WSR 07-17-096

PROPOSED RULES

HEALTH CARE AUTHORITY


(Public Employees Benefits Board)

[ Order 07-01 -- Filed August 16, 2007, 1:37 p.m. ]

Supplemental Notice to WSR 07-14-135.

Preproposal statement of inquiry was filed as WSR 07-09-034.

Title of Rule and Other Identifying Information: PEBB rules related to enrollment in chapter 182-08 WAC; eligibility in chapter 182-12 WAC; and appeals in chapter 182-16 WAC.

Hearing Location(s): Health Care Authority, 676 Woodland Square Loop S.E., The Sue Crystal Center, Olympia, WA, on September 25, 2007, at 3:30 p.m.

Date of Intended Adoption: September 28, 2007.

Submit Written Comments to: Barbara Scott or Ashley DeMoss, PEBB Benefits Services Program, P.O. Box 42684, Olympia, WA 98504-2684, e-mail Barbara.scott@hca.wa.gov, fax (360) 923-2606, by September 25, 2007.

Assistance for Persons with Disabilities: Contact Nikki Johnson by September 21, 2007, 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 additional clarifying amendments to the following rules:

WAC 182-08-180, proposed language will clarify when premium payments begin for insurance coverage for retirees, COBRA beneficiaries or individuals continuing coverage under PEBB extension of coverage rules.

WAC 182-12-171, proposed language will clarify PEBB retiree eligibility criteria by stating that eligible employees must meet their retirement plan's age and years of service requirement when their employer paid or COBRA coverage ends. Proposed language corrects the placement of language allowing certain eligible employees who are not a member of the Washington state-sponsored public employee's retirement system (PERS) to qualify based on the age and years of service requirements under PERS Plan 1 or Plan 2. Proposed language restores eligibility language for employees who are permanently and totally disabled, correcting an administrative error from an earlier rule making.

WAC 182-16-030, proposed language will create additional appeal rights for employees who meet their retirement plan age requirement within sixty days of their employer paid or COBRA coverage ending.

Statutory Authority for Adoption: Chapter 41.05 RCW.

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

Name of Proponent: , governmental.

Name of Agency Personnel Responsible for Drafting: Barbara Scott, 676 Woodland Square Loop, Lacey, WA, (360) 923-2642; Implementation: Ashley DeMoss, 676 Woodland Square Loop, Lacey, WA, (360) 923-2644; 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.

August 16, 2007

Jason Siems

Rules Coordinator

OTS-9818.3


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

WAC 182-08-010   Declaration of purpose.   The general purpose of this chapter is to establish a set of rules ((used by)) to administer the health care authority's (HCA) public employees benefits board (PEBB) ((for designing)) employee and retiree eligibility and ((insurance)) PEBB benefits ((and for administration of these insurance plans by the Washington State Health Care Authority (HCA))).

[Statutory Authority: Chapter 41.05 RCW. 96-08-042, 182-08-010, filed 3/29/96, effective 4/29/96; Order 7228, 182-08-010, filed 12/8/76.]


AMENDATORY SECTION(Amending Order 06-09, filed 11/22/06, effective 12/23/06)

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.

"Comprehensive employer sponsored medical" includes insurance coverage continued by the employee or their dependent under COBRA.

"Creditable coverage" means coverage that meets the definition of "creditable coverage" under RCW 48.66.020 (13)(a) and includes payment of medical and hospital benefits.

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

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

"Effective date of enrollment" means the first date when 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.

(("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 a medical ((and)) or dental ((coverage)) plan developed by the public employees benefits board and provided by a contracted vendor or self-insured plans administered by the HCA.

"Insurance coverage" means any health plan, life ((or)) insurance, long-term care insurance, long-term disability insurance ((plan)), or property and casualty insurance 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, and retiree life insurance.

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

(("PEBB plan" or)) "PEBB" means the public employees benefits board.

"PEBB benefits" means one or more insurance coverage((s approved)) or other employee benefit administered by the ((public employees' benefits board for eligible enrollees and their dependents)) PEBB benefit services program within the HCA.

"PEBB benefits services program" means the program within the health care authority which administers insurance and other benefits to eligible employees of the state (as defined in WAC 182-12-115), eligible retired and disabled employees of the state (as defined in WAC 182-12-171), and others as defined in RCW 41.05.011.

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

"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 41.05.068. 06-23-165 (Order 06-09), 182-08-015, filed 11/22/06, effective 12/23/06. 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 Order 02-07, filed 8/14/03, effective 9/14/03)

WAC 182-08-120   Employer contribution.   The employers' contribution must be used to provide insurance 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 coverage((s)).

[Statutory Authority: RCW 41.05.160 and 41.05.165. 03-17-031 (Order 02-07), 182-08-120, filed 8/14/03, effective 9/14/03. 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 WSR 04-18-039, filed 8/26/04, effective 1/1/05)

WAC 182-08-180   Premium payments and refunds.   PEBB premium payments for retiree, COBRA or an extension of PEBB insurance coverage begin to accrue the first of the month after other insurance ends. The effective date of health plan enrollment will be retroactive to the loss of other coverage.

Premium is due for the entire month of insurance coverage and will not be prorated during the month of death or loss of eligibility of the enrollee except when eligible for life insurance conversion.

PEBB premiums will be refunded using the following method:

(1) When a PEBB subscriber submits an enrollment change affecting eligibility, such as for example: Death, divorce, or when no longer a dependent as defined at WAC 182-12-260 no more than three months of accounting adjustments and any excess premium paid will be refunded to any individual or agency except as ((provided)) indicated in WAC 182-12-148(3).

(2) Notwithstanding subsection (1) of this section, the PEBB assistant administrator or designee may approve a refund which does not exceed twelve months of premium ((provided)) if both of the following occur:

(a) The PEBB subscriber or a dependent or beneficiary of a subscriber submits a written appeal to the HCA; and

(b) Proof is provided that extraordinary circumstances beyond the control of the subscriber, dependent or beneficiary made it virtually impossible to submit the necessary information to accomplish an enrollment change within sixty days after the event that created a change of premium.

(3) Errors resulting in an underpayment to HCA 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 designed not to create undue hardship on the employer or subscriber.

(4) HCA errors will be adjusted by returning the excess premium paid, if any, to the employer, subscriber, or beneficiary, as appropriate.

(((5) 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 except when eligible for life insurance conversion.))

[Statutory Authority: RCW 41.05.160 and 41.05.165. 04-18-039, 182-08-180, filed 8/26/04, effective 1/1/05; 03-17-031 (Order 02-07), 182-08-180, filed 8/14/03, effective 9/14/03. 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 WSR 04-18-039, filed 8/26/04, effective 1/1/05)

WAC 182-08-190   The employer contribution ((shall be)) is 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)) must pay premium contributions to the HCA for insurance coverage for all eligible employees and their dependents.

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

(2) Employer contributions ((shall)) must 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)) are eligible for the employer contribution. The entire employer contribution is due and payable to HCA even if medical ((coverage)) is waived.

(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)) canceled by HCA if the premium contributions are delinquent more than ninety days.

(5) Washington state patrol officers disabled while performing their duties as determined by the chief of the Washington state patrol are eligible for the employer contribution for PEBB benefits as authorized in RCW 43.43.040. No other retiree or disabled employee is eligible for the employer contribution for PEBB benefits unless they are an eligible employee as defined in WAC 182-12-115.

[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 182-08-196   What happens if my health ((carrier)) plan becomes unavailable?   Employees and retirees for whom the chosen health ((carrier)) plan becomes unavailable due to a change in service area, the health ((carrier)) plan no longer contracting with HCA, or the retiree's entitlement to Medicare must select a new health plan within sixty days after notification by the PEBB benefit services program.

(1) Employees ((that)) who fail to select a new ((health)) medical or dental plan within the prescribed time period will be enrolled in the health ((carrier's)) plan's successor plan if one is available or will be enrolled in the Uniform Medical Plan ((and)) Preferred Provider Organization or the Uniform Dental Plan with existing dependent enrollment ((by default)).

(2) Retirees and ((surviving dependents)) survivors eligible under WAC 182-12-250 or 182-12-265 ((that)) who fail to select a new health plan within the prescribed time period will be enrolled in the health ((carrier's)) plan's successor plan if one is available or will be enrolled in the Uniform Medical Plan Preferred Provider Organization and the Uniform Dental Plan((, except that)). However, retirees enrolled in Medicare Parts A and B, and who enroll in Medicare Part D may be ((defaulted)) assigned to a PEBB((-sponsored)) Medicare plan that does not include a pharmacy benefit.

Any ((employee or retiree defaulted to a carrier's successor plan, the Uniform Medical Plan or the Uniform Dental Plan)) subscriber assigned to a health plan as described in this rule may not change health plans until the next open enrollment except as ((set forth)) allowed in WAC 182-08-198.

(3) Enrollees continuing PEBB health plan ((coverage as provided in)) under WAC 182-12-133, 182-12-148 or 182-12-270 (2) or (3) must select a new health plan no later than sixty days after notification by the PEBB benefit services program or their health plan ((coverage)) enrollment will ((terminate)) end as of the last day of the month in which the plan is no longer available.

[Statutory Authority: RCW 41.05.160, 41.05.350, and 41.05.165. 05-16-046 (Order 05-01), 182-08-196, filed 7/27/05, effective 8/27/05. Statutory Authority: RCW 41.05.160 and 41.05.165. 04-18-039, 182-08-196, filed 8/26/04, effective 1/1/05; 03-17-031 (Order 02-07), 182-08-196, filed 8/14/03, effective 9/14/03.]


AMENDATORY SECTION(Amending Order 06-02, filed 5/24/06, effective 6/24/06)

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)) for PEBB benefits.   (1) Employees who are newly eligible ((employees)) for PEBB benefits must ((select a medical and dental plan (if dental is available based on employer participation in PEBB insurance coverages))) complete an enrollment form indicating their health plan choice and return it to their employing agency no later than thirty-one days after they become eligible to apply for ((coverage)) PEBB benefits, as stated in WAC 182-12-115. Newly eligible employees who do not ((select a)) return an enrollment form to their employing agency indicating their medical and dental ((plan)) choice within thirty-one days will be ((defaulted to Uniform Medical Plan Preferred Provider Organization and Uniform Dental Plan)) enrolled in a health plan as follows:

(a) Medical enrollment will be Uniform Medical Plan Preferred Provider Organization; and

(b) Dental enrollment (if the employing agency participates in PEBB dental) will be Uniform Dental Plan.

(2) Newly eligible employees may enroll in optional insurance coverage (except for employees of agencies that do not participate in life insurance or long-term disability insurance).

(a) To enroll in the amounts of optional life insurance available without health underwriting, employees must return a completed life insurance enrollment form to their agency no later than sixty days after becoming eligible for PEBB benefits.

(b) To enroll in optional long-term disability insurance without health underwriting, employees must return a completed long-term disability enrollment form to their agency no later than thirty-one days after becoming eligible for PEBB benefits.

(c) To enroll in long-term care insurance with limited health underwriting, employees must return a completed long-term care enrollment form to the contracted vendor no later than thirty-one days after becoming eligible for PEBB benefits.

(d) Employees may apply for optional life, long-term disability, and long-term care insurance at any time by providing evidence of insurability and receiving approval from the contracted vendor.

(3) When an employee's employment ends, insurance coverage ends (WAC 182-12-131). Employees who are later reemployed and become eligible for PEBB benefits enroll as described in subsections (1) and (2) of this section, with the following exceptions in which insurance coverage elections stay the same:

(a) When an employee transfers from one agency to another agency without a break in state service. This includes movement of employees between any agencies described as eligible groups in WAC 182-12-111 and participating in PEBB benefits.

(b) When employees have a break in state service that does not interrupt their employer contribution-based enrollment in PEBB insurance coverage.

(c) When employees continue insurance coverage under WAC 182-12-133 (1) or (2) and are reemployed into a benefits eligible position before the end of the maximum number of months allowed for continuing PEBB health plan enrollment. Employees who are eligible to continue optional life or optional long-term disability but discontinue that insurance coverage are subject to the insurance underwriting requirements if they apply for the insurance when they return to employment.

[Statutory Authority: RCW 41.05.160. 06-11-156 (Order 06-02), 182-08-197, filed 5/24/06, effective 6/24/06. 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 Order 06-09, filed 11/22/06, effective 12/23/06)

WAC 182-08-198   When may ((an enrollee)) a subscriber change health plans?   (1) ((Enrollees)) Subscribers may change health plans during the annual open enrollment. The enrollee must request the health plan change no later than the end of the open enrollment period. Enrollment in the new health plan(('s coverage)) will begin the first day of January after open enrollment.

(2) ((Enrollees)) Subscribers may change health plans outside of the annual open enrollment period under ((some)) the circumstances indicated below. To make a health plan change, the ((enrollee)) subscriber must send a completed enrollment form (and a completed disenrollment form, if required) to the PEBB benefits services program no later than sixty days after the event occurs. Enrollment in the new health plan(('s coverage)) will begin the first day of the month after the PEBB benefits services program receives the form(s). These are the circumstances:

(a) Enrollees ((may change health plans if they)) move and their current health plan is not available in their new location. If the ((enrollee)) subscriber does not select a new health plan, the PEBB benefits services program ((will automatically)) may enroll them in the Uniform Medical Plan Preferred Provider Organization or Uniform Dental Plan.

(b) Enrollees ((may change health plans if they)) move and a health plan that was not available to them before is available to them in the new location. The ((enrollee)) subscriber may only choose a newly available health plan.

(c) ((Enrollees)) Subscribers may change health plans if a court order requires the ((enrollee)) subscriber to provide insurance coverage for an eligible spouse, ((same-sex)) qualified domestic partner, or child and the ((enrollee)) subscriber adds the dependent to their insurance coverage.

(d) Seasonal employees whose off-season is during the annual open enrollment period may select a new health plan upon their return to work.

(e) ((Employees)) Subscribers may change health plans when they enroll in PEBB retiree insurance coverage.

(f) ((Enrollees)) Subscribers may change health plans when they or an eligible dependent becomes entitled to Medicare or enrolls in a Medicare Part D plan.

(g) ((Enrollees)) Subscribers may change health plans if they or their enrolled dependent reaches their medical plan's lifetime maximum.

(h) Subscribers may not change their health plan if their or an enrolled dependent's physician stops participation with the ((enrollee's)) subscriber's health plan unless the PEBB appeals manager determines that a continuity of care issue exists. However, if the employee is having premiums taken from payroll on a pretax basis a plan change will not be approved if it would conflict with provisions of the benefits contribution plan authorized under RCW 41.05.300. The PEBB appeals manager will use criteria that include but are not limited to the following in determining if a continuity of care issue exists:

(i) Active cancer treatment; or

(ii) Recent transplant (within the last twelve months); or

(iii) Scheduled surgery within the next sixty days; or

(iv) Major surgery within the previous sixty days; or

(v) Third trimester of pregnancy; or

(vi) Language barrier.

(((h) Enrollees may change health plans if they reach their medical plan's lifetime maximum.))

[Statutory Authority: RCW 41.05.160 and 41.05.068. 06-23-165 (Order 06-09), 182-08-198, filed 11/22/06, effective 12/23/06. Statutory Authority: RCW 41.05.160, 41.05.350, and 41.05.165. 05-16-046 (Order 05-01), 182-08-198, filed 7/27/05, effective 8/27/05.]


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

WAC 182-08-200   Which employing agency is responsible to pay the employer contribution for eligible employees changing agency employment?   When an eligible employee's employment ceases with an employing agency at any time ((prior to)) before the end of the month for which a premium contribution is due and that employee transfers to another agency, the losing agency is responsible for the payment of the contribution for that employee for that month. The receiving agency would not be liable for any employer contribution for that eligible employee until the month following the transfer.

[Statutory Authority: RCW 41.05.160 and 41.05.165. 04-18-039, 182-08-200, filed 8/26/04, effective 1/1/05. Statutory Authority: Chapter 41.05 RCW. 96-08-042, 182-08-200, filed 3/29/96, effective 4/29/96; Order 3-77, 182-08-200, filed 11/17/77.]


AMENDATORY SECTION(Amending Order 02-07, filed 8/14/03, effective 9/14/03)

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

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

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

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

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

[Statutory Authority: RCW 41.05.160 and 41.05.165. 03-17-031 (Order 02-07), 182-08-220, filed 8/14/03, effective 9/14/03. 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.]


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

WAC 182-08-230   Participation in PEBB benefits by employer groups, K-12 school districts and educational service districts.   This section applies to all employer groups, K-12 school districts and educational service districts participating in PEBB insurance coverage((s)).

(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 coverage((s)).

(2)(a) Each employer group ((shall)) must 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)) must 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)) must sign an interlocal agreement with the HCA.

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

(4) At least twenty days ((prior to)) before the premium due date, the HCA ((shall)) will 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)) must be submitted to the HCA ((prior to)) before the twentieth day of the month ((during which)) when 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)) must 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)) must 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)) must 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)) must 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)) Before termination for nonpayment of premium, the HCA ((shall cause)) will send 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)) canceled 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)) whose coverage is canceled 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 coverage((s)) 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 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-9819.5


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

WAC 182-12-108   Purpose.   The purpose of this chapter is to establish eligibility criteria for and effective date of enrollment in the public employees((')) benefits board (PEBB) approved benefits.

[Statutory Authority: RCW 41.05.160 and 41.05.165. 04-18-039, 182-12-108, filed 8/26/04, effective 1/1/05.]


AMENDATORY SECTION(Amending Order 06-09, filed 11/22/06, effective 12/23/06)

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.

"Comprehensive employer sponsored medical" includes insurance coverage continued by the employee or their dependent under COBRA.

"Creditable coverage" means coverage that meets the definition of "creditable coverage" under RCW 48.66.020 (13)(a) and includes payment of medical and hospital benefits.

"Defer" means to postpone enrollment or interrupt enrollment in PEBB ((sponsored)) medical ((coverage)) insurance by a retiree or ((surviving dependent)) eligible survivor.

"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)) when 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 a medical ((and dental coverages)) or dental plan developed by the public employees benefits board and provided by a contracted vendor or self-insured plans administered by the HCA.

"Insurance coverage" means any health plan, life insurance, ((or)) long-term care insurance, long-term disability insurance ((plan)), or property and casualty insurance 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, and retiree life insurance.

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

(("PEBB plan" or)) "PEBB" means the public employees benefits board.

"PEBB benefits" means one or more insurance coverage((s approved)) or other employee benefit administered by the ((public employees' benefits board for eligible enrollees and their dependents)) PEBB benefits services program within HCA.

"PEBB benefits services program" means the program within the health care authority which administers insurance and other benefits to eligible employees of the state (as defined in WAC 182-12-115), eligible retired and disabled employees of the state (as defined in WAC 182-12-171), and other as defined in RCW 41.05.011.

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

"Waive" means to interrupt enrollment or postpone enrollment in a PEBB ((sponsored)) health plan by an employee (as ((set forth)) 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 41.05.068. 06-23-165 (Order 06-09), 182-12-109, filed 11/22/06, effective 12/23/06. 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 WSR 04-18-039, filed 8/26/04, effective 1/1/05)

WAC 182-12-111   Eligible entities and individuals.   The following entities and individuals shall be eligible ((to participate in)) for PEBB insurance coverage((s)) 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, the higher education coordinating board, and the state board for community and technical colleges is required to participate in all PEBB ((approved insurance coverage)) benefits. 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)) end PEBB ((insurance coverage)) benefits by January 1, 1996, or the expiration of the current collective bargaining agreements, whichever is later. Employees electing to ((terminate)) end PEBB ((coverage)) benefits have a one-time reenrollment option after a five year wait. Employees of a bargaining unit may ((terminate)) end PEBB benefit participation only as an entire bargaining unit. All administrative or managerial employees may ((terminate)) end PEBB participation only as an entire unit.

(b) Community and 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)) insurance coverages 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 insurance 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 health plans must be the only employer sponsored health plans available to eligible employees.

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

(d) The legislative authority or the board of directors must maintain its PEBB ((plan)) insurance coverage participation ((for a minimum of)) at least one full year, and may ((terminate)) end participation only at the end of a 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 must be submitted to HCA.

(f) The eligibility requirements for dependents must be the same as the requirements for dependents of the state employees and retirees as ((set forth)) in WAC 182-12-260.

(g) The legislative authority or the board of directors ((shall provide)) must give the HCA ((with)) written notice of its intent to ((terminate)) end PEBB ((plan)) insurance coverage participation ((no fewer than)) at least thirty days ((prior to)) before the effective date of termination. If the employee organization ((terminates coverage in)) ends PEBB insurance coverage, retired and disabled employees who began participating after September 15, 1991, are not eligible ((to participate in)) for PEBB insurance coverage beyond the mandatory extension requirements specified in WAC 182-12-146.

(3) Blind vendors means a "licensee" 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 coverage.

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

(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 set forth)) in WAC 182-12-260.

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

(a) All eligible employees of the entity must transfer to PEBB insurance 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 health plans must be the only employer sponsored health plans available to eligible employees.

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

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

(e) The terms and conditions for the payment of the insurance premiums 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 must be submitted to HCA.

(f) The eligibility requirements for dependents of local government employees must be the same as the requirements for dependents of state employees and retirees ((as set forth)) in WAC 182-12-260.

(g) The legislative authority or the board of directors ((shall provide)) must give the HCA ((with)) written notice of its intent to ((terminate)) end PEBB ((plan)) insurance coverage participation ((no fewer than)) at least thirty days ((prior to)) before the effective date of termination. If a county, municipality, or political subdivision ((terminates)) ends coverage in PEBB insurance coverage, retired and disabled employees who began participating after September 15, 1991, are not eligible ((to participate in)) for PEBB insurance coverage beyond the mandatory extension requirements specified in WAC 182-12-146.

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

(a) All eligible employees of the entity must transfer to PEBB insurance 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)) for the PEBB insurance coverage is subject to the approval of the HCA.

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

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

(e) Beginning September 1, 2003, the HCA will collect an amount equal to the composite rate charged to state agencies plus an amount equal to the employee premium by health ((carrier)) plan and family size as would be charged to state employees for each participating school district or educational service district. Each participating school district or educational service district must agree to collect an employee premium by health ((carrier)) 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 must be the same as the requirements for dependents of the state employees and retirees ((as set forth)) in WAC 182-12-260.

(g) The school district or educational service district must ((provide)) give the HCA ((with)) written notice of its intent to ((terminate)) end PEBB ((plan)) insurance coverage participation ((no fewer than)) at least thirty days ((prior to)) before the effective date of termination, and may ((terminate)) end 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 health plans ((coverage)) while enrolled in that program.

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

[Statutory Authority: RCW 41.05.160 and 41.05.165. 04-18-039, 182-12-111, filed 8/26/04, effective 1/1/05; 03-17-031 (Order 02-07), 182-12-111, filed 8/14/03, effective 9/14/03. 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 04-18-039, filed 8/26/04, effective 1/1/05)

WAC 182-12-112   Insurance eligibility for higher education.   For ((the purpose of)) insurance eligibility, the HCA considers the higher education personnel board, the council for postsecondary education, and the state board for community colleges to be higher education agencies.

[Statutory Authority: RCW 41.05.160 and 41.05.165. 04-18-039, 182-12-112, filed 8/26/04, effective 1/1/05.]


AMENDATORY SECTION(Amending Order 06-01, filed 5/25/06, effective 6/25/06)

WAC 182-12-115   Eligible employees.   The following employees of state government, higher education, participating K-12 school districts, educational service districts, political subdivisions and employee organizations representing state civil service workers are eligible for PEBB insurance coverage.

A person whose employment situation can be described by more than one of the eligibility categories in subsections (1) through (7) of this section shall have his or her eligibility determined solely by the criteria of the one category that most closely describes his or her employment situation.

(1) "Permanent employees." Those who work at least half-time per month and are expected to be employed for more than six months. These employees are eligible for benefits on their date of employment. Insurance 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, insurance 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. These employees are eligible for benefits on the first day of the seventh month of half-time or more employment. Insurance coverage begins on the first day of the seventh month following the date of employment.

(3) "Career seasonal employees." Those who work at least half-time per month during a designated season for a minimum of three months but less than twelve months per year and who have an understanding of continued employment season after season. These employees are eligible for benefits on their date of employment. Insurance 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, insurance coverage begins on the date of employment. Career seasonal employees who work at least half-time per month for a season that extends for nine or more months are eligible for the employer contribution during the break between seasons of employment. However, career seasonal employees who work at least half-time per month for less than nine months in a season are not eligible for the employer contribution during the break between seasons of employment but may be eligible to continue insurance coverage by self-paying premiums.

(4) "Instructional year employees." Employees who work half-time or more on an instructional year (school year) or equivalent nine-month basis. These employees are eligible for benefits on their date of employment. Insurance 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, insurance coverage begins on the date of employment. These employees are eligible to receive the employer contribution for insurance coverage during the off-season following each instructional year period of employment. The provisions of this subsection do not apply to persons employed on a quarter-to-quarter or semester-to-semester contract basis.

(5)(a) "Part-time faculty" and "part-time academic employees." Employees who are employed on a quarter/semester to quarter/semester basis are eligible for insurance coverage ((beginning with)) starting the second consecutive quarter/semester of half-time or more employment at one or more state institutions of higher education including one or more college districts. These employees are eligible for benefits the first day of the second consecutive quarter/semester of half-time or more employment. Insurance 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, insurance coverage begins at the beginning of the second consecutive quarter/semester.

((For the purpose of determining)) To determine eligibility for part-time faculty and part-time academic employees, employers must:

(i) Consider spring and fall as consecutive quarters/semesters when first establishing eligibility; and

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

(iii) At the beginning of each quarter/semester notify, in writing, all current and newly hired part-time faculty and part-time academic employees of their potential right to benefits under this subsection; and

(iv) Where concurrent employment at more than one state higher education institution is used to determine total 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 employee 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.

Part-time faculty and part-time academic employees employed at more than one state institution of higher education are responsible for notifying each employer quarterly, in writing, of the employee's multiple employment. In no case will retroactive insurance coverage be permitted or employer contribution paid to HCA if an employee ((fails to)) does not inform all of his((/)) or her employing institutions about employment at all institutions within the current quarter.

Once enrolled, if a part-time faculty or part-time academic employee 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.

(b) Part-time academic employees of community and technical colleges who have a reasonable expectation of continued employment at one or more college districts shall be eligible for the employer contribution for benefits during the period between the end of the spring quarter and the beginning of the fall quarter, or other quarter break period, if they meet the following conditions of this subsection (5)(b).

Part-time academic employees who work half-time or more in each instructional year quarter of an academic year, or equivalent nine-month season, in a single college district or multiple college districts, as determined from the payroll records of the employing community or technical college district(s), are eligible for the employer contribution for health benefits during the quarter or off season period immediately following the end of one academic year or equivalent nine-month season.

For ((the purposes of)) this subsection (5)(b):

(i) "Academic employee" ((has the meaning set forth)) is defined in RCW 28B.50.489(3).

(ii) "Academic year" means fall, winter, and spring quarters in a community or technical college, as determined from the payroll records of the employing college district or college districts.

(iii) "Equivalent nine-month seasonal basis" means a nine consecutive month period of employment at half-time or more by a single college district or multiple college districts, as determined from the payroll records of the employing college district(s).

(iv) "Health benefits" means the particular medical and/or dental coverage in place at the end of the academic year or equivalent nine-month season. Changes to health benefits may be made only as ((set forth)) allowed in chapter 182-08 WAC or during an annual open enrollment period.

(c) Part-time academic employees who have established eligibility, as determined from the payroll records of the employing community or technical college districts, for employer contributions for benefits and who have worked an average of half-time or more in each of the two preceding academic years, through employment at one or more community or technical college districts, are eligible for continuation of employer contributions for the subsequent summer period between the end of the spring quarter and the beginning of the fall quarter.

(d) Once a part-time academic employee meets the criteria in (c) of this subsection, the employee shall continue to receive uninterrupted employer contributions for benefits if the employee works at least ((three of the four)) two quarters of the academic year with an average academic year workload of half-time or more for three quarters of the academic year. Benefits provided under this subsection (5)(d) cease ((at the end of the academic year)) if this criteria is not met. Continuous benefits shall be reinstated once the employee reestablishes eligibility under (c) of this subsection.

(e) As used in (c) and (d) of this subsection, "academic year" means the summer, fall, winter, and spring quarters. As used in this subsection, "academic employees" has the meaning provided in RCW 28B.50.489.

(f) To be eligible for maintenance of benefits through averaging pursuant to (c) and (d) of this subsection, part-time academic employees must notify their employers of their potential eligibility.

(6) "Appointed and elected officials." Legislators are eligible ((to apply for coverage)) for benefits 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)) for benefits on the date their term begins or they take the oath of office, whichever occurs first. Insurance 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, insurance coverage begins on the first day of their term. Insurance 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, insurance 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 courts of appeals and the superior courts become eligible ((to apply for coverage)) for benefits on the date they take the oath of office. Insurance 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, insurance coverage begins on the date the term begins, or the oath of office is taken.

[Statutory Authority: RCW 41.05.160. 06-12-002 (Order 06-01), 182-12-115, filed 5/25/06, effective 6/25/06; 05-17-132 (Order 04-04), 182-12-115, filed 8/19/05, effective 9/2/05. Statutory Authority: RCW 41.05.160 and 41.05.165. 03-17-031 (Order 02-07), 182-12-115, filed 8/14/03, effective 9/14/03. 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 06-02, filed 5/24/06, effective 6/24/06)

WAC 182-12-116   Who is eligible ((to participate in)) for the PEBB flexible spending account plan?   Beginning January 1, 2006, all employees of public four-year institutions of higher education, of the state community and technical colleges and of 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)) for the PEBB medical flexible spending account plan. Beginning July 1, 2006, all employees of state agencies who are eligible for PEBB ((insurance)) benefits, are eligible ((to participate in)) for 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. 06-11-156 (Order 06-02), 182-12-116, filed 5/24/06, effective 6/24/06. 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)) enrollment is prohibited.   PEBB health plan coverage is limited to a single enrollment per individual.

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

(2) ((One insurance-)) An eligible employee may waive medical ((coverage for himself or herself)) and enroll as a ((spouse or)) dependent on the coverage of his or her eligible spouse or qualified domestic partner as stated in WAC 182-12-128. ((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 medical coverage as an employee and enroll as a dependent on the medical coverage of the other spouse.

(b) A dependent child that is)) Children eligible for ((coverage)) medical and dental 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))) (4) An employee employed in ((an insurance-)) a benefits 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)) PEBB benefits under the employer that:

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

(((ii))) (b) 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 PEBB insurance coverage)) health plan enrollment for their self or their eligible dependent?   (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.)) Employees may waive medical if they have other comprehensive group medical coverage. To waive medical, the employee must complete an enrollment/change form. If an employee waives medical, then medical is automatically waived for all eligible dependents.

(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)) long-term disability.

(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.)) An employee may waive medical or dental, or both, for any or all eligible dependents.

(4) ((If the dental portion of the health plan coverage is waived, an otherwise eligible dependent may not enroll in PEBB dental coverage except)) Once health plan enrollment is waived, enrollment is only allowed 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:)) After losing other health insurance. The employee must provide evidence:

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

(ii) ((The period between loss of the other dental and application for PEBB dental coverage is sixty days or less.)) Enrollment was continuous from the most recent PEBB open enrollment period; and

(iii) The date coverage was lost.

Application to enroll in a PEBB health plan must be made no later than sixty days after the date the other health insurance was lost.

(((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)) (c) After acquiring a new dependent. Application for enrollment must be made no later than sixty days after acquiring the new dependent through marriage, establishment of a qualified domestic partnership, birth, adoption or placement for adoption ((of a child)).

[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 182-12-131   When does employer paid insurance coverage end?   PEBB medical, dental and life insurance ((coverages)) for a terminated employee, spouse, qualified ((same sex)) domestic partner or ((dependent)) child ceases at 12:00 midnight, the last day of the month in which the ((employee or dependent)) enrollee is eligible. Basic long-term disability ((coverage)) insurance ceases at 12:00 midnight the date employment ((terminates)) ends or immediately upon the death of the employee.

[Statutory Authority: RCW 41.05.160 and 41.05.165. 04-18-039, 182-12-131, filed 8/26/04, effective 1/1/05.]


AMENDATORY SECTION(Amending Order 06-02, filed 5/24/06, effective 6/24/06)

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 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;)) or

(f) The employee is on approved educational leave.

(2) Part-time faculty and part-time academic employees may self-pay premium at the group rate between periods of eligibility for a maximum of eighteen months. ((Part-time faculty)) These employees 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)) twenty-nine 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. 06-11-156 (Order 06-02), 182-12-133, filed 5/24/06, effective 6/24/06. 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 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 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 a PEBB health plan ((coverage)) effective the first day of the month after the date the other comprehensive group health plan coverage ((terminates)) ends, provided ((proof)) evidence of such other comprehensive group health plan coverage is provided to the ((HCA)) PEBB benefits services program 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 WSR 04-18-039, filed 8/26/04, effective 1/1/05)

WAC 182-12-138   If an employee is approved for family and medical leave, what ((PEBB)) insurance coverage may be continued?   Employees on leave under the federal Family and Medical Leave Act (FMLA) 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 also continue current optional life and long-term disability. All employee premium amounts associated with insurance coverage must be paid monthly as they become due. If premiums are more than sixty days delinquent, insurance coverage will ((be terminated)) end as of the last day of the month of fully paid coverage.

[Statutory Authority: RCW 41.05.160 and 41.05.165. 04-18-039, 182-12-138, filed 8/26/04, effective 1/1/05.]


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

WAC 182-12-141   If I revert from an eligible position to an ineligible position what happens to my insurance coverage?   Employees who revert to a position that is ineligible for employer contribution toward insurance coverage may continue enrollment in a PEBB health plan ((coverage)) by self-paying premium for up to eighteen months (and in some cases up to twenty-nine months) under the same terms as an employee who is granted leave without pay.

[Statutory Authority: RCW 41.05.160 and 41.05.165. 04-18-039, 182-12-141, filed 8/26/04, effective 1/1/05.]


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

WAC 182-12-146   ((PEBB)) Continuing health plan coverage under COBRA.   Enrollees and eligible dependents who become ineligible for ((health plan)) coverage and who qualify for continued coverage under the Consolidated Omnibus Budget Reconciliation Act (COBRA) may continue their ((plan coverage)) medical and dental by self-payment of health plan premiums in accordance with COBRA statutes and regulations.

[Statutory Authority: RCW 41.05.160 and 41.05.165. 04-18-039, 182-12-146, filed 8/26/04, effective 1/1/05.]


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

WAC 182-12-148   May an employee continue PEBB insurance coverage during their appeal of dismissal?   (1) Employees awaiting hearing of a dismissal action before any of the following may continue their insurance coverage by self-payment of premium on the same terms as an employee who is granted leave without pay.

(a) For an appeal filed on or before June 30, 2005, the personnel appeals board or any court.

(b) For an appeal filed on or after July 1, 2005, the personnel resources board, an arbitrator, a grievance or appeals committee established under a collective bargaining agreement for union represented employees.

(2) If the dismissal is upheld, all insurance coverage ((shall terminate)) will end at the end of the month in which the decision is entered, or the date to which premiums have been paid, whichever is earlier.

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

(b) HCA will refund to the employee any premiums the employee paid that may be provided for as a result of the reinstatement of the employer contribution only if the employee makes retroactive payment of any employee contribution amounts associated with the insurance coverage. In the alternative, at the request of the employee, HCA may deduct the employee's contribution from the refund of any premiums self-paid by the employee during the appeal period.

(c) All optional life and long-term disability insurance which was in force at the time of dismissal shall be reinstated retroactively only if 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 restore such optional coverage.

[Statutory Authority: RCW 41.05.160, 41.05.350, and 41.05.165. 05-16-046 (Order 05-01), 182-12-148, filed 7/27/05, effective 8/27/05. Statutory Authority: RCW 41.05.160 and 41.05.165. 04-18-039, 182-12-148, filed 8/26/04, effective 1/1/05.]


AMENDATORY SECTION(Amending Order 06-02, filed 5/24/06, effective 6/24/06)

WAC 182-12-171   ((Eligible retirees.)) When are retiring employees eligible to enroll in retiree insurance?   (1) ((Eligible)) Procedural requirements. Retiring 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:)) must meet these procedural requirements, as well as have substantive eligibility under subsection (2) or (3) of this section.

(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)) The employee must submit an election form to enroll or defer insurance coverage within sixty days after their employer paid or COBRA coverage ends. The effective date of health plan enrollment will be the first of the month following the loss of other coverage. Employees who cancel PEBB health plan coverage or do not enroll in a PEBB health plan at retirement are only eligible to enroll if they have deferred enrollment and maintained comprehensive coverage as defined in WAC 182-12-200 or 182-12-205.

(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;

(v) State judges/judicial retirement system;

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

(vii) Washington state patrol retirement system.

(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)) employee and enrolled dependents who are entitled to Medicare must enroll and maintain enrollment in both Medicare parts A and B if the employee retired after July 1, 1991. If the employee or an enrolled dependent becomes entitled to Medicare after enrollment in PEBB retiree insurance, they must enroll and maintain enrollment in Medicare.

(2) Eligibility requirements. 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)) (as defined in WAC 182-12-115) who end public employment after becoming vested in a Washington state-sponsored retirement plan (as defined in subsection (4) of this section) are eligible to continue PEBB insurance coverage as a retiree if they meet procedural and eligibility requirements. To be eligible to continue PEBB insurance coverage as a retiree the employee must be eligible to retire under a Washington state-sponsored retirement plan when their employer paid or COBRA coverage ends.

Employees who do not meet their Washington state-sponsored retirement plan's age requirements when their employer paid or COBRA coverage ends, but who meet the age requirement within sixty days of coverage ending, may request that their eligibility be reviewed by the health care authority's appeals committee to determine eligibility (see WAC 182-16-030). Employees must meet other retiree insurance election procedural requirements.

Employees must immediately begin to receive a monthly retirement plan payment, with exceptions described below.

Employees who receive a lump-sum payment instead of a monthly retirement plan payment are only eligible if this is required by department of retirement systems because their monthly retirement plan payment is below the minimum payment that can be paid.

Employees who are members of a Plan 3 retirement, also called separated employees (defined in RCW 41.05.011(13)), are eligible if they meet their retirement plan's age requirement and length of service when PEBB employee insurance coverage ends. They do not have to receive a retirement plan payment.

Employees who are members of a Washington higher education retirement plan are eligible if they immediately begin to receive a monthly retirement plan payment, or meet their plan's age requirement, or are at least age fifty-five with ten years of state service.

Employees who are permanently and totally disabled are eligible if they start receiving or defer a monthly disability retirement plan payment.

Employees not retiring under the public employees' retirement system must meet the same age and years of service had the person been employed as a member of either public employees retirement system Plan 1 or Plan 2 for the same period of employment.

Employees who retire from a local government that participates in PEBB insurance coverage for their employees are eligible to continue PEBB insurance coverage as a retiree.

(a) Local government employees. If the local government ends participation in PEBB insurance coverage, employees who enrolled after September 15, 1991, are no longer eligible for PEBB retiree insurance. These employees may continue PEBB health plan enrollment under COBRA (see WAC 182-12-146).

(b) Washington state K-12 school district and educational service district employees for districts that do not participate in PEBB benefits. Employees of Washington state K-12 school districts and educational service districts who separate from employment after becoming vested in a Washington state-sponsored retirement system are eligible to enroll in PEBB health plans when retired or permanently and totally disabled.

Except for employees who are members of a retirement Plan 3, employees who separate on or after October 1, 1993, must immediately begin to receive a monthly retirement plan payment from a Washington state-sponsored retirement system. Employees who receive a lump-sum payment instead of a monthly retirement plan payment are only eligible if department of retirement systems requires this because their monthly retirement plan payment is below the minimum payment that can be paid or they enrolled before 1995.

Employees who are members of a Plan 3 retirement, also called separated employees (defined in RCW 41.05.011(13)), are eligible if they meet their retirement plan's age requirement and length of service when employer paid or COBRA coverage ends.

Employees who separate from employment due to total and permanent disability who are eligible for a deferred retirement allowance under a Washington state-sponsored retirement system (as defined in chapter 41.32, 41.35 or 41.40 RCW) are eligible if they enrolled before 1995 or within sixty days following retirement.

Employees who retired as of September 30, 1993, and began receiving a retirement allowance from a state-sponsored retirement system (as defined in chapter 41.32, 41.35 or 41.40 RCW) are eligible if they enrolled in a PEBB health plan not later than the HCA's open enrollment period for the year beginning January 1, 1995.

(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.)) Elected state officials. Employees who are elected state officials (as defined under WAC 182-12-115(6)) who voluntarily or involuntarily leave public office are eligible to continue PEBB insurance coverage as a retiree if they meet procedural and eligibility requirements. They do not have to receive a retirement plan payment from a state-sponsored retirement system.

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

Higher education retirement plans;

Law enforcement officers' and fire fighters' retirement system;

Public employees' retirement system;

Public safety employees' retirement system;

School employees' retirement system;

State judges/judicial retirement system;

Teacher's retirement system; and

State patrol retirement system.

(((5))) The two federal retirement systems, Civil Service Retirement System and Federal Employees' Retirement System, ((shall be)) are 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. 06-11-156 (Order 06-02), 182-12-171, filed 5/24/06, effective 6/24/06. 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 182-12-175   May a local government entity applying for participation in PEBB insurance coverage include their retirees in the transfer unit?   Local government entities applying for participation in PEBB insurance coverage under WAC 182-12-111(4), may request inclusion of retired employees who are covered under their retiree health plan at the time of application. The PEBB benefits services program will use the following criteria for approval of these requests for inclusion of retirees.

(1) The local government retiree health plan must have existed ((for a minimum of)) at least three years ((prior to)) before the date of application for participation in PEBB health plans.

(2) Eligibility for coverage under the local government's retiree health plan must have required immediate enrollment in retiree health plan coverage upon termination of employee coverage.

(3) The retiree must have maintained continuous enrollment in their local government retiree health plan.

(4) To protect the integrity of the risk pool, if total local government retiree enrollment exceeds ten percent of the total PEBB retiree population, the PEBB benefits services program may:

(a) Stop approving inclusion of retirees with local government unit transfers; or

(b) May adopt a new rating methodology reflective of the cost of covering local government retirees.

(5) Retirees and dependents included in the transfer unit are subject to the enrollment and eligibility rules outlined in chapters 182-08, 182-12 and 182-16 WAC.

(6) Employees eligible for retirement subsequent to the local government transferring to PEBB health plan coverage must meet retiree eligibility as outlined in chapter 182-12 WAC.

[Statutory Authority: RCW 41.05.160, 41.05.350, and 41.05.165. 05-16-046 (Order 05-01), 182-12-175, filed 7/27/05, effective 8/27/05.]


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

WAC 182-12-200   May a retiree who is enrolled as a dependent in a PEBB ((sponsored)) health plan or a Washington state K-12 school district sponsored health plan ((coverage)) defer enrollment in a PEBB retiree health plan((s))?   ((A retiree, whose spouse is enrolled as an eligible employee in a PEBB or Washington state school district sponsored health plan,)) Retirees who are enrolled in a PEBB health plan or Washington state K-12 school district sponsored health plan as a dependent may defer enrollment in a PEBB retiree health plan ((coverage and enroll in the spouse's PEBB or school district sponsored health plan coverage. If a retiree)). Retirees who defer((s)) enrollment in ((PEBB retiree)) medical ((coverage, enrollment must also be deferred for dental coverage)) cannot remain enrolled in dental. ((The retiree and eligible dependents)) Retirees who defer may ((subsequently)) later enroll themselves and their dependents in PEBB retiree medical ((coverage)), or medical and dental ((coverage)), if ((the retiree was continuously enrolled under the spouse's)) they provide evidence of continuous enrollment in a PEBB or K-12 school district sponsored health plan ((coverage)). Continuous enrollment must be from the date the retiree was initially eligible for retiree insurance ((coverage)). Retirees may enroll:

(1) During any PEBB open enrollment period ((determined by the HCA)) (Enrollment in the PEBB health plan will begin the first day of January after the open enrollment period.); or

(2) ((Within)) No later than sixty days after enrollment in the ((date the spouse ceases to be enrolled in a)) PEBB or K-12 school district sponsored health plan ((as an eligible employee; or

(3) Within sixty days of the date after the retiree's loss of eligibility as a dependent under the spouse's PEBB or school district sponsored health plan coverage.)) ends. (Enrollment in the PEBB health plan will begin the first day of the month after the PEBB or K-12 school district health plan ends.)

[Statutory Authority: RCW 41.05.160 and 41.05.165. 04-18-039, 182-12-200, filed 8/26/04, effective 1/1/05. Statutory Authority: RCW 41.05.160. 01-17-041 (Order 01-00), 182-12-200, filed 8/9/01, effective 9/9/01; 97-21-127, 182-12-200, filed 10/21/97, effective 11/21/97. Statutory Authority: Chapter 41.05 RCW. 96-08-043, 182-12-200, filed 3/29/96, effective 4/29/96; Order 4-77, 182-12-200, filed 11/17/77.]


AMENDATORY SECTION(Amending Order 06-09, filed 11/22/06, effective 12/23/06)

WAC 182-12-205   ((Retirees)) May a retiree defer enrollment in a PEBB health plan ((coverage)) at or after retirement((.))?   Except as stated in subsection (1)(c) of this section, if a retiree defers enrollment in a PEBB health plan ((coverage)), ((PEBB)) they also ((waives coverage)) defer enrollment for all eligible dependents. Retirees may not defer their retiree term life insurance, even if they have other ((coverage)) life insurance.

(1) Retirees may defer enrollment in a PEBB health plan ((coverage)) at or after retirement if continuously enrolled in other comprehensive medical ((coverage)) as ((stated)) identified below:

(a) Beginning January 1, 2001, retirees may defer ((their PEBB health plan coverage)) enrollment if they are enrolled in comprehensive employer-sponsored medical ((coverage)) as an employee or the ((spouse or same-sex domestic partner)) dependent of an employee.

(b) Beginning January 1, 2001, retirees may defer ((their PEBB health plan coverage)) enrollment if they are enrolled in medical ((coverage)) as a retiree or the ((spouse or same-sex domestic partner)) dependent of a retiree enrolled in a federal retiree plan.

(c) Beginning January 1, 2006, retirees may defer ((their PEBB health plan coverage)) enrollment if they are enrolled in Medicare Parts A and B and a Medicaid program that provides creditable coverage as defined in this chapter. The retiree's dependents may continue their PEBB ((coverage)) health plan enrollment if they meet PEBB eligibility criteria and are not eligible for creditable coverage under a Medicaid program.

(2) To defer health plan ((coverage)) enrollment, the retiree must send a completed ((enrollment)) election form to the PEBB benefits services program requesting to defer ((coverage)). The PEBB benefits services program must receive the form before ((coverage)) health plan enrollment is deferred or no later than sixty days after the date the retiree becomes eligible to apply for PEBB retiree ((benefits)) insurance coverage.

(3) Retirees who defer ((PEBB coverage)) may enroll in a PEBB ((coverage)) health plan as follows:

(a) Retirees who defer ((PEBB health plan coverage)) while enrolled in employer-sponsored medical ((coverage)) may enroll in a PEBB health plan ((coverage)) by sending a completed ((enrollment)) election form and ((proof)) evidence of continuous enrollment in comprehensive employer-sponsored ((coverage)) medical to the PEBB benefits services program:

(i) During ((an annual)) open enrollment ((period)) (Enrollment in the PEBB ((coverage)) health plan will begin the first day of January after the open enrollment period.); or

(ii) No later than sixty days after their employer-sponsored ((coverage)) medical ends. (Enrollment in the PEBB ((coverage)) health plan will begin the first day of the month after the employer-sponsored ((coverage)) medical ends.)

(b) Retirees who defer ((PEBB health plan coverage)) enrollment while enrolled as a retiree or dependent of a retiree in a federal retiree medical plan will have a one-time opportunity to ((reenroll)) enroll in a PEBB health plan ((coverage)) by sending a completed ((enrollment)) election form and ((proof)) evidence of continuous enrollment in a federal retiree medical plan to the PEBB benefits services program:

(i) During ((an annual)) open enrollment ((period)) (Enrollment in the PEBB ((coverage)) health plan will begin the first day of January after the open enrollment period.); or

(ii) No later than sixty days after the federal retiree ((coverage)) medical ends. (Enrollment in the PEBB ((coverage)) health plan will begin the first day of the month after the federal retiree ((coverage)) medical ends.)

(c) Retirees who defer ((PEBB health plan coverage)) enrollment while enrolled in Medicare Parts A and B and Medicaid may enroll in a PEBB health plan ((coverage)) by sending a completed ((enrollment)) election form and ((proof)) evidence of continuous enrollment in creditable coverage to the PEBB benefits services program:

(i) During ((the annual)) open enrollment ((period)) (Enrollment in the PEBB ((coverage)) health plan will begin the first day of January after the open enrollment period.); or

(ii) No later than sixty days after their Medicaid coverage ends (Enrollment in the PEBB ((coverage)) health plan will begin the first day of the month after the Medicaid coverage ends.); or

(iii) No later than the end of the calendar year ((during which)) when their Medicaid coverage ends if the retiree was also determined eligible under 42 USC 1395w-114 and subsequently enrolled in a Medicare Part D plan. (Enrollment in the PEBB ((coverage)) health plan will begin the first day of January following the end of the calendar year ((during which)) when the Medicaid coverage ends.)

[Statutory Authority: RCW 41.05.160 and 41.05.068. 06-23-165 (Order 06-09), 182-12-205, filed 11/22/06, effective 12/23/06. 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.]


NEW SECTION
WAC 182-12-207   When can a retiree or eligible dependent's insurance coverage be canceled by HCA?   (1) Failure to provide information requested by the due date or knowingly providing false information.

(2) Failure to pay the premium when due or an underpayment of premium.

(3) If a retiree's insurance coverage is canceled for misconduct, insurance coverage will not be reinstated at a later date. Examples of such termination include, but are not limited to the following:

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

(b) Abusive or threatening conduct repeatedly directed to an HCA employee, a health plan or other HCA contracted vendor providing insurance coverage on behalf of the HCA, its employees, or other persons.

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NEW SECTION
WAC 182-12-208   May a retiree enroll only in dental?   If an enrollee is enrolled in retiree insurance coverage, they may not enroll in dental unless they also enroll in medical.

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NEW SECTION
WAC 182-12-209   Who is eligible for retiree life insurance?   Eligible employees who participate in PEBB life insurance as an employee and meet qualifications for retiree insurance coverage as provided in WAC 182-12-171 are eligible for PEBB retiree life insurance. They must submit an election form to the PEBB benefits services program no later than sixty days after the date their PEBB employee life insurance ends. However, employees whose life insurance premiums are being waived under the terms of the life insurance contract are not eligible for retiree term life insurance until their waiver of premium benefit ends. Retirees may not defer enrollment in retiree term life insurance.

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

WAC 182-12-211   If department of retirement systems makes a formal determination of retroactive eligibility, may the retiree enroll in PEBB ((sponsored)) retiree insurance coverage?   (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 enrollment in a PEBB ((retiree)) health plan ((coverage)) only if application is made within sixty days after the date of notice from DRS.

(2) All premiums 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)) the PEBB benefits services program.

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

[Statutory Authority: RCW 41.05.160 and 41.05.165. 04-18-039, 182-12-211, filed 8/26/04, effective 1/1/05.]


AMENDATORY SECTION(Amending Order 06-08, filed 10/3/06, effective 11/3/06)

WAC 182-12-250   Insurance coverage eligibility for ((surviving dependents)) survivors of emergency service personnel killed in the line of duty.   Surviving ((dependents)) spouses and dependent children of emergency service personnel who are killed in the line of duty are eligible ((for)) to enroll in health plans ((coverage)) administered by the PEBB benefits services program within HCA.

(1) This section applies to the ((dependents)) surviving spouse and dependent children of emergency service personnel "killed in the line of duty" as determined by the Washington state department of labor and industries.

(2) "Emergency service personnel" means law enforcement officers and fire fighters as defined in RCW 41.26.030, members of the Washington state patrol retirement fund as defined in RCW 43.43.120, and reserve officers and fire fighters as defined in RCW 41.24.010.

(3) "Surviving ((dependent)) spouse and children" means:

(a) A lawful spouse;

(b) An ex-spouse as defined in RCW 41.26.162;

(c) ((Dependent)) Children. The term "children" includes the following unmarried children of the emergency service worker who are: Under the age of twenty or under the age of twenty-four if he or she is a dependent student attending high school or registered at an accredited secondary school, college, university, vocational school, or school of nursing. ((Disabled dependents)) Children with disabilities as defined in RCW 41.26.030(7) are eligible at any age. "Children" are defined as:

(i) Biological children (including the emergency service worker's posthumous children);

(ii) Stepchildren; and

(iii) Legally adopted children.

(4) Surviving ((dependents)) spouses and children who are entitled to Medicare must enroll in both parts A and B of Medicare.

(5) The ((surviving dependent)) survivor (or agent acting on their behalf) must send a completed ((enrollment)) election form (to either enroll or defer ((public employees' benefits board ()) enrollment in a PEBB(() coverage)) health plan) to PEBB benefits services ((department)) program no later than one hundred eighty days after the latter of:

(a) The death of the emergency service worker;

(b) The date on the letter from the department of retirement systems or the board for volunteer fire fighters and reserve officers that informs the survivor that he or she is determined to be an eligible survivor;

(c) The last day the surviving ((dependent)) spouse or child was covered under any health plan through the emergency service worker's employer; or

(d) The last day the surviving ((dependent)) spouse or child was covered under the Consolidated Omnibus Budget Reconciliation Act (COBRA) coverage from the emergency service worker's employer.

(6) Survivors ((that)) who do not choose to defer enrollment in a PEBB ((coverage)) health plan may choose among the following options for when their enrollment in a PEBB ((coverage)) health plan will begin:

(a) June 1, 2006, for survivors whose ((enrollment)) election form is received by the PEBB benefits services program no later than September 1, 2006;

(b) The first of the month that is no more than sixty days before the date that the PEBB benefits services program receives the ((enrollment)) election form (for example, if the PEBB benefits services program receives the ((enrollment)) election form on August 29, the survivor may request ((coverage)) health plan enrollment to begin on July 1); or

(c) The first of the month after the date that the PEBB benefits services program receives the ((enrollment)) election form.

For surviving ((dependents)) spouses and children who enroll, monthly health plan premiums ((for PEBB health plan coverage)) must be paid by the survivor except as provided in RCW 41.26.510(5) and 43.43.285 (2)(b).

(7) ((Surviving dependents)) Survivors must choose one of the following two options to maintain eligibility for PEBB ((health plan)) insurance coverage:

(a) Enroll in a PEBB health plan ((coverage)):

(i) Enroll in medical ((coverage)); or

(ii) Enroll in medical and dental ((coverage)).

(iii) ((The dependent)) Survivors enrolling in dental must stay enrolled in dental ((coverage)) for at least two years before dental ((coverage)) can be dropped.

(iv) Dental only ((coverage)) is not an option.

(b) Defer enrollment:

(i) ((Surviving dependents)) Survivors may defer enrollment in a PEBB health plan ((coverage)) if ((they are)) enrolled in comprehensive medical coverage through an employer.

(ii) ((Surviving dependents)) Survivors may enroll in a PEBB health plan ((coverage)) when they lose employer medical coverage. ((Dependents)) Survivors will need to ((prove)) provide evidence that they were continuously enrolled in comprehensive coverage through an employer when applying for a PEBB ((coverage)) health plan, and apply within sixty days after the date their other coverage ended.

(iii) PEBB health plan ((coverage)) enrollment and premiums will begin the first day of the month following the day that the other coverage ended for ((dependents that reenroll)) eligible spouses and children who enroll.

(8) ((Surviving dependents)) Survivors may change their health plan during open enrollment. In addition to open enrollment, ((they)) survivors may change health plans ((if they move out of their health plan's service area or into a service area where a health plan that was not previously offered is now available)) as described in WAC 182-08-198.

(9) ((Surviving dependents)) Survivors may not add new dependents acquired through birth, marriage, or establishment of a qualified ((same-sex)) domestic partnership.

(10) ((Surviving dependents)) Survivors will lose their right to enroll in a PEBB health plan ((coverage)) if they:

(a) Do not apply to enroll or defer PEBB health plan ((coverage)) enrollment within the timelines stated in subsection (5) of this section; or

(b) Do not maintain continuous enrollment in comprehensive medical coverage through an employer during the deferral period, as provided in subsection (7)(b)(i) of this section.

[Statutory Authority: RCW 41.05.160 and 41.05.080. 06-20-099 (Order 06-08), 182-12-250, filed 10/3/06, effective 11/3/06. Statutory Authority: RCW 41.05.160 and 41.05.165. 04-18-039, 182-12-250, filed 8/26/04, effective 1/1/05.]


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

WAC 182-12-260   Who are eligible dependents ((defined.))?   The following are eligible as dependents under the PEBB eligibility rules:

(1) Lawful spouse.

(2) ((A same sex)) Domestic partner qualified ((through)) by the PEBB declaration ((certificate issued by PEBB)) of domestic partnership that meets all of the following criteria:

(a) Partners have a close personal relationship in lieu of a lawful marriage;

(b) Partners are not married to anyone;

(c) Partners are each other's sole domestic partner and are responsible for each other's common welfare;

(d) Partners are not related by blood as close as would bar marriage; and

(e) Partners are barred from a lawful marriage.

(3) Domestic partner qualified by the certificate of state registered domestic partnership or registration card issued by the Washington secretary of state for a same-sex partnership.

(((3) Dependent)) (4) Children through age nineteen. ((The term "children" includes)) Children include:

(a) The subscriber's biological 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 ((same sex)) domestic partner, or children specified in a court order or divorce decree((.));

(b) Married children who qualify as dependents of the subscriber under the Internal Revenue Code((, and));

(c) Extended dependents ((approved by PEBB are included. To qualify for PEBB approval, the subscriber must demonstrate)) in the legal custody ((for the child with)) or legal guardianship of the subscriber, their spouse, or qualified domestic partner. The legal responsibility is demonstrated by a valid court order((,)) and the child's((:

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

(b) Must not be a)) official residence with the custodian or guardian. This does not include foster ((child)) children for whom support payments are made to the subscriber through the state department of social and health services (((DSHS))) foster care program((.));

(((4) Dependent)) (d) Children age twenty through age twenty-three ((and)) who are attending high school or registered students at an accredited secondary school, college, university, vocational school, or school of nursing.

(((a) Dependent)) (i) Student ((coverage)) health plan enrollment begins the first day of the month ((in which)) of the quarter((/)) or semester for which the ((dependent)) child is registered begins ((and)). Health plan enrollment ends the last day of the month in which the ((dependent)) student stops attending or in which the quarter((/)) or semester ends, whichever is first, except that dependent student eligibility continues year-round for those who attend three of the four school quarters or two semesters.

(((b) Dependent)) (ii) Student ((coverage)) eligibility for enrollment in a PEBB health plan continues during the three month period following graduation provided the subscriber is covered, ((at the same time,)) the ((dependent)) child has not reached age twenty-four, and ((the dependent)) meets all other eligibility requirements.

(iii) Student recertification occurs annually.

(e) Children as defined in (a) through (d) of this subsection who have disabilities are eligible by subsection (5) of this section.

(5) ((Dependent)) Children of any age with disabilities, developmental disabilities, mental illness or mental retardation who are incapable of self-support, provided such condition occurs ((prior to)) before age twenty or during the time the dependent was eligible as a student under subsection (4) of this section.

(a) The subscriber must provide ((proof)) evidence that such disability occurred ((prior to)) as stated below:

(i) For children enrolled in PEBB insurance coverage, the subscriber must provide evidence of the disability before the ((dependent's)) child's attainment of age twenty ((or during the time)).

(ii) For children enrolled in PEBB insurance coverage as a student under subsection (4)(d) of this section, the subscriber must provide evidence of the disability within sixty days after the student is no longer eligible under subsection (4)(d) of this section.

(iii) To enroll a dependent child with disabilities, age twenty or older, the subscriber must provide evidence that the condition occurred before the child reached age twenty or evidence that when the condition occurred the ((dependent satisfies)) child would have satisfied eligibility for student coverage under subsection (4) of this section((, and as)). The PEBB benefits services program will request evidence of the child's disability periodically ((requested)) thereafter ((by the PEBB program)).

(((a))) (b) The subscriber must notify the PEBB benefits services program, in writing, no later than sixty days after the date that a ((dependent)) child age twenty or older no longer qualifies under this subsection.

(i) For example, children who become self-supporting are not eligible under this rule as of the last day of the month in which they become capable of self-support. The ((dependent)) child may be eligible to continue enrollment in a PEBB ((coverage)) health plan under provisions of WAC 182-12-270.

(ii) Children age twenty and older ((that)) who become capable of self-support do not regain eligibility under subsection (5) of this section if they later become incapable of self-support.

(c) Disability recertification occurs periodically.

(6) ((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:

(i) The parent maintains continuous ((coverage)) enrollment in PEBB ((sponsored)) medical ((coverage));

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

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

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

(b) ((Dependent)) Parents ((that are)) eligible under (((a) of)) this subsection may be enrolled with a different health ((carrier)) plan than that selected by the ((eligible)) subscriber((; however, dependent)). Parents may not add additional dependents to their insurance coverage.

(7) The enrollee (or the subscriber on their behalf) must notify the PEBB benefits services program, in writing, no later than sixty days after the date ((that a dependent)) they are no longer ((qualifies)) eligible under ((subsection (1), (2), (3), (4) or (6) of)) this section. ((The subscriber must notify the PEBB program in writing no later than sixty days after the date a dependent no longer qualifies under subsection (5) of this section.)) A PEBB continuation of coverage election notice and continued health plan enrollment will only be available if the PEBB benefits services program is notified in writing within the sixty-day period.

[Statutory Authority: RCW 41.05.160, 41.05.350, and 41.05.165. 05-16-046 (Order 05-01), 182-12-260, filed 7/27/05, effective 8/27/05. Statutory Authority: RCW 41.05.160 and 41.05.165. 04-18-039, 182-12-260, filed 8/26/04, effective 1/1/05.]


AMENDATORY SECTION(Amending Order 06-09, filed 11/22/06, effective 12/23/06)

WAC 182-12-265   What options for continuing health plan ((coverage)) enrollment are available to widows, widowers and dependent children if the employee or retiree dies?   The surviving dependent of an eligible employee or retiree who meets the eligibility criteria in subsection (1), (2), or (3) of this section is eligible to enroll in public employees((')) benefits board (PEBB) retiree insurance coverage as a surviving dependent. An eligible surviving ((dependent)) spouse, qualified domestic partner, or child must enroll in or defer enrollment in a PEBB health plan ((coverage)) no later than sixty days after the date of the employee(('s)) or retiree's death.

(1) Dependents ((that)) who lose eligibility due to the death of an eligible employee may continue enrollment in a PEBB health plan ((coverage)) as a survivor under ((a)) retiree ((plan)) insurance coverage 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)) health plan enrollment until death.

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

(c) If a surviving ((dependent)) spouse, qualified domestic partner, or child 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 is not eligible ((to participate in)) for PEBB retiree ((coverage)) insurance as a survivor. However, the dependent may continue health plan ((coverage)) enrollment 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)) who lose eligibility due to the death of a PEBB eligible retiree may continue health plan ((coverage)) enrollment under ((a)) retiree ((plan)) insurance.

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

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

(c) Dependents ((that)) who are waiving enrollment in a PEBB health plan ((coverage)) at the time of the retiree's death are eligible to enroll or defer enrollment in PEBB retiree ((coverage)) insurance. A form to enroll or defer PEBB health plan ((coverage)) enrollment must be hand-delivered or mailed to the PEBB benefits services program no later than sixty days after the retiree's death. To enroll in a PEBB health plan ((coverage)), the dependent must provide satisfactory evidence ((that)) of continuous 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 a 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)) enrollment until death.

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

(4) Surviving dependents must notify the PEBB benefits services program of their decision to enroll or defer enrollment in a PEBB health plan ((coverage)) no later than sixty days after the date of death of the employee or retiree. If PEBB ((coverage)) health plan enrollment ended due to the death of the employee or retiree, PEBB will reinstate health plan ((coverage)) enrollment without a gap subject to payment of premium. In order to avoid duplication of group medical coverage, surviving dependents may defer enrollment in a PEBB health plan ((coverage)) under WAC 182-12-200 and 182-12-205. To notify the PEBB benefits services program of their intent to enroll or defer enrollment in a PEBB health plan ((coverage)) the surviving dependent must send a completed ((enrollment)) election form to the PEBB benefits services program no later than sixty days after the date of death of the employee or retiree.

[Statutory Authority: RCW 41.05.160 and 41.05.068. 06-23-165 (Order 06-09), 182-12-265, filed 11/22/06, effective 12/23/06. 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.]


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

WAC 182-12-270   What options are available to dependents ((that)) who cease to meet the ((definition of dependent)) eligibility criteria in WAC 182-12-260?   If eligible, dependents may continue health plan enrollment ((in PEBB health plan coverage)) under one of the continuation options in subsection (1), (2), or (3) of this section by self-paying premiums following their loss of eligibility. The PEBB benefits services program must receive a timely election form as outlined in the PEBB Initial Notice of COBRA and Continuation Coverage Rights. Options for continuing ((coverage)) health plan enrollment are based on the reason that eligibility was lost.

(1) ((Dependents that)) Spouses, qualified domestic partners, or children who lose eligibility due to the death of an employee or retiree may be eligible to continue ((coverage)) health plan enrollment under provisions of WAC 182-12-250 or 182-12-265.

(2) Dependents of a lawful marriage ((that)) who lose eligibility because they no longer meet the ((definition of dependent as defined)) eligibility criteria in WAC 182-12-260 are eligible to continue ((coverage)) health plan enrollment under provisions of the federal Consolidated Omnibus Budget Reconciliation Act (COBRA); or

(3) Dependents of a qualified ((same sex)) domestic partnership ((that)) who lose eligibility because they no longer meet the ((definition of dependent as defined)) eligibility criteria in WAC 182-12-260 may continue health plan enrollment under an extension of PEBB insurance coverage for a maximum of thirty-six months.

No extension of PEBB coverage will be offered unless the PEBB benefits services program is notified through hand-delivery or United States Postal Service mail of a completed notice of qualifying event as outlined in the PEBB Initial Notice of COBRA and Continuation Coverage Rights.

[Statutory Authority: RCW 41.05.160, 41.05.350, and 41.05.165. 05-16-046 (Order 05-01), 182-12-270, filed 7/27/05, effective 8/27/05. Statutory Authority: RCW 41.05.160 and 41.05.165. 04-18-039, 182-12-270, filed 8/26/04, effective 1/1/05.]


REPEALER

     The following section of the Washington Administrative Code is repealed:
WAC 182-12-190 May a retiree change health carriers at retirement?

OTS-9820.3


AMENDATORY SECTION(Amending WSR 91-14-025, filed 6/25/91, effective 7/26/91)

WAC 182-16-020   Definitions.   As used in this chapter the term:

(((1))) "Administrator" ((shall)) means the administrator of the health care authority (HCA) or designee;

(((2))) "Agency" ((shall)) means the health care authority;

(((3))) "Agent" ((shall)) means a person, association, or corporation acting on behalf of the health care authority pursuant to a contract between the health care authority and the person, association, or corporation.

"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.

"Health plan" or "plan" means a medical or dental plan developed by the public employees benefits board and provided by a contracted vendor or self-insured plans administered by the HCA.

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

"PEBB" means the public employees benefits board.

"PEBB benefits services program" means the program within the health care authority which administers insurance and other benefits to eligible employees of the state (as defined in WAC 182-12-115), eligible retired and disabled employees of the state (as defined in WAC 182-12-171), and others as defined in RCW 41.05.011.

[Statutory Authority: RCW 41.05.010 and 34.05.250. 91-14-025, 182-16-020, filed 6/25/91, effective 7/26/91.]


AMENDATORY SECTION(Amending WSR 97-21-128, filed 10/21/97, effective 11/21/97)

WAC 182-16-030   Appeals ((from)) of decisions of the agency ((decisions)) or its agent -- Applicability.   ((Any enrollee of the health care authority's administered insurance plans (the self-insured plans) aggrieved by a decision of the agency or its agent concerning any matter related to scope of coverage, denials of claims, determinations of eligibility, or cancellations or nonrenewals of coverage may obtain administrative review of such decision by filing a notice of appeal with the health care authority's appeals committee. Review of decisions made by HMOs or similar health care contractors will be pursuant to the grievance/arbitration provisions of those plans and are not subject to these rules. Except that decisions concerning eligibility determinations are reviewable only by the health care authority.)) Except as provided by RCW 48.43.530 and 48.43.535, any person aggrieved by a decision of the health care authority or its agent may appeal that decision.

(1) Eligibility appeals. Decisions concerning eligibility determinations are reviewable by the health care authority. The PEBB appeals manager must receive the appeal within ninety days from the date of the denial notice.

(2) Noneligibility appeals. Appeals of decisions made by the agency's self-insured medical plans, managed health care plans, and other agency contractors are governed by the appeal provisions of those plans. Those appeals are not subject to this chapter, except for eligibility determinations.

(3) Dental plan appeals. Any enrollee of the health care authority's self-administered dental plan aggrieved by a decision of the agency or its agent may appeal to the PEBB appeals manager. The PEBB appeals manager must receive the appeal within ninety days from the date of the denial notice.

(4) Retirement plan age appeals. Employees who do not meet their Washington state-sponsored retirement plan's age requirements when their employer paid or COBRA coverage ends, but who meet the age requirement within sixty days of coverage ending, may appeal the denial of their retiree insurance eligibility. The PEBB appeals manager must receive the appeal within ninety days from the date of the denial notice. Employees must meet other retiree insurance election procedural requirements. Eligibility denials caused by these circumstances may be reversed:

(a) Misleading or incorrect written information provided by employees of the health care authority or employers;

(b) Loss of COBRA coverage due to Medicare eligibility;

(c) Other related miscalculations of the duration of COBRA coverage; or

(d) Administrative errors or delays attributable to the state that have material impact on eligibility.

(5) Limited retiree insurance coverage reinstatement. Reinstatement of a retiree's insurance coverage may be approved when coverage was terminated because of late payment or late paperwork, or in extraordinary circumstances such as the retiree's impaired decision-making which adversely affects eligibility. No retiree's insurance coverage may be reinstated more than three times. Reinstatement may be approved only if:

(a) The retiree or a representative acting on their behalf submits a written appeal within sixty days after the notice of termination was mailed; and

(b) The retiree agrees to make payment in accordance with the terms of an agreement with the HCA.

[Statutory Authority: RCW 41.05.160. 97-21-128, 182-16-030, filed 10/21/97, effective 11/21/97. Statutory Authority: RCW 41.05.010 and 34.05.250. 91-14-025, 182-16-030, filed 6/25/91, effective 7/26/91.]


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

WAC 182-16-040   Appeals -- Notice of appeal contents.   Except as provided by RCW 48.43.530 and 48.43.535 and WAC 182-16-030(2), any person aggrieved by a decision of the health care authority(('s PEBB program)) or its agent may appeal that decision by filing a notice of appeal with the PEBB ((program's)) appeals manager. The notice of appeal must contain:

(1) The name and mailing address of the enrollee;

(2) The name and mailing address of the appealing party;

(3) The name and mailing address of the appealing party's representative, if any;

(4) A statement identifying the specific portion of the decision being appealed making it clear what ((it is that)) is believed to be unlawful or unjust;

(5) A clear and concise statement of facts in support of appealing party's position;

(6) Any ((and all)) information or documentation that the ((aggrieved person)) appealing party would like considered and ((feels)) substantiates why the decision should be reversed ((()). Information or documentation submitted at a later date, unless specifically requested by the PEBB appeals manager, may not be considered in the appeal decision(()));

(7) A copy of the ((PEBB program's)) health care authority's or ((health carrier's)) its agent's response to the issue the ((appellant)) appealing party has raised;

(8) The type of relief sought;

(9) A statement that the appealing party has read the notice of appeal and believes the contents to be true((, followed by his or her));

(10) The appealing party's signature and the signature of his or her representative, if any;

(((10))) (11) The appealing party shall file the original notice of appeal with the PEBB benefits services program using hand delivery, electronic mail or United States Postal Service mail. The notice of appeal must be received by the PEBB benefits services program within ((sixty)) ninety days after the decision of the PEBB staff was mailed to the appealing party. The PEBB appeals manager shall acknowledge receipt of the copies filed with the PEBB benefits services program;

(((11))) (12) The health care authority's appeals ((officer)) committee will render a written decision within thirty working days after receipt of the complete notice of appeal.

[Statutory Authority: RCW 41.05.160, 41.05.350, and 41.05.165. 05-16-046 (Order 05-01), 182-16-040, filed 7/27/05, effective 8/27/05. Statutory Authority: RCW 41.05.160. 97-21-128, 182-16-040, filed 10/21/97, effective 11/21/97. Statutory Authority: RCW 41.05.010 and 34.05.250. 91-14-025, 182-16-040, filed 6/25/91, effective 7/26/91.]


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

WAC 182-16-050   Appeals -- Hearings.   (1) If the appealing party is not satisfied with the decision of the health care authority's appeals ((officer upholds the original denial)) committee, the ((enrollee)) appealing party may request an administrative hearing. The request must be made in writing to the PEBB ((program's)) appeals manager. The appeal is not effective unless the PEBB ((benefit services must)) appeals manager receives the written request for a hearing within ((fifteen)) thirty days of the date the appeals decision was mailed to the ((appellant)) appealing party.

(2) The agency shall set the time and place of the hearing and give not less than ((seven)) twenty days notice to all parties and persons who have filed written petitions to intervene.

(3) The administrator or his or her designee shall preside at all hearings resulting from the filings of appeals under this chapter.

(4) All hearings ((shall)) must be conducted in compliance with these rules, chapter 34.05 RCW and chapter 10-08 WAC as applicable.

(5) Within ninety days ((of)) after the hearing record is closed, the administrator or his or her designee shall render a decision which shall be the final decision of the agency. A copy of that decision accompanied by a written statement of the reasons for the decision shall be served on all parties and persons who have intervened.

[Statutory Authority: RCW 41.05.160, 41.05.350, and 41.05.165. 05-16-046 (Order 05-01), 182-16-050, filed 7/27/05, effective 8/27/05. Statutory Authority: RCW 41.05.160. 97-21-128, 182-16-050, filed 10/21/97, effective 11/21/97. Statutory Authority: RCW 41.05.010 and 34.05.250. 91-14-025, 182-16-050, filed 6/25/91, effective 7/26/91.]

Washington State Code Reviser's Office