PROPOSED RULES
(Public Employees Benefits Board)
Original Notice.
Preproposal statement of inquiry was filed as WSR 08-09-066.
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 23, 2008, at 1:00 p.m.
Date of Intended Adoption: September 30, 2008.
Submit Written Comments to: Matthew Albright, 676 Woodland Square Loop S.E., P.O. Box 42684, Olympia, WA 98504-2684, e-mail bsco107@hca.wa.gov, fax (360) 923-2602, by September 23, 2008.
Assistance for Persons with Disabilities: Contact Nikki Johnson by September 16, 2008, TTY (888) 923-5622 or (360) 923-2805.
Purpose of the Proposal and Its Anticipated Effects, Including Any Changes in Existing Rules: The main purpose of the rule making is to amend existing PEBB rules in TITLE 182 WAC and adopt new rules to:
| • | Implement legislation extending participation in the PEBB program to tribal governments. |
| • | Implement legislation to expand eligible dependents to include unmarried adult children up to age twenty five. |
| • | Amend and clarify rules regarding participation, withdrawal, and appeals by certain employing entities. |
| • | Clarify rules regarding retiree enrollment and eligibility. |
| • | Amend rules affected by a recent amendment to the Family Medical Leave Act. |
| • | Add the dependent care assistance program as a benefit for state agencies and higher education. |
| • | Amend rules regarding PEBB member appeals. |
Statutory Authority for Adoption: Chapter 41.05 RCW.
Statute Being Implemented: RCW 41.05.095, 41.05.295, 41.05.021.
Rule is not necessitated by federal law, federal or state court decision.
Name of Proponent:
Name of Agency Personnel Responsible for Drafting: Matthew Albright, 676 Woodland Square Loop, Lacey, WA, (360) 923-2629; Implementation: Barbara Scott, 676 Woodland Square Loop, Lacey, WA, (360) 923-2642; and Enforcement: Mary Fliss, 676 Woodland Square Loop, Lacey, WA, (360) 923-2640.
No small business economic impact statement has been prepared under chapter 19.85 RCW. The joint administrative rules review committee has not requested the filing of a small business economic impact statement, and there will be no costs to small businesses.
A cost-benefit analysis is not required under RCW 34.05.328. RCW 34.05.328 does not apply to the health care authority rules unless requested by the joint administrative rules [review] committee or applied voluntarily.
August 19, 2008
Jason Siems
Rules Coordinator
OTS-1801.2
AMENDATORY SECTION(Amending Order 07-01, filed 10/3/07,
effective 11/3/07)
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.
"Agency" means the health care authority.
"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 medical insurance by a retiree or eligible survivor.
"Dependent" means a person who meets eligibility requirements in WAC 182-12-260.
"Dependent care assistance program" or "DCAP" means a benefit plan whereby state and public employees may pay for certain employment related dependent care with pretax dollars as provided in the salary reduction plan authorized in chapter 41.05 RCW.
"Effective date of enrollment" means the first date when an enrollee is entitled to receive covered benefits.
"Employer group" means those employee organizations representing state civil service employees, blind vendors, counties, municipalities, political subdivisions, and tribal governments participating in PEBB insurance coverage under contractual agreement as described in WAC 182-08-230.
"Employing agency" means a division, department, or separate agency of state government; a county, municipality, school district, educational service district, or other political subdivision; or a tribal government covered by chapter 41.05 RCW.
"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.
"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, life insurance offered to employees on an optional basis, and retiree life insurance.
"Medical flexible spending arrangement" or "medical FSA" means a benefit plan whereby state and public employees may reduce their salary before taxes to pay for medical expenses not reimbursed by insurance as provided in the salary reduction plan authorized in chapter 41.05 RCW.
"Open enrollment" means a time period ((designated by the
administrator)) when: Subscribers may apply to transfer their
enrollment from one health plan to another((, enroll in
medical if the subscriber had previously waived such insurance
coverage, or add dependents)); a dependent may be enrolled; a
dependent's enrollment may be waived; or an employee who
previously waived medical may enroll in medical. Open
enrollment is also the time when employees may enroll in or
change their election under the DCAP, the medical FSA, or the
premium payment plan. An "annual" open enrollment, designated
by the administrator, is an open enrollment when all PEBB
subscribers may make enrollment changes for the upcoming year.
A "special" open enrollment is triggered by a specific life
event. For special open enrollment events as they relate to
specific PEBB benefits, see WAC 182-08-198, 182-08-199,
182-12-128, 182-12-262.
"PEBB" means the public employees benefits board.
"PEBB appeals committee" means the committee that considers appeals relating to the administration of PEBB benefits by the PEBB benefits services program. The administrator has delegated the authority to hear appeals at the level below an administrative hearing to the PEBB appeals committee.
"PEBB benefits" means one or more insurance coverage or other employee benefit administered by the PEBB benefits services program within the HCA.
"PEBB benefits services program" means the program within
the health care authority which administers insurance and
other benefits ((to)) for 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),
eligible dependents (as defined in WAC 182-12-250 and
182-12-260) and others as defined in RCW 41.05.011.
"Premium payment plan" means a benefit plan whereby state and public employees may pay their share of group health plan premiums with pretax dollars as provided in the salary reduction plan.
"Salary reduction plan" means a benefit plan whereby state and public employees may agree to a reduction of salary on a pretax basis to participate in the DCAP, medical FSA, or premium payment plan as authorized in chapter 41.05 RCW.
"Subscriber" or "insured" means the employee, retiree, COBRA beneficiary or eligible survivor who has been designated by the HCA as the individual to whom the HCA and contracted vendors will issue all notices, information, requests and premium bills on behalf of enrollees.
"Tribal government" means an Indian tribal government as defined in Section 3(32) of the Employee Retirement Income Security Act of 1974 (ERISA), as amended, or an agency or instrumentality of the tribal government, that has government offices principally located in this state.
"Waive" means to interrupt enrollment or postpone enrollment in a PEBB health plan by an employee (as defined in WAC 182-12-115) or a dependent who meets eligibility requirements in WAC 182-12-260.
[Statutory Authority: RCW 41.05.160. 07-20-129 (Order 07-01), § 182-08-015, filed 10/3/07, effective 11/3/07. 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.]
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 employing agency except as indicated in WAC 182-12-148(3).
(2) Notwithstanding subsection (1) of this section, the
PEBB assistant administrator or ((designee)) the PEBB appeals
committee may approve a refund which does not exceed twelve
months of premium 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)) PEBB
appeals committee; 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)) employing agency,
subscriber, or beneficiary, as appropriate.
[Statutory Authority: RCW 41.05.160. 07-20-129 (Order 07-01), § 182-08-180, filed 10/3/07, effective 11/3/07. 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.]
(1) Employer contributions are set by the HCA and are subject to the approval of the governor.
(2) Employer contributions 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) is eligible for the employer contribution. The entire employer contribution is due and payable to HCA even if medical is waived.
(4) PEBB insurance coverage for any county, municipality or other political subdivision, tribal government, or an agency or instrumentality of a tribal government, or any K-12 school district or educational service district may be 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. 07-20-129 (Order 07-01), § 182-08-190, filed 10/3/07, effective 11/3/07. 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.]
(1) Employees who fail to select a new medical or dental plan within the prescribed time period will be enrolled in a successor plan if one is available or will be enrolled in the Uniform Medical Plan Preferred Provider Organization or the Uniform Dental Plan with existing dependent enrollment.
(2) Retirees and survivors eligible under WAC 182-12-250 or 182-12-265 who fail to select a new health plan within the prescribed time period will be enrolled in a successor plan if one is available or will be enrolled in the Uniform Medical Plan Preferred Provider Organization and the Uniform Dental Plan. However, retirees enrolled in Medicare Parts A and B, and who enroll in Medicare Part D may be assigned to a PEBB Medicare plan that does not include a pharmacy benefit.
Any subscriber assigned to a health plan as described in this rule may not change health plans until the next open enrollment except as allowed in WAC 182-08-198.
(3) Enrollees continuing PEBB health plan enrollment
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 benefits services program or their
health plan enrollment will end as of the last day of the
month in which the plan is no longer available.
[Statutory Authority: RCW 41.05.160. 07-20-129 (Order 07-01), § 182-08-196, filed 10/3/07, effective 11/3/07. 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.]
(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 employing 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 employing 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) Employees who are eligible to participate in the state's salary reduction plan (see WAC 182-12-116) will be automatically enrolled in the premium payment plan upon enrollment in medical so employee medical premiums are taken on a pretax basis. To opt out of the premium payment plan, new employees must complete the appropriate form and return it to their employing agency no later than thirty-one days after they become eligible for PEBB benefits.
(4) Employees who are eligible to participate in the state's salary reduction plan may enroll in the state's medical FSA or DCAP or both. To enroll in these optional PEBB benefits, employees must return the appropriate enrollment forms to their employing agency or PEBB designee no later than thirty-one days after becoming eligible for PEBB benefits.
(5) When an employee's employment ends, insurance coverage ends (WAC 182-12-131). Employees who are later reemployed and become newly 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 employing agency to another employing 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.
(6) When an employee's employment ends, participation in the state's salary reduction plan ends. If the employee is hired into a new position that is eligible for PEBB benefits in the same year, the employee may not resume participation in DCAP or medical FSA until the beginning of the next plan year, unless the time between employments is less than thirty days.
[Statutory Authority: RCW 41.05.160. 07-20-129 (Order 07-01), § 182-08-197, filed 10/3/07, effective 11/3/07; 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.]
(2) Subscribers may change health plans outside of the
annual open enrollment if a special open enrollment event
occurs. The change in enrollment must ((be based on and
related)) correspond to the ((change in status)) event that
((created)) creates the special open enrollment
((opportunity)) for either the subscriber ((and)) or the
subscriber's dependents or both. To make a health plan
change, the subscriber must submit the appropriate enrollment
form((())s(())) (and a completed disenrollment form, if
required) no later than sixty days after the event occurs. Employees submit the enrollment form((())s(())) to their
employing agency. All other subscribers submit the enrollment
form((())s(())) to the PEBB benefits services program. Enrollment in the new health plan will begin the first day of
the month following the event that created the special open
enrollment; or in cases where the event occurs on the first
day of the month, enrollment will begin on that date. If the
special open enrollment is due to the birth or adoption of a
child, enrollment will begin the month in which the event
occurs. The following events create a special open
enrollment:
(a) Subscriber acquires a new eligible dependent through marriage, domestic partnership, birth, adoption or placement for adoption, legal custody or legal guardianship;
(b) Subscriber's dependent child becomes eligible by fulfilling PEBB dependent eligibility criteria;
(c) Subscriber loses an eligible dependent or a dependent no longer meets PEBB eligibility criteria;
(d) Subscriber has a change in marital status, including legal separation documented by a court order;
(e) Subscriber or a dependent loses comprehensive group
((insurance)) health coverage;
(f) Subscriber or a dependent has a change in employment
status that affects ((whether enrollment in PEBB insurance
coverage will benefit the subscriber or the subscriber's
dependent(s): This includes beginning or end of employment,
beginning or returning from an unpaid leave of absence, strike
or lockout, change in worksite, becoming eligible for benefits
or eligibility ending)) the subscriber's or a dependent's
eligibility, level of benefits, or cost of insurance coverage.
(g) Subscriber(('s)) or ((their)) a dependent(('s)) has a
change in residence ((changes affecting the)) that affects
health plan availability ((or the)), benefits, or ((the)) cost
of ((their)) insurance coverage. If the subscriber moves and
((their)) the subscriber's current health plan is not
available in ((their)) the new location but ((they do)) the
subscriber does not select a new health plan, the PEBB
benefits services program may enroll ((them)) the subscriber
in the Uniform Medical Plan Preferred Provider Organization or
Uniform Dental Plan.
(h) Subscriber receives a court order or medical support
order requiring the subscriber, ((their)) the subscriber's
spouse, or the subscriber's qualified domestic partner to
provide insurance coverage for an eligible dependent.
(i) Subscriber receives formal notice that the department of social and health services has determined it is more cost-effective to enroll the eligible subscriber or eligible dependent in PEBB medical than a medical assistance program.
(j) Seasonal employees whose off-season occurs during the annual open enrollment. They may select a new health plan upon their return to work.
(k) Subscriber enrolls in PEBB retiree insurance coverage.
(l) Subscriber or an eligible dependent becomes entitled to Medicare, enrolls in or disenrolls from a Medicare Part D plan.
(m) Subscriber experiences a disruption that could
function as a reduction in benefits for the subscriber or the
subscriber's dependent(s) due to a specific condition or
ongoing course of treatment. A subscriber may not change
their health plan if ((their)) the subscriber's or an enrolled
dependent's physician stops participation with the
subscriber's health plan unless the PEBB appeals manager
determines that a continuity of care issue exists. 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.
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 salary reduction plan authorized under RCW 41.05.300.
[Statutory Authority: RCW 41.05.160. 08-09-027 (Order 08-01), § 182-08-198, filed 4/8/08, effective 4/9/08; 07-20-129 (Order 07-01), § 182-08-198, filed 10/3/07, effective 11/3/07. 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.]
(2) Employees may enroll or change their election under the state's premium payment plan, medical FSA or DCAP outside of the annual open enrollment if a special open enrollment event occurs. The enrollment or change in enrollment must be allowable under Internal Revenue Code (IRC) and correspond to the event that creates the special open enrollment. To make a change or enroll, the employee must submit the appropriate forms as instructed on the forms no later than sixty days after the event occurs. Enrollment will begin the first day of the month following approval by the plan administrator. For purposes of this section, an eligible dependent includes the employee's opposite sex spouse and any other person who qualifies as the employee's dependent under Section 152 of the IRC without regard to the income limitations of that section. It does not include a domestic partner who is the same sex as the subscriber unless the domestic partner otherwise qualifies as a dependent under Section 152 of the IRC. The following changes are events that create a special open enrollment for purposes of an eligible employee making a change:
(a) Employee acquires a new eligible dependent;
(b) Employee's dependent child becomes eligible by fulfilling PEBB dependent eligibility criteria;
(c) Employee loses an eligible dependent or a dependent no longer meets PEBB eligibility criteria;
(d) Employee has a change in marital status, including legal separation documented by a court order;
(e) Employee or a dependent has a change in employment status that affects the employee's or a dependent's eligibility, level of benefits, or cost of insurance coverage under a plan provided by the employee's employer or the dependent's employer;
(f) Employee's or a dependent's residence changes that affects health plan availability, level of benefits, or cost of insurance coverage;
(g) Employee receives a court order or medical support order requiring the employee or the employee's spouse to provide insurance coverage for an eligible dependent;
(h) Employee receives formal notice that the department of social and health services has determined it is more cost-effective to enroll the eligible employee or eligible dependent in PEBB medical than in a medical assistance program;
(i) Seasonal employees whose off-season occurs during the annual open enrollment may enroll in the plan upon their return to work;
(j) Employee or an eligible dependent gains or loses eligibility for Medicare or Medicaid;
(k) Employees who change dependent care providers may make a change in their DCAP to reflect the cost of the new provider;
(l) If an employee's dependent care provider imposes a change in the cost of dependent care, the employee may make a change in the DCAP to reflect the new cost if the dependent care provider is not a relative as defined in Section 152 (a)(1) through (8), incorporating the rules of Section 152 (b)(1) and (2) of the IRC;
(m) The employee or the employee's spouse experiences a change in the number of qualifying individuals as defined in IRC Section 21 (b)(1).
[]
(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.
(2)))(a) Each employer group 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 must submit required documentation and meet all participation requirements in the then-current Introduction to PEBB Coverage K-12 and Employer Groups booklet(s).
(((3)(a))) (2) Each employer group, K-12 school district
or educational service district applying for participation in
PEBB insurance coverage must sign an ((interlocal)) agreement
with the HCA.
(((b) Each interlocal agreement must be renewed no less
frequently than once in every two-year period.
(4))) (3) At least twenty days before the premium due date, the HCA 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 must be submitted to the HCA before the twentieth day of the month 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 must be accompanied by a full explanation of the circumstances of the late notification.
(((5))) (4) An employer group, K-12 school district or
educational service district 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))) (5) Each employer group, K-12 school district or
educational service district 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 must not withhold
portions of the monthly premium due because it has failed to
collect the entire employee share.
(((7))) (6) 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) Before termination for nonpayment of premium, the HCA will send a notice of overdue premium 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
have the right to a dispute resolution hearing in accordance
with the terms of the ((interlocal)) agreement.
(e) Employees 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). Employees 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 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))) (7) A disenrolled employer group, K-12 school
district or educational service district may apply for
reinstatement in PEBB insurance coverage 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))) (8) 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. 07-20-129 (Order 07-01), § 182-08-230, filed 10/3/07, effective 11/3/07. 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-1802.2
AMENDATORY SECTION(Amending Order 07-01, filed 10/3/07,
effective 11/3/07)
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.
"Agency" means the health care authority.
"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 medical insurance by a retiree or eligible survivor.
"Dependent" means a person who meets eligibility requirements in WAC 182-12-260.
"Dependent care assistance program" or "DCAP" means a benefit plan whereby state and public employees may pay for certain employment related dependent care with pretax dollars as provided in the salary reduction plan authorized in chapter 41.05 RCW.
"Effective date of enrollment" means the first date when an enrollee is entitled to receive covered benefits.
"Employing agency" means a division, department, or separate agency of state government; a county, municipality, school district, educational service district, or other political subdivision; or a tribal government covered by chapter 41.05 RCW.
"Employer group" means those employee organizations representing state civil service employees, blind vendors, counties, municipalities, political subdivisions, and tribal governments participating in PEBB insurance coverage under contractual agreement as described in WAC 182-08-230.
"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.
"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, life insurance offered to employees on an optional basis, and retiree life insurance.
"Medical flexible spending arrangement" or "medical FSA" means a benefit plan whereby state and public employees may reduce their salary before taxes to pay for medical expenses not reimbursed by insurance as provided in the salary reduction plan authorized in chapter 41.05 RCW.
"Open enrollment" means a time period ((designated by the
administrator)) when: Subscribers may ((apply to)) transfer
their enrollment from one health plan to another((, enroll in
medical if the enrollee had previously waived such insurance
coverage or add dependents)); a dependent may be enrolled; a
dependent's enrollment may be waived; or an employee who
previously waived medical may enroll in medical. Open
enrollment is also the time when employees may enroll in or
change their election under the DCAP, the medical FSA, or the
premium payment plan. An "annual" open enrollment, designated
by the administrator, is an open enrollment when all PEBB
subscribers may make enrollment changes for the upcoming year.
A "special" open enrollment is triggered by a specific life
event. For special open enrollment events as they relate to
specific PEBB benefits, see WAC 182-08-198, 182-08-199,
182-12-128, 182-12-262.
"PEBB" means the public employees benefits board.
"PEBB appeals committee" means the committee that considers appeals relating to the administration of PEBB benefits by the PEBB benefits services program. The administrator has delegated the authority to hear appeals at the level below an administrative hearing to the PEBB appeals committee.
"PEBB benefits" means one or more insurance coverage or other employee benefit administered by the 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)) for 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),
eligible dependents (as defined in WAC 182-12-250 and
182-12-260) and others as defined in RCW 41.05.011.
"Premium payment plan" means a benefit plan whereby state and public employees may pay their share of group health plan premiums with pretax dollars as provided in the salary reduction plan.
"Salary reduction plan" means a benefit plan whereby state and public employees may agree to a reduction of salary on a pretax basis to participate in the DCAP, medical FSA, or premium payment plan as authorized in chapter 41.05 RCW.
"Subscriber" or "insured" means the employee, retiree,
COBRA beneficiary or eligible survivor who has been designated
by the HCA as the individual to whom the HCA and
((contractual)) contracted vendors will issue all notices,
information, requests and premium bills on behalf of
enrollees.
"Tribal government" means an Indian tribal government as defined in Section 3(32) of the Employee Retirement Income Security Act of 1974 (ERISA), as amended, or an agency or instrumentality of the tribal government, that has government offices principally located in this state.
"Waive" means to interrupt enrollment or postpone enrollment in a PEBB health plan by an employee (as defined in WAC 182-12-115) or a dependent who meets eligibility requirements in WAC 182-12-260.
[Statutory Authority: RCW 41.05.160. 07-20-129 (Order 07-01), § 182-12-109, filed 10/3/07, effective 11/3/07. 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.]
(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 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 end PEBB benefits by January 1, 1996, or the expiration of the current collective bargaining agreements, whichever is later. Employees electing to end PEBB benefits have a one-time reenrollment option after a five year wait. Employees of a bargaining unit may end PEBB benefit participation only as an entire bargaining unit. All administrative or managerial employees may 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 purchasing insurance benefits, may participate in PEBB 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,)) with the
following exceptions:
• 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) 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 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 insurance coverage participation at least one full year, and may end participation only at the end of a plan year.
(e) The terms and conditions for the payment of the
insurance premiums must be in the provisions of ((the)) a
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 in WAC 182-12-260.
(g) The legislative authority or the board of directors
must give the HCA written notice of its intent to end PEBB
insurance coverage participation at least ((thirty)) sixty
days before the effective date of termination. If the
employee organization ends PEBB insurance coverage, retired
and disabled employees who began participating after September
15, 1991, are not eligible for PEBB insurance coverage beyond
the mandatory extension requirements specified in WAC 182-12-146.
(h) Employees eligible for PEBB participation include only those employees whose services are substantially all in the performance of essential governmental functions but not in the performance of commercial activities, whether or not those activities qualify as essential governmental functions. Employers shall determine eligibility in order to ensure PEBB's continued status as a governmental plan under Section 3(32) of the Employee Retirement Income Security Act of 1974 (ERISA) as amended.
(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 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,)) with the
following exception:
• 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 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 insurance coverage participation 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 in the provisions of ((the)) a
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 in WAC 182-12-260.
(g) The legislative authority or the board of directors
must give the HCA written notice of its intent to end PEBB
insurance coverage participation at least ((thirty)) sixty
days before the effective date of termination. If a county,
municipality, or political subdivision ends ((coverage in))
PEBB insurance coverage, retired and disabled employees who
began participating after September 15, 1991, are not eligible
for PEBB insurance coverage beyond the mandatory extension
requirements specified in WAC 182-12-146.
(h) Employees eligible for PEBB participation include only those employees whose services are substantially all in the performance of essential governmental functions but not in the performance of commercial activities, whether or not those activities qualify as essential governmental functions. Employers shall determine eligibility in order to ensure PEBB's continued status as a governmental plan under Section 3(32) of the Employee Retirement Income Security Act of 1974 (ERISA) as amended.
(5) K-12 school districts and educational service districts: Employees of school districts or educational service districts may participate in PEBB insurance coverage provided all of the following requirements are met:
(a) All eligible employees of the ((entity)) K-12 school
district or educational service district 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,)) with the following exceptions:
• Bargaining units may elect to participate separately
from the whole group((. For enrolling by bargaining unit,
all)); and
• Nonrepresented employees ((will be considered a single
bargaining unit)) may elect to participate separately from the
whole group provided all nonrepresented employees join as a
group.
(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)) an estimate of the number of employees and
dependents to be enrolled. The application for the PEBB
insurance coverage is subject to ((the approval of the HCA))
review for compliance with PEBB terms and conditions of
participation.
(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 insurance coverage participation at least one full year, and may 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 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 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 in WAC 182-12-260.
(g) The school district or educational service district
must give the HCA written notice of its intent to end PEBB
insurance coverage participation at least ((thirty)) sixty
days before the effective date of termination, and may end
participation only at the end of a plan year.
(h) Employees eligible for PEBB participation include only those employees whose services are substantially all in the performance of essential governmental functions but not in the performance of commercial activities, whether or not those activities qualify as essential governmental functions. Employers shall determine eligibility in order to ensure PEBB's continued status as a governmental plan under Section 3(32) of the Employee Retirement Income Security Act of 1974 (ERISA) as amended.
(6) Tribal governments: Employees of a tribal government, or an agency or instrumentality of a tribal government, 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 as a unit with the following exceptions:
• Bargaining units may elect to participate separately from the whole group; and
• 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 tribal council 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 for PEBB insurance coverage is subject to the approval of the HCA.
(d) The tribal council or the board of directors must maintain its PEBB insurance coverage participation 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 in the provisions of a 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 tribal government employees must be the same as the requirements for dependents of state employees and retirees in WAC 182-12-260.
(g) The tribal council or the board of directors must give the HCA written notice of its intent to end PEBB insurance coverage participation at least sixty days before the effective date of termination. If a tribal government, or an agency or instrumentality of a tribal government, ends PEBB insurance coverage, retired and disabled employees are not eligible for PEBB insurance coverage beyond the mandatory extension requirements specified in WAC 182-12-146.
(h) Employees eligible for PEBB participation include only those employees whose services are substantially all in the performance of essential governmental functions but not in the performance of commercial activities, whether or not those activities qualify as essential governmental functions. Employers shall determine eligibility in order to ensure PEBB's continued status as a governmental plan under Section 3(32) of the Employee Retirement Income Security Act of 1974 (ERISA) as amended.
(7) 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 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. 07-20-129 (Order 07-01), § 182-12-111, filed 10/3/07, effective 11/3/07. 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.]
[Statutory Authority: RCW 41.05.160. 07-20-129 (Order 07-01), § 182-12-112, filed 10/3/07, effective 11/3/07. Statutory Authority: RCW 41.05.160 and 41.05.165. 04-18-039, § 182-12-112, filed 8/26/04, effective 1/1/05.]
(a) Employees of public four-year institutions of higher
education((,)).
(b) Employees of the state community and technical
colleges and of the state board for community and technical
colleges ((who are eligible for PEBB benefits, as defined in
WAC 182-12-115, are eligible for the PEBB medical flexible
spending account plan. Beginning July 1, 2006, all)).
(c) Employees of state agencies ((who are eligible for
PEBB benefits, are eligible 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 benefits, the employee may not resume participation in the PEBB medical flexible spending account until the beginning of the next plan year)).
(2) Employees of employer groups, K-12 school districts and educational service districts are not eligible to participate in the state's salary reduction plan.
[Statutory Authority: RCW 41.05.160. 07-20-129 (Order 07-01), § 182-12-116, filed 10/3/07, effective 11/3/07; 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.]
(a) Employees may waive medical when they become eligible
for PEBB benefits. ((The)) Employees must indicate they are
waiving medical on the appropriate enrollment form they submit
to their employing agency no later than thirty-one days after
the date they become eligible (see WAC 182-08-197). Medical
will be waived as of the date the employee becomes eligible
for PEBB benefits.
(b) Employees may waive medical during the annual open enrollment if they submit the appropriate enrollment form to their employing agency before the end of the annual open enrollment. Medical will be waived beginning January of the following year.
(c) Employees may waive medical during a special open enrollment as described in subsection (4) of this section.
(2) If an employee waives medical, medical is automatically waived for all eligible dependents, with the exception of adult dependents who may enroll in a health plan if the employee has waived medical coverage.
(3) Once medical is waived, enrollment is only allowed during the following times:
(a) The annual open enrollment period;
(b) A special open enrollment created by an event that
allows for enrollment outside of the annual open enrollment as
described in subsection (4) of this section. In addition to
the appropriate ((enrollment)) form((())s(())), the PEBB
benefits services program may require the employee to provide
evidence of eligibility and evidence of the event that creates
a special open enrollment.
(4) Employees may waive enrollment in medical or enroll
in medical if one of these special open enrollment events
occur. The change in enrollment must ((be based on and
related)) correspond to the ((change in status)) event that
creates the special open enrollment. The following changes
are events that create a special open enrollment:
(a) Employee acquires a new eligible dependent through marriage, domestic partnership, birth, adoption or placement for adoption, legal custody or legal guardianship;
(b) Employee's dependent child becomes eligible by fulfilling PEBB dependent eligibility criteria;
(c) Employee loses an eligible dependent or a dependent no longer meets PEBB eligibility criteria;
(d) Employee has a change in marital status, including legal separation documented by a court order;
(e) Employee or a dependent loses comprehensive group insurance coverage;
(f) Employee or ((one of the employee's)) a
dependent((s)) has a change in employment status that affects
((whether enrollment in PEBB insurance coverage will benefit
the subscriber or the subscriber's dependent: This includes
beginning or end of employment, beginning or returning from an
unpaid leave of absence, strike or lockout, change in
worksite, becoming eligible or ceasing to be eligible for
employer benefits)) the employee's or a dependent's
eligibility, level of benefits, or cost of insurance coverage;
(g) Employee or a dependent has a change in place of
residence that affects the ((subscriber's)) employee's or
((the)) a dependent's ((health plan)) eligibility ((or the)),
level of benefits, or cost of ((the)) insurance coverage;
(h) Employee receives a court order or medical support
enforcement order requiring the employee, ((their)) spouse, or
qualified domestic partner to enroll an eligible dependent;
(i) Employee receives formal notice that the department of social and health services has determined it is more cost-effective to enroll the employee or an eligible dependent in PEBB medical than a medical assistance program.
To change enrollment during a special open enrollment,
the employee must submit the appropriate ((enrollment))
form((())s(())) to their employing agency no later than sixty
days after the event that creates the special open enrollment.
Enrollment in insurance coverage will begin the first of the month following the event that created the special open enrollment; or in cases where the event occurs on the first day of a month, enrollment will begin on that date. If the special open enrollment is due to the birth or adoption of a child, insurance coverage will begin the month in which the event occurs.
[Statutory Authority: RCW 41.05.160. 08-09-027 (Order 08-01), § 182-12-128, filed 4/8/08, effective 4/9/08; 07-20-129 (Order 07-01), § 182-12-128, filed 10/3/07, effective 11/3/07. Statutory Authority: RCW 41.05.160 and 41.05.165. 04-18-039, § 182-12-128, filed 8/26/04, effective 1/1/05.]
(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); 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. 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 medical and dental for a period of eighteen to 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)) twenty-six weeks, as provided in WAC 182-12-138.
[Statutory Authority: RCW 41.05.160. 07-20-129 (Order 07-01), § 182-12-133, filed 10/3/07, effective 11/3/07; 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.]
[Statutory Authority: RCW 41.05.160. 07-20-129 (Order 07-01), § 182-12-138, filed 10/3/07, effective 11/3/07. Statutory Authority: RCW 41.05.160 and 41.05.165. 04-18-039, § 182-12-138, filed 8/26/04, effective 1/1/05.]
(a) The employee must submit ((an election)) the
appropriate forms to enroll or defer insurance coverage within
sixty days after ((their)) the employee's employer paid or
COBRA coverage ends. The effective date of health plan
enrollment will be the first day of the month following the
loss of other coverage.
| Exception: | The effective dates of health plan enrollment for retirees who defer enrollment in a PEBB health plan at or after retirement are identified in WAC 182-12-200 and 182-12-205. |
(b) The 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 (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)) the employee's
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)) PEBB appeals committee to determine eligibility
(see WAC ((182-16-030)) 182-16-032). 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'))
a Washington state-sponsored retirement ((system)) plan 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 or tribal
government that participates in PEBB insurance coverage for
their employees are eligible to continue PEBB insurance
coverage as ((a)) retirees if the employees meet the
procedural and eligibility requirements under this section.
(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) Tribal government employees. If a tribal government ends participation in PEBB insurance coverage, its employees are no longer eligible for PEBB retiree insurance. These employees may continue PEBB health plan enrollment under COBRA (see WAC 182-12-146).
(c) 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 annual open enrollment period for the year beginning January 1, 1995.
(3) 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) 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.
The two federal retirement systems, Civil Service Retirement System and Federal Employees' Retirement System, are considered a Washington state-sponsored retirement system for Washington State University Extension employees covered under the PEBB insurance coverage at the time of retirement or disability.
[Statutory Authority: RCW 41.05.160. 07-20-129 (Order 07-01), § 182-12-171, filed 10/3/07, effective 11/3/07; 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.]
(1) The local government or tribal government retiree health plan must have existed at least three years before the date of application for participation in PEBB health plans.
(2) Eligibility for coverage under the local government's or tribal 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 or tribal government retiree health plan.
(4) To protect the integrity of the risk pool, if total local government or tribal 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 or tribal government unit transfers; or
(b) May adopt a new rating methodology reflective of the cost of covering local government or tribal 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 or tribal government transferring to PEBB health plan coverage must meet retiree eligibility as outlined in chapter 182-12 WAC.
[Statutory Authority: RCW 41.05.160. 07-20-129 (Order 07-01), § 182-12-175, filed 10/3/07, effective 11/3/07. 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.]
(1) During any PEBB annual open enrollment period. (Enrollment in the PEBB health plan will begin the first day of January after the annual open enrollment period.); or
(2) No later than sixty days after enrollment in the PEBB or K-12 school district sponsored medical plan 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. 07-20-129 (Order 07-01), § 182-12-200, filed 10/3/07, effective 11/3/07. 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.]
(1) Retirees may defer enrollment in a PEBB health plan at or after retirement if continuously enrolled in other comprehensive medical as identified below:
(a) Beginning January 1, 2001, retirees may defer enrollment if they are enrolled in comprehensive employer-sponsored medical as an employee or the dependent of an employee.
(b) Beginning January 1, 2001, retirees may defer enrollment if they are enrolled in medical as a retiree or the dependent of a retiree enrolled in a federal retiree plan.
(c) Beginning January 1, 2006, retirees may defer 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 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 enrollment, the retiree must
((send a completed election)) submit the appropriate forms to
the PEBB benefits services program requesting to defer. The
PEBB benefits services program must receive the form before
health plan enrollment is deferred or no later than sixty days
after the date the retiree becomes eligible to apply for PEBB
retiree insurance coverage.
(3) Retirees who defer may enroll in a PEBB health plan as follows:
(a) Retirees who defer while enrolled in
employer-sponsored medical may enroll in a PEBB health plan by
((sending a completed election)) submitting the appropriate
forms and evidence of continuous enrollment in comprehensive
employer-sponsored medical to the PEBB benefits services
program:
(i) During annual open enrollment. (Enrollment in the
PEBB health plan will begin the first day of January after the
annual open enrollment ((period)).); or
(ii) No later than sixty days after their employer-sponsored medical ends. (Enrollment in the PEBB health plan will begin the first day of the month after the employer-sponsored medical ends.)
(b) Retirees who defer enrollment while enrolled as a
retiree or dependent of a retiree in a federal retiree medical
plan will have a one-time opportunity to enroll in a PEBB
health plan by ((sending a completed election)) submitting the
appropriate forms and evidence of continuous enrollment in a
federal retiree medical plan to the PEBB benefits services
program:
(i) During annual open enrollment. (Enrollment in the
PEBB health plan will begin the first day of January after the
annual open enrollment ((period)).); or
(ii) No later than sixty days after the federal retiree medical ends. (Enrollment in the PEBB health plan will begin the first day of the month after the federal retiree medical ends.)
(c) Retirees who defer enrollment while enrolled in
Medicare Parts A and B and Medicaid may enroll in a PEBB
health plan by ((sending a completed election)) submitting the
appropriate forms and evidence of continuous enrollment in
creditable coverage to the PEBB benefits services program:
(i) During annual open enrollment. (Enrollment in the
PEBB health plan will begin the first day of January after the
annual open enrollment ((period)).); or
(ii) No later than sixty days after their Medicaid coverage ends (Enrollment in the PEBB 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 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 health plan will begin the first day of January following the end of the calendar year when the Medicaid coverage ends.)
(d) Retirees who defer enrollment may enroll in a PEBB health plan if the retiree receives formal notice that the department of social and health services has determined it is more cost-effective to enroll the retiree or the retiree's eligible dependent(s) in PEBB medical than a medical assistance program.
[Statutory Authority: RCW 41.05.160. 08-09-027 (Order 08-01), § 182-12-205, filed 4/8/08, effective 4/9/08; 07-20-129 (Order 07-01), § 182-12-205, filed 10/3/07, effective 11/3/07. 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.]
[Statutory Authority: RCW 41.05.160. 07-20-129 (Order 07-01), § 182-12-209, filed 10/3/07, effective 11/3/07.]
(1) This section applies to the 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 spouse and children" means:
(a) A lawful spouse;
(b) An ex-spouse as defined in RCW 41.26.162;
(c) 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))
under the age of twenty-five. Children with disabilities as
defined in RCW 41.26.030(7) are eligible at any age. "Children" ((are)) is defined as:
(i) Biological children (including the emergency service worker's posthumous children);
(ii) Stepchildren; and
(iii) Legally adopted children.
(4) Surviving spouses and children who are entitled to Medicare must enroll in both parts A and B of Medicare.
(5) The survivor (or agent acting on their behalf) must
((send a completed election)) submit the appropriate forms (to
either enroll or defer enrollment in a PEBB health plan) to
PEBB benefits services 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 spouse or child was covered under any health plan through the emergency service worker's employer; or
(d) The last day the surviving spouse or child was covered under the Consolidated Omnibus Budget Reconciliation Act (COBRA) coverage from the emergency service worker's employer.
(6) Survivors who do not choose to defer enrollment in a PEBB health plan may choose among the following options for when their enrollment in a PEBB health plan will begin:
(a) June 1, 2006, for survivors whose ((election))
appropriate forms ((is)) are received by the PEBB benefits
services program no later than September 1, 2006;
(b) The first of the month that is ((no more)) not
earlier than sixty days before the date that the PEBB benefits
services program receives the ((election)) appropriate forms
(for example, if the PEBB benefits services program receives
the ((election)) appropriate forms on August 29, the survivor
may request 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 ((election))
appropriate forms.
For surviving spouses and children who enroll, monthly health plan premiums must be paid by the survivor except as provided in RCW 41.26.510(5) and 43.43.285 (2)(b). For children age twenty through age twenty-four who enroll and are not students under the age of twenty-four attending high school or registered at an accredited secondary school, college, university, vocational school, or school of nursing: The adult dependent premium must be paid by the survivor except as provided in RCW 41.26.510(5) and 43.43.285 (2)(b).
(7) Survivors must choose one of the following two options to maintain eligibility for PEBB insurance coverage:
(a) Enroll in a PEBB health plan:
(i) Enroll in medical; or
(ii) Enroll in medical and dental.
(iii) Survivors enrolling in dental must stay enrolled in dental for at least two years before dental can be dropped.
(iv) Dental only is not an option.
(b) Defer enrollment:
(i) Survivors may defer enrollment in a PEBB health plan if enrolled in comprehensive medical coverage through an employer.
(ii) Survivors may enroll in a PEBB health plan when they lose employer medical coverage. Survivors will need to provide evidence that they were continuously enrolled in comprehensive medical coverage through an employer when applying for a PEBB health plan, and apply within sixty days after the date their other coverage ended.
(iii) PEBB health plan enrollment and premiums will begin the first day of the month following the day that the other coverage ended for eligible spouses and children who enroll.
(8) Survivors may change their health plan during annual open enrollment. In addition to annual open enrollment, survivors may change health plans as described in WAC 182-08-198.
(9) Survivors may not add new dependents acquired through birth, marriage, or establishment of a qualified domestic partnership.
(10) Survivors will lose their right to enroll in a PEBB health plan if they:
(a) Do not apply to enroll or defer PEBB health plan 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. 07-20-129 (Order 07-01), § 182-12-250, filed 10/3/07, effective 11/3/07. 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.]
(1) Lawful spouse.
(2) Domestic partner qualified by the PEBB declaration 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 in Washington state.
(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.
(4) Children ((through age nineteen)). Children are
defined as the subscriber's biological children, stepchildren,
legally adopted children, children for whom the subscriber has
assumed a legal obligation for total or partial support in
anticipation of adoption of the child, children of the
subscriber's qualified domestic partner, or children specified
in a court order or divorce decree. In addition, children
include extended dependents in the legal custody or legal
guardianship of the subscriber, the subscriber's spouse, or
subscriber's qualified domestic partner. The legal
responsibility is demonstrated by a valid court order and the
child's official residence with the custodian or guardian.
"Children" does not include foster children for whom support
payments are made to the subscriber through the state
department of social and health services foster care program.
Eligible 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 domestic partner, or children
specified in a court order or divorce decree;)) Unmarried
children through age nineteen.
(b) Married children through age nineteen who qualify as
dependents of the subscriber under the Internal Revenue
Code((;)).
(c) ((Extended dependents in the legal custody 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 official residence with
the custodian or guardian. This does not include foster
children for whom support payments are made to the subscriber
through the state department of social and health services
foster care program;
(d))) Unmarried children age twenty through age twenty-three who are attending high school or are registered students at an accredited secondary school, college, university, vocational school, or school of nursing (students). A married child is eligible as a student if the child is a dependent of the subscriber under the Internal Revenue Code.
(i) ((Student health plan enrollment begins the first day
of the month of the quarter or semester for which the child is
registered begins. Health plan enrollment ends the last day
of the month in which the 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.
(ii) Student eligibility for enrollment in a PEBB health plan continues during the three month period following graduation provided the subscriber is covered, the child has not reached age twenty-four, and meets all other eligibility requirements.
(iii))) A child is eligible as a student or can maintain eligibility as a student when not registered for courses through the summer or off quarter/semester as long as the child meets all other eligibility requirements and is in any one of the following circumstances:
• The child attended the three consecutive quarters or two consecutive semesters before the off quarter/semester.
• The child is an enrolled dependent turning age twenty or renewing annual student certification and the child is expected to register for three consecutive quarters or two consecutive semesters after the off quarter/semester.
• The child recently graduated. Graduation is defined as the successful completion of studies to earn a degree or certificate, not the date of the graduation ceremony. The child is eligible for the three month period following graduation.
(ii) For student dependents who are not eligible for the summer or off quarter/semester according to (c)(i) of this subsection, student eligibility begins the first day of the month of the quarter or semester for which the child is registered, and eligibility ends the last day of the month in which the student stops attending or in which the quarter or semester ends, whichever is first.
The PEBB benefits services program certifies students
((recertification occurs)) annually. Health plan enrollment
ends the last day of the month in which certification ends or
the student ceases to meet eligibility criteria, whichever
comes first. See WAC 182-12-262 (3)(g) and (7) for enrollment
requirements.
(d) Unmarried children age twenty through age twenty-four (adult dependents).
Subscriber must pay the adult dependent premium for adult dependents whom the subscriber has enrolled. Nonpayment of premium will result in termination of coverage back to the end of the month for which the last full month premium was paid.
Adult dependents must enroll in the same health plan as the subscriber.
| Exception: | The adult dependent may enroll in a different health plan than the subscriber if the dependent does not reside within the subscriber's plan service area or the subscriber has waived or deferred medical. |
(5))) Children of any age with disabilities,
developmental disabilities, mental illness or mental
retardation who are incapable of self-support, provided such
condition occurs before age twenty or during the time the
dependent was eligible as a student under (c) of this
subsection (((4) of this section)).
(((a))) The subscriber must provide evidence that such
disability occurred as stated below:
(i) For ((children)) a child enrolled in PEBB insurance
coverage, the subscriber must provide evidence of the
disability within sixty days of the child's attainment of age
twenty.
(ii) For ((children)) a child enrolled in PEBB insurance
coverage as a student under (c) of this 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 (c) of this subsection (((4)(d) of this
section)).
(iii) ((To enroll)) For a child, age twenty or older, who
is a new dependent or for a child, age twenty or older, who is
a dependent of a newly eligible subscriber, the child may be
enrolled as a dependent child with disabilities((, age twenty
or older,)) if the subscriber ((must)) provides evidence that
the condition occurred before the child reached age twenty or
evidence that when the condition occurred the child would have
satisfied PEBB eligibility for student coverage under (c) of
this subsection (((4) of this section. The PEBB benefits
services program will request evidence of the child's
disability periodically thereafter)) had the subscriber been
eligible for PEBB benefits at the time.
(((b))) The subscriber must notify the PEBB benefits
services program, in writing, no later than sixty days after
the date that a 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 child
may be eligible to continue enrollment as an adult dependent,
as per (d) of this subsection, or in a PEBB health plan under
provisions of WAC 182-12-270.
(((ii))) Children age twenty and older who become capable
of self-support do not regain eligibility under (e) of this
subsection (((5) of this section)) if they later become
incapable of self-support.
(((c) Disability recertification occurs)) The PEBB
benefits services program will recertify the eligibility of
children with disabilities periodically.
(((6))) (5) Parents.
(a) Parents covered under PEBB medical before July 1, 1990, may continue enrollment on a self-pay basis as long as:
(i) The parent maintains continuous enrollment in PEBB medical;
(ii) The parent qualifies under the Internal Revenue Code as a dependent of the subscriber;
(iii) The subscriber continues enrollment in PEBB insurance coverage; and
(iv) The parent is not covered by any other group medical plan.
(b) Parents eligible under this subsection may be enrolled with a different health plan than that selected by the subscriber. Parents may not add additional dependents to their insurance coverage.
(((7))) (6) 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 they are no
longer eligible under 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. 07-20-129 (Order 07-01), § 182-12-260, filed 10/3/07, effective 11/3/07. 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.]
| Exceptions: | • Adult dependents may enroll in a health plan if the employee has waived medical coverage or the retiree has deferred enrollment in PEBB retiree insurance in accordance with PEBB rule; |
| OR | |
| • Eligible dependents of a retiree may enroll in a health plan if the retiree deferred PEBB retiree insurance coverage due to the retiree's enrollment in Medicare and creditable Medicaid under WAC 182-12-205 (1)(c). |
(3) Subscribers may enroll a newly acquired dependent or a dependent that becomes eligible during a special open enrollment.
(a) A spouse may be enrolled upon marriage. If the date
of marriage is the first day of the month, ((insurance))
health plan coverage will begin on that date; otherwise, it
will begin the first of the following month.
(b) A qualified domestic partner may be enrolled upon
declaration or registration of the domestic partnership (see
WAC 182-12-260). If the date of declaration or registration
is the first day of the month, ((insurance)) health plan
coverage will begin on that date; otherwise, it will begin the
first of the following month.
(c) Newborn children may be enrolled upon birth and
adopted children may be enrolled when the subscriber assumes
legal responsibility for the child in anticipation of
adoption. The child's ((insurance)) health plan coverage will
begin on the date of birth or the date the subscriber assumes
legal responsibility for the child in anticipation of
adoption. The subscriber must submit the appropriate
((enrollment)) form((())s(())) as described in subsection (7)
of this section no later than sixty days after birth or
assuming legal responsibility for the child.
(d) Children acquired through marriage or a qualified domestic partnership may be enrolled upon marriage or declaration or registration of the domestic partnership as described in (a) or (b) of this subsection.
(e) ((Children)) Extended dependents acquired through
legal guardianship or legal custody (see WAC 182-12-260(4)(((c)))) may be enrolled upon issuance of a court
order granting such responsibility to the subscriber,
((their)) spouse, or qualified domestic partner. If legal
guardianship or legal custody begins on the first day of the
month, ((insurance)) health plan coverage will begin on that
date; otherwise, it will begin the first of the following
month.
(f) Children age twenty through age twenty-four (adult dependents) may be enrolled when they become eligible (see WAC 182-12-260 (4)(d)). If they become eligible on the first day of the month, health plan coverage will begin on that date; otherwise, it will begin the first of the month following the date they become eligible. For enrollment requirements, see subsection (7) of this section.
(g) Children ((twenty years or older)) who become
eligible as ((a)) students ((or as a child with disabilities))
may be enrolled ((after)) provided the child's eligibility is
certified by the PEBB benefits services program. If enrolled,
the child's insurance coverage will begin ((as follows:
(i) Insurance coverage for a student will begin on the first day of the month of the quarter or semester for which the student is registered.
(ii) Insurance)) or continue on the first day of the month the child becomes eligible as a student according to WAC 182-12-260 (4)(c).
(h) A child twenty years or older who becomes eligible as a child with disabilities under WAC 182-12-260 (4)(e) may be enrolled after the child's eligibility is certified by the PEBB benefits services program.
Health plan coverage ((for a child with disabilities))
will begin on the first day of the month that eligibility is
certified by the PEBB benefits services program.
(4) Subscribers may change the enrollment (enroll, waive
or remove) of their dependents outside of the annual open
enrollment if a special open enrollment event occurs. The
change in enrollment must ((be based on and related))
correspond to the ((change in status)) event that creates the
special open enrollment for either the subscriber ((and)) or
the subscriber's dependents or both. Enrollment in
((insurance)) health plan coverage will begin the first of the
month following the event that created the special open
enrollment; or in cases where the event occurs on the first
day of a month, enrollment will begin on that date. If the
special open enrollment is due to the birth or adoption of a
child, ((insurance)) health plan coverage will begin the month
in which the event occurs. The following changes are events
that create a special open enrollment for medical and dental:
(a) Subscriber acquires ((a new)) an eligible dependent
through marriage, domestic partnership, birth, adoption or
placement for adoption, legal custody or legal guardianship;
(b) Subscriber loses an eligible dependent or a dependent no longer meets PEBB eligibility criteria;
(c) Subscriber has a change in marital status, including legal separation documented by a court order;
(d) Subscriber or a dependent loses comprehensive group health insurance coverage;
(e) Subscriber or ((one of the subscriber's)) a
dependent((s)) has a change in employment status that affects
((whether enrollment in PEBB insurance coverage will benefit
the subscriber or the subscriber's dependent: This includes
beginning or end of employment, beginning or returning from an
unpaid leave of absence, strike or lockout, change in
worksite, becoming eligible for or ceasing to be eligible for
employer benefits)) the subscriber's or a dependent's
eligibility, level of benefits, or cost of insurance coverage;
(f) Subscriber or a dependent has a change in place of
residence that affects the subscriber's or ((the)) a
dependent's ((health plan)) eligibility ((or the)), level of
benefits, or cost of ((the)) insurance coverage;
(g) Subscriber receives a court order or medical support enforcement order requiring the subscriber, their spouse, or qualified domestic partner to provide insurance coverage for an eligible dependent. (A former spouse is not an eligible dependent.);
(h) Subscriber receives formal notice that the department of social and health services has determined it is more cost-effective to enroll an eligible dependent in PEBB medical than a medical assistance program.
(5) Subscribers may waive (interrupt or postpone) enrollment of an eligible dependent.
(a) Employees may only waive dependents if those
dependents are enrolled in ((other)) another comprehensive
group ((insurance coverage)) health plan. Employees may only
waive an eligible dependent's enrollment at the following
times:
(i) When the employee is first eligible and enrolls in PEBB benefits. (The dependent's enrollment will be waived beginning with the employee's effective date.);
(ii) During the annual open enrollment. (The dependent's enrollment will be waived beginning January of the following year.);
(iii) No later than sixty days after the dependent becomes eligible as described in subsection (3) of this section. (The dependent's enrollment will be waived beginning the date enrollment would have begun.); or
(iv) During a special open enrollment as described in
subsection (4) of this section. (The dependent's enrollment
will be waived as of the date corresponding to the ((change in
status)) event that ((created)) creates the special open
enrollment.)
(b) Retirees, survivors or individuals continuing PEBB insurance coverage under WAC 182-12-133 or 182-12-270 may waive enrollment of an eligible dependent outside of the annual open enrollment or a special open enrollment. Unless otherwise approved by the PEBB benefits services program, enrollment will be waived prospectively.
(c) Subscribers may enroll eligible dependents that were waived as stated in subsections (2) and (4) of this section.
(6) Subscribers must remove dependents from the subscriber's insurance coverage within sixty days of the date the dependent no longer meets eligibility criteria in WAC 182-12-250 or 182-12-260. Insurance coverage enrollment ends the last day of the month in which the dependent is eligible.
Subscribers may remove a lawful spouse from PEBB insurance coverage in the event of legal separation documented by a court order, provided the court did not order the subscriber to maintain the spouse's health plan enrollment. Subscribers must remove former spouses and former qualified domestic partners upon finalization of a divorce, annulment, or termination of a partnership, even if a court order requires the subscriber to provide health insurance for the former spouse or partner.
Consequences for not submitting notice as described in subsection (7) of this section within sixty days of any dependent ceasing to be eligible may include:
(a) The dependent's loss of eligibility to continue health plan enrollment under one of the continuation options described in WAC 182-12-270;
(b) The subscriber being billed for claims paid by the health plan for services after the dependent lost eligibility; and
(c) The subscriber being responsible for premiums paid by the state for the dependent's health plan enrollment after the dependent lost eligibility.
(7) Subscribers must submit the appropriate
((enrollment)) form((())s(())) within the time frames
described in this subsection. Employees submit the
((enrollment)) appropriate form((())s(())) to their employing
agency. All other subscribers submit the ((enrollment))
appropriate form((())s(())) to the PEBB benefits services
program. In addition to the appropriate forms indicating
dependent enrollment, the PEBB benefits services program may
require the subscriber to provide evidence of eligibility or
evidence of the event that created the special open
enrollment.
(a) If a subscriber wants to enroll their eligible
dependent(s) when the subscriber becomes eligible to enroll in
PEBB benefits, the subscriber must include the dependent's
enrollment information on the ((enrollment)) appropriate
form((())s(())) that the subscriber submits within the
relevant time frame described in WAC 182-08-197, 182-12-171,
or 182-12-250.
(b) If a subscriber wants to enroll eligible dependents
during the annual open enrollment, the subscriber must submit
the appropriate ((enrollment)) forms((())s(())) no later than
the end of the annual open enrollment.
(c) If a subscriber wants to enroll newly eligible
dependents, the subscriber must submit the appropriate
enrollment form((())s(())) no later than sixty days after the
dependent becomes eligible.
(d) ((If the subscriber wants to enroll a child age
twenty or older as a registered student, the subscriber must
submit the appropriate enrollment form(s) required to certify
the child as a student no later than sixty days after the
first day of the month of the quarter or semester that the
subscriber wants to enroll the student in PEBB insurance
coverage.
(e))) If the subscriber wants to enroll a child age
twenty or older as a child with disabilities, the subscriber
must submit the appropriate enrollment form(s) required to
certify the dependent's eligibility within the relevant time
frame described in WAC 182-12-250(3) or 182-12-260(((5))) (4).
(((f))) (e) If the subscriber wants to change a
dependent's enrollment status during a special open
enrollment, the subscriber must submit the appropriate
((enrollment)) form((())s(())) no later than sixty days after
the event that creates the special open enrollment.
(((g))) (f) If the subscriber wants to waive a
dependent's enrollment, the subscriber must submit the
appropriate ((enrollment)) forms. Unless otherwise approved
by the PEBB benefits services program, enrollment will be
waived prospectively.
[Statutory Authority: RCW 41.05.160. 08-09-027 (Order 08-01), § 182-12-262, filed 4/8/08, effective 4/9/08.]
(1) Dependents who lose eligibility due to the death of an eligible employee may continue enrollment in a PEBB health plan enrollment as a survivor under retiree 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 domestic partner may continue health plan enrollment until death.
(b) Children may continue health plan enrollment until they lose eligibility under PEBB rules.
(c) If a surviving 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 for PEBB retiree insurance as a survivor. However, the dependent may continue health plan 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 who lose eligibility due to the death of a PEBB eligible retiree may continue health plan enrollment under retiree insurance.
(a) The retiree's spouse or qualified domestic partner may continue health plan enrollment until death.
(b) Children may continue health plan enrollment until they lose eligibility under PEBB rules.
(c) Dependents ((who are waiving enrollment in a PEBB
health plan)), whose enrollment in a PEBB health plan is
waived at the time of the retiree's death, are eligible to
enroll or defer enrollment in PEBB retiree insurance. A form
to enroll or defer PEBB health plan 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, the dependent must provide satisfactory
evidence of continuous enrollment in other medical coverage
from the most recent open enrollment for which enrollment in
PEBB was waived.
(3) Surviving spouses or eligible 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 health plan 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 domestic partner may continue health plan enrollment until death.
(b) Children may continue 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 no later than sixty days
after the date of death of the employee or retiree. If PEBB
health plan enrollment ended due to the death of the employee
or retiree, PEBB will reinstate health plan 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 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 the surviving dependent must ((send a
completed election)) submit the appropriate forms 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. 07-20-129 (Order 07-01), § 182-12-265, filed 10/3/07, effective 11/3/07. 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.]
(1) Spouses, qualified domestic partners, or children who
lose eligibility due to the death of an employee or retiree
may be eligible to continue health plan enrollment under
provisions of WAC 182-12-250 or 182-12-265((.)); or
(2) Dependents ((of a lawful marriage)) who lose
eligibility because they no longer meet the eligibility
criteria in WAC 182-12-260 are eligible to continue health
plan enrollment under provisions of the federal Consolidated
Omnibus Budget Reconciliation Act (COBRA)((; or
(3) Dependents of)).
| Exception: | A qualified domestic partner who loses eligibility because he or she no longer meets the 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. |
[Statutory Authority: RCW 41.05.160. 07-20-129 (Order 07-01), § 182-12-270, filed 10/3/07, effective 11/3/07. 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.]
OTS-1803.2
AMENDATORY SECTION(Amending WSR 91-14-025, filed 6/25/91,
effective 7/26/91)
WAC 182-16-010
Adoption of model rules of procedure.
The model rules of procedure adopted by the chief
administrative law judge pursuant to RCW 34.05.250, as now or
hereafter amended, are hereby adopted for use by this agency
in PEBB benefits related proceedings. Those rules may be
found in chapter 10-08 WAC. Other procedural rules adopted in
this title are supplementary to the model rules of procedure. In the case of a conflict between the model rules of procedure
and the procedural rules adopted in this title, the procedural
rules adopted in this title shall govern.
[Statutory Authority: RCW 41.05.010 and 34.05.250. 91-14-025, § 182-16-010, filed 6/25/91, effective 7/26/91.]
"Administrator" means the administrator of the health care authority (HCA) or designee;
"Agency" means the health care authority;
(("Agent" 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.)) "Dependent care assistance
program" or "DCAP" means a benefit plan whereby state and
public employees may pay for certain employment related
dependent care with pretax dollars as provided in the salary
reduction plan authorized in chapter 41.05 RCW.
"Employing agency" means a division, department, or separate agency of state government; a county, municipality, school district, educational service district, or other political subdivision; or a tribal government covered by chapter 41.05 RCW.
"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.
"Medical flexible spending arrangement" or "medical FSA" means a benefit plan whereby state and public employees may reduce their salary before taxes to pay for medical expenses not reimbursed by insurance as provided in the salary reduction plan authorized in chapter 41.05 RCW.
"PEBB" means the public employees benefits board.
"PEBB appeals committee" means the committee that considers appeals relating to the administration of PEBB benefits by the PEBB benefits services program. The administrator has delegated the authority to hear appeals at the level below an administrative hearing to the PEBB appeals committee.
"PEBB benefits" means one or more insurance coverage or other employee benefit administered by the PEBB benefits services program within the HCA.
"PEBB benefits services program" means the program within
the health care authority which administers insurance and
other benefits ((to)) for 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),
eligible dependents (as defined in WAC 182-12-250 and
182-12-260), and others as defined in RCW 41.05.011.
"Premium payment plan" means a benefit plan whereby state and public employees may pay their share of group health plan premiums with pretax dollars as provided in the salary reduction plan.
"Salary reduction plan" means a benefit plan whereby state and public employees may agree to a reduction of salary on a pretax basis to participate in the DCAP, medical FSA, or premium payment plan as authorized in chapter 41.05 RCW.
[Statutory Authority: RCW 41.05.160. 07-20-129 (Order 07-01), § 182-16-020, filed 10/3/07, effective 11/3/07. Statutory Authority: RCW 41.05.010 and 34.05.250. 91-14-025, § 182-16-020, filed 6/25/91, effective 7/26/91.]
(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.)) Any employee or employee's dependent aggrieved by a decision made by an employing agency with regard to public employee benefits eligibility or enrollment may appeal that decision to the employing agency.
| Note: | Eligibility decisions address whether an employee or an employee's dependent is entitled to insurance coverage, as described in PEBB rules and policies. Enrollment decisions address the application for PEBB benefits as described in PEBB rules and policies, including but not limited to the submission of proper documentation and meeting enrollment deadlines. |
(1) Any employee or employee's dependent aggrieved by an eligibility or enrollment decision made by an employing agency may appeal the decision by submitting a written request for review to the employing agency. The employing agency must receive the request for review within thirty days of the date of the initial denial notice. The contents of the request for review are to be provided in accordance with WAC 182-16-040.
(a) Upon receiving the request for review, the employing agency shall make a complete review of the initial denial by one or more staff who did not take part in the initial denial. As part of the review, the employing agency may hold a formal meeting or hearing, but is not required to do so.
(b) The employing agency shall render a written decision within thirty days of receiving the request for review. The written decision shall be sent to the appellant.
(c) A copy of the employing agency's written decision shall be sent to the employing agency's administrator or designee and to the PEBB appeals manager. The employing agency's written decision shall become the employing agency's final decision effective fifteen days after the date it is rendered.
(2) Any employee or employee's dependent who disagrees with the employing agency's decision in response to a request for review, as described in subsection (1) of this section, may appeal that decision by submitting a notice of appeal to the PEBB appeals committee. The PEBB appeals manager must receive the notice of appeal within thirty days of the date of the employing agency's written decision on the request for review.
As well, any employee or employee's dependent may appeal a decision about premium payments by submitting a notice of appeal to the PEBB appeals committee. The PEBB appeals manager must receive the notice of appeal within thirty days of the date of the denial notice. The contents of the notice of appeal are to be provided in accordance with WAC 182-16-040.
(a) The PEBB appeals manager shall notify the appellant in writing when the notice of appeal has been received.
(b) The PEBB appeals committee shall render a written decision within thirty days of receiving the notice of appeal. The written decision shall be sent to the appellant.
(c) Any appellant who disagrees with the decision of the PEBB appeals committee may request an administrative hearing, as described in WAC 182-16-050.
[Statutory Authority: RCW 41.05.160. 07-20-129 (Order 07-01), § 182-16-030, filed 10/3/07, effective 11/3/07; 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.]
| Note: | Eligibility decisions address whether a retiree, self-pay enrollee or their dependent is entitled to insurance coverage, as described in PEBB rules and policies. Enrollment decisions address the application for PEBB benefits as described in PEBB rules and policies, including, but not limited to the submission of proper documentation, enrollment deadlines, and premium related issues. |
(1) The PEBB appeals manager shall notify the appellant in writing when the notice of appeal has been received.
(2) The PEBB appeals committee shall render a written decision within thirty days of receiving the notice of appeal. The written decision shall be sent to the appellant.
(3) Any appellant who disagrees with the decisions of the PEBB appeals committee may request an administrative hearing, as described in WAC 182-16-050.
[]
[]
(2) Any enrollee who disagrees with a decision in response to an appeal filed with the third-party administrator that administers the medical FSA and DCAP under the state's salary reduction plan may appeal to the PEBB appeals committee. The PEBB appeals manager must receive the notice of appeal within thirty days of the date of the appeal decision by the third-party administrator that administers the medical FSA and DCAP offered under the state's salary reduction plan. The contents of the notice of appeal are to be provided in accordance with WAC 182-16-040.
(a) The PEBB appeals manager shall notify the appellant in writing when the notice of appeal has been received.
(b) The PEBB appeals committee shall render a written decision within thirty days of receiving the notice of appeal. The written decision shall be sent to the appellant.
(c) Any appellant who disagrees with the decision of the PEBB appeals committee may request an administrative hearing, as described in WAC 182-16-050.
(3) Any enrollee aggrieved by a decision regarding the administration of the premium payment plan offered under the state's salary reduction plan may appeal that decision to the PEBB appeals committee. The PEBB appeals manager must receive the notice of appeal within thirty days of the date of the denial notice by the PEBB benefits services program. The contents of the notice of appeal are to be provided in accordance with WAC 182-16-040.
(a) The PEBB appeals manager shall notify the appellant in writing when the notice of appeal has been received.
(b) The PEBB appeals committee shall render a written decision within thirty days of receiving the notice of appeal. The written decision shall be sent to the appellant.
(c) Any appellant who disagrees with the decision of the PEBB appeals committee may request an administrative hearing, as described in WAC 182-16-050.
[]
(1) The PEBB appeals manager shall notify the appellant in writing when the notice of appeal has been received.
(2) The PEBB appeals committee shall render a written decision within thirty days of receiving the notice of appeal. The written decision shall be sent to the appellant.
(3) Any appellant who disagrees with the decision of the PEBB appeals committee may request an administrative hearing, as described in WAC 182-16-050.
[]
(1) The PEBB appeals manager shall notify the appealing party in writing when the notice of appeal has been received.
(2) The PEBB appeals committee shall render a written decision on the notice of appeal within thirty days of receiving the notice of appeal. The written decision shall be sent to the appealing party.
(3) Any appealing party aggrieved with the decision of the PEBB appeals committee may request an administrative hearing, as described in WAC 182-16-050.
[]
(1) ((The name and mailing address of the enrollee;
(2))) The name and mailing address of the appealing party;
(((3))) (2) The name and mailing address of the appealing
party's representative, if any;
(3) Documentation, or reference to documentation, of decisions previously rendered through the appeal process, if any;
(4) A statement identifying the specific portion of the
decision being appealed ((making it clear)) and clarifying
what is believed to be unlawful or ((unjust)) in error;
(5) A ((clear and concise)) statement of facts in support
of the appealing party's position;
(6) Any information or documentation that the appealing party would like considered and 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 health care authority's or its
agent's response to the issue the appealing party has raised;
(8))) The type of relief sought;
(((9))) (8) A statement that the appealing party has read
the notice of appeal and believes the contents to be true;
(((10))) (9) The signature of the appealing party(('s
signature and)) or the ((signature of his or her)) appealing
party's representative((, if any;
(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 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;
(12) The health care authority's appeals committee will render a written decision within thirty working days after receipt of the complete notice of appeal)).
[Statutory Authority: RCW 41.05.160. 07-20-129 (Order 07-01), § 182-16-040, filed 10/3/07, effective 11/3/07. 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.]
(2) The request must be made in writing to the PEBB
appeals manager. ((The appeal is not effective unless)) The
PEBB appeals manager must receive((s)) the ((written)) request
for ((a)) an administrative hearing within thirty days of the
date of the ((appeals)) written decision ((was mailed to the
appealing party)) by the PEBB appeals committee.
(((2))) (3) The agency shall set the time and place of
the hearing and give not less than twenty days notice to all
parties ((and persons who have filed written petitions to
intervene)).
(((3))) (4) The administrator, or his or her designee,
shall preside at all hearings resulting from the filings of
appeals under this chapter.
(((4))) (5) All hearings must be conducted in compliance
with these rules, chapter 34.05 RCW and chapter 10-08 WAC as
applicable.
(((5))) (6) Within ninety days 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)) mailed to all parties ((and persons who have
intervened)).
[Statutory Authority: RCW 41.05.160. 07-20-129 (Order 07-01), § 182-16-050, filed 10/3/07, effective 11/3/07. 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.]