for adoption. Application for enrollment must be made no later than sixty days after the change in family status.

[Statutory Authority: RCW 41.05.160 and 41.05.165. 04-18-039, 182-12-128, filed 8/26/04, effective 1/1/05.]


AMENDATORY SECTION(Amending WSR 04-18-039, filed 8/26/04, effective 1/1/05)

WAC 182-12-133   What options for continuing coverage are available to employees when they are no longer eligible for PEBB insurance coverage paid for by their employer?   Eligible employees covered by PEBB insurance coverage have options for providing continued coverage for themselves and their dependents during temporary or permanent loss of eligibility. Except in the case of approved family and medical leave, and except as otherwise provided, only employees in pay status eight or more hours per month are eligible to receive the employer contribution.

(1) When an employee is on leave without pay due to an event described in (a) through (f) of this subsection, insurance coverage may be continued at the group rate by self-paying premiums. Employees may self-pay for a maximum of twenty-nine months. The number of months that an employee self-pays premium during a period of leave without pay will count toward the total months of continuation coverage allowed under the federal Consolidated Omnibus Budget Reconciliation Act (COBRA). Employees may continue any combination of medical, dental and life insurance; however, only employees on approved educational leave may continue long term disability insurance. The following types of leave qualify to continue coverage under this provision:

(a) The employee is on authorized leave without pay;

(b) The employee is laid off because of a reduction in force (RIF);

(c) The employee is receiving time-loss benefits under workers' compensation;

(d) The employee is applying for disability retirement;

(e) The employee is called to active ((military)) duty in the uniformed services as defined under the Uniformed Services Employment and Reemployment Rights Act (USERRA); however, self-payment of life insurance is limited to twelve months from the date the employee is called to active duty;

(f) The employee is on approved educational leave.

(2) Part-time faculty may self-pay premium at the group rate between periods of eligibility for a maximum of eighteen months. Part-time faculty may continue any combination of medical, dental and life insurance.

(3) The federal Consolidated Omnibus Budget Reconciliation Act (COBRA) gives enrollees the right to continue group medical and dental coverage for a period of eighteen to thirty-six months when they lose eligibility due to one of the following qualifying events.

(a) Termination of employment.

(b) The employee's hours are reduced to the extent of losing eligibility.

(4) Employees who are approved for leave under the federal Family and Medical Leave Act (FMLA) are eligible to receive the employer contribution toward premium for up to twelve weeks, as provided in WAC 182-12-138.

[Statutory Authority: RCW 41.05.160 and 41.05.165. 04-18-039, 182-12-133, filed 8/26/04, effective 1/1/05.]


AMENDATORY SECTION(Amending WSR 04-18-039, filed 8/26/04, effective 1/1/05)

WAC 182-12-136   May an employee on approved educational leave ((waive)) decline PEBB health plan coverage?   In order to avoid duplication of group health plan coverage, the following shall apply to employees during any period of approved educational leave. Employees eligible for coverage provided in WAC 182-12-133 who obtain comprehensive health plan coverage under another group plan may ((waive)) decline continuance of such coverage for each full calendar month in which they maintain coverage under the other comprehensive group health plan. These employees have the right to reenroll in PEBB health plan coverage effective the first day of the month after the date the other comprehensive group health plan coverage terminates, provided proof of such other comprehensive group health plan coverage is provided to the HCA upon application for reenrollment.

[Statutory Authority: RCW 41.05.160 and 41.05.165. 04-18-039, 182-12-136, filed 8/26/04, effective 1/1/05.]


AMENDATORY SECTION(Amending Order 05-01, filed 7/27/05, effective 8/27/05)

WAC 182-12-171   Eligible retirees.   (1) Eligible employees who terminate public employment after becoming vested in a Washington state sponsored retirement system are eligible to continue PEBB sponsored insurance coverage as a retiree provided the following requirements in (a) and (b) of this subsection as well as one of (c) through (g) of this subsection are met:

(a) If the retiree or enrolled dependent(s) is entitled to Medicare and the retiree retired after July 1, 1991, the Medicare-entitled retiree or Medicare-entitled dependent must enroll in both Medicare Parts A and B; and

(b) The retiring employee must submit an election form to enroll or defer health plan coverage within sixty days after their employer paid 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 upon termination 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) Public safety employees' retirement system;

(iv) School employees' retirement system Plan 2;

(((iv))) (v) State judges/judicial retirement system;

(((v))) (vi) Teachers' retirement system Plan 1 or 2; or

(((vi))) (vii) Washington state patrol retirement system.

(((vii))) (viii) 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), 41.37.200(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 of state of Washington 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; or

(iii) Teachers' retirement system Plan 3.

(e) The person is a member of a 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 Plan 1 or Plan 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 the person receives a benefit from a state retirement system.

(2) Eligible employees who participate in PEBB sponsored life insurance as an active employee and meet qualifications for retiree insurance coverage as provided in subsection (1) of this section are eligible for PEBB sponsored retiree life insurance if they submit an election form no later than sixty days after the date their PEBB employee life insurance terminates, providing their employee life insurance premium is not being waived by the life insurance carrier at the time they elect retiree life insurance.

(3) The following retired and disabled school district and educational service district employees are eligible to participate in health plan coverage only, provided they meet all of the enrollment criteria stated below and, if they are entitled to Medicare, are also enrolled in both 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 health plan coverage 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 health plan coverage not later than the end of the open enrollment period established by the HCA for the plan year beginning January 1, 1995, or sixty days following retirement, whichever is later.

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

(5) The two federal retirement systems, Civil Service Retirement System and Federal Employees Retirement System, shall be considered a Washington state sponsored retirement system for Washington State University Extension employees who are covered under the PEBB insurance coverage at the time of retirement or disability.

(6) Employees who do not elect enrollment in PEBB retiree insurance coverage no later than sixty days immediately after termination of employment for retirement, or immediately after continuous Consolidated Omnibus Budget Reconciliation Act (COBRA) coverage ends, or who terminate PEBB retiree coverage no later than sixty days after retirement, or who terminate PEBB retiree coverage after retirement, are not eligible to reenroll in PEBB retiree insurance coverage unless they retired and deferred PEBB retiree coverage pursuant to WAC 182-12-205 or retired and deferred PEBB retiree coverage pursuant to WAC 182-12-200.

(7)(a) If a retiree's insurance 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:

(i) Failure to continue to meet eligibility requirements;

(ii) 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;

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

(iv) 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

(v) Intentional misconduct.

(b) If a retiree fails to pay the premium when due or an underpayment of premium is made, PEBB sponsored insurance coverage will terminate on the last day of the month for which the last full premium was received.

(c) Notwithstanding (a) of this subsection, the PEBB assistant administrator or designee may approve reinstatement of insurance coverage if the retiree or their dependent or beneficiary submits a written appeal and provides proof that extraordinary circumstances made it virtually impossible to make the payment and the retiree agrees to make payment in accordance with the terms of an agreement with the HCA. No insurance coverage will be reinstated more than three times.

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

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

[Statutory Authority: RCW 41.05.160, 41.05.350, and 41.05.165. 05-16-046 (Order 05-01), 182-12-171, filed 7/27/05, effective 8/27/05. Statutory Authority: RCW 41.05.160 and 41.05.165. 04-18-039, 182-12-171, filed 8/26/04, effective 1/1/05.]


AMENDATORY SECTION(Amending Order 05-01, filed 7/27/05, effective 8/27/05)

WAC 182-12-205   Retirees may defer enrollment in PEBB health plan coverage at or following retirement.   (1) Beginning January 1, 2001, retirees may defer enrollment in health plan coverage at or following retirement if they are continuously covered under:

(a) Comprehensive employer sponsored medical coverage as an employee or as the spouse or same sex domestic partner of an employee; or

(b) As a retiree or as the spouse or as the same sex domestic partner of a retiree's retirement insurance from a federal retiree plan.

(2) If a retiree defers enrollment in PEBB health plan coverage, coverage is automatically ((waived)) declined for all eligible dependents.

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

(4) In order to defer health plan coverage, a retiree must submit the appropriate form to the PEBB program requesting deferment of coverage. The notice of deferral must be received by PEBB benefit services prior to the date coverage is deferred or within sixty days after the date the retiree is eligible to apply for PEBB sponsored retiree benefits.

(5) Retirees may reenroll in PEBB coverage following the end of a deferral period under conditions listed below.

(a) Retirees who defer PEBB health plan coverage while enrolled in employer sponsored medical coverage, may reenroll in PEBB health plan coverage by submitting the appropriate form(s) and satisfactory evidence of continuous enrollment in comprehensive employer sponsored coverage to the PEBB program:

(i) During an annual open enrollment period; or

(ii) No later than sixty days after the last day of the employer sponsored coverage.

(b) Retirees who defer PEBB health plan coverage while enrolled as a retiree or dependent of a retiree in a federal retiree plan will have a one-time opportunity to reenroll in PEBB health plan coverage by submitting the appropriate form(s) and satisfactory evidence of continuous enrollment in a federal retiree medical plan to the PEBB program:

(i) During an annual open enrollment period; or

(ii) No later than sixty days after the date their federal retiree coverage ends.

(c) PEBB health plan enrollment will be effective the first day of the month following the date employer sponsored coverage or coverage under a federal retiree plan ended, except that reenrollment in PEBB insurance coverage during the annual open enrollment will become effective the first day of January following the open enrollment period.

[Statutory Authority: RCW 41.05.160, 41.05.350, and 41.05.165. 05-16-046 (Order 05-01), 182-12-205, filed 7/27/05, effective 8/27/05. Statutory Authority: RCW 41.05.160 and 41.05.165. 04-18-039, 182-12-205, filed 8/26/04, effective 1/1/05.]


AMENDATORY SECTION(Amending Order 05-01, filed 7/27/05, effective 8/27/05)

WAC 182-12-265   What options for continuing health plan coverage are available to widows, widowers and dependent children if the employee or retiree dies?   (1) Dependents that lose eligibility due to the death of an eligible employee may continue health plan coverage under a retiree plan provided they immediately begin receiving a monthly retirement benefit from any state of Washington sponsored retirement system.

(a) The employee's spouse or qualified same sex domestic partner may continue coverage until death.

(b) Other dependents may continue coverage until they lose eligibility under PEBB rules.

(c) If a surviving dependent of an eligible employee is not eligible for a monthly retirement benefit or a lump-sum payment because the monthly pension payment would be less than the minimum amount established by the department of retirement systems, the dependent may continue health plan coverage under provisions of the federal Consolidated Omnibus Budget Reconciliation Act (COBRA) or WAC 182-12-270.

(d) The two federal retirement systems, Civil Service Retirement System and Federal Employees Retirement System, shall be considered a Washington sponsored retirement system for Washington State University extension service employees who were covered under PEBB insurance coverage at the time of death.

(2) Dependents that lose eligibility due to the death of a PEBB eligible retiree may continue health plan coverage under a retiree plan.

(a) The retiree's spouse or qualified same sex domestic partner may continue coverage until death.

(b) Other dependents may continue coverage until they lose eligibility under PEBB rules.

(c) Dependents that are ((waiving)) declining PEBB health plan coverage at the time of the retiree's death are eligible to enroll or defer PEBB retiree coverage. A form to enroll or defer PEBB health plan coverage must be hand-delivered or mailed to PEBB benefit services no later than sixty days after the retiree's death. To enroll in PEBB health plan coverage, the dependent must provide satisfactory evidence that enrollment in other health plan coverage was continuous from the most recent open enrollment period for which PEBB coverage was waived.

(3) Surviving spouses or eligible dependent children of a deceased school district or educational service district employee who were not enrolled in PEBB insurance coverage at the time of the subscriber's death may enroll in PEBB sponsored health plan 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, 41.35 or 41.40 RCW.

(a) The employee's spouse or qualified same-sex domestic partner may continue health plan coverage until death.

(b) Other dependents may continue coverage until they lose eligibility under PEBB rules.

(4) Application for surviving dependent coverage must be made in writing on an election form approved by PEBB no later than sixty days after the date of death of the employee or retiree. Coverage is retroactive to the date the employee or retiree insurance coverage terminated subject to the payment of premium. In order to avoid duplication of group medical coverage, surviving dependents may defer enrollment in PEBB health plan coverage for each full calendar month in which they maintain coverage under other employer sponsored comprehensive medical coverage. Notice of intent to defer PEBB coverage must be sent in writing to PEBB benefit services no later than sixty days after the date of death of the subscriber.

(5) Surviving dependents that defer coverage while enrolled in an employer sponsored comprehensive medical plan must submit an application to reenroll in PEBB coverage no later than sixty days after the last day of coverage under the employer sponsored medical plan. Satisfactory evidence of continuous enrollment in an employer sponsored comprehensive medical coverage will be required by the PEBB program prior to reenrollment in a PEBB health plan.

[Statutory Authority: RCW 41.05.160, 41.05.350, and 41.05.165. 05-16-046 (Order 05-01), 182-12-265, filed 7/27/05, effective 8/27/05. Statutory Authority: RCW 41.05.160 and 41.05.165. 04-18-039, 182-12-265, filed 8/26/04, effective 1/1/05.]

Washington State Code Reviser's Office