WSR 08-17-081

PROPOSED RULES

HEALTH CARE AUTHORITY


(Public Employees Benefits Board)

[ Order 08-03 -- Filed August 19, 2008, 1:45 p.m. ]

     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.
     In addition to these specific subject areas, the health care authority is proposing amendments that will clarify eligibility for student dependents and dependents with disabilities.

     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.]


AMENDATORY SECTION(Amending Order 07-01, filed 10/3/07, effective 11/3/07)

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

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

     PEBB premiums will be refunded using the following method:

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


AMENDATORY SECTION(Amending Order 07-01, filed 10/3/07, effective 11/3/07)

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

     (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.]


AMENDATORY SECTION(Amending Order 07-01, filed 10/3/07, effective 11/3/07)

WAC 182-08-196   What happens if my health plan becomes unavailable?   Employees and retirees for whom the chosen health plan becomes unavailable due to a change in contracting service area, or the retiree's entitlement to Medicare must select a new health plan within sixty days after notification by the PEBB benefits services program.

     (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.]


AMENDATORY SECTION(Amending Order 07-01, filed 10/3/07, effective 11/3/07)

WAC 182-08-197   Employees must select ((insurance coverages)) PEBB benefits and complete enrollment forms within thirty-one days of the date they become eligible for PEBB benefits.   (1) Employees who are newly eligible for PEBB benefits must complete ((an enrollment)) the appropriate forms indicating enrollment and their health plan choice ((and return it)), or their decision to waive medical under WAC 182-12-128. Employees must return the forms to their employing agency no later than thirty-one days after they become eligible for PEBB benefits, as stated in WAC 182-12-115. Newly eligible employees who do not return an enrollment form to their employing agency indicating their medical and dental choice within thirty-one days will be enrolled in a health plan as follows:

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

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

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

     (a) To enroll in the amounts of optional life insurance available without health underwriting, employees must return a completed life insurance enrollment form to their 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.]


AMENDATORY SECTION(Amending Order 08-01, filed 4/8/08, effective 4/9/08)

WAC 182-08-198   When may a subscriber change health plans?   (1) Subscribers may change health plans during the annual open enrollment. The subscriber must submit the appropriate enrollment form((())s(())) to change health plan no later than the end of the annual open enrollment. Enrollment in the new health plan will begin January of the following year.

     (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.]


NEW SECTION
WAC 182-08-199   When may an employee enroll in or change their election under the premium payment plan, medical flexible spending arrangement (FSA) or dependent care assistance program (DCAP)?   (1) An eligible employee may enroll in or change their election under the state's premium payment plan, medical FSA or DCAP during the annual open enrollment. Employees must submit the appropriate enrollment form, or complete the appropriate on-line enrollment process, to reenroll no later than the end of the annual open enrollment. The enrollment or new election will begin January of the following year.

     (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).

[]


AMENDATORY SECTION(Amending Order 07-01, filed 10/3/07, effective 11/3/07)

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

     (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.]


AMENDATORY SECTION(Amending Order 07-01, filed 10/3/07, effective 11/3/07)

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

     (1) State agencies. Every department, division, or separate agency of state government, including all state higher education institutions, the higher education coordinating board, and the state board for community and technical colleges is required to participate in all PEBB 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.]


AMENDATORY SECTION(Amending Order 07-01, filed 10/3/07, effective 11/3/07)

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

[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.]


AMENDATORY SECTION(Amending Order 07-01, filed 10/3/07, effective 11/3/07)

WAC 182-12-116   Who is eligible ((for the PEBB flexible spending account)) to participate in the state's salary reduction plan?   ((Beginning January 1, 2006, all)) (1) The following employees are eligible to participate in the state's salary reduction plan provided they are eligible for PEBB benefits as defined in WAC 182-12-115 and they elect to participate within the time frames described in WAC 182-08-197 or 182-08-199.

     (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.]


AMENDATORY SECTION(Amending Order 08-01, filed 4/8/08, effective 4/9/08)

WAC 182-12-128   May an employee waive health plan enrollment?   (1) Employees must enroll in dental, life and long-term disability insurance (unless the employing agency does not participate in these PEBB insurance coverages). However, employees may waive PEBB medical if they have other comprehensive group medical coverage. Employees may waive enrollment in PEBB medical by submitting the appropriate enrollment form to their employing agency during the following times:

     (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.]


AMENDATORY SECTION(Amending Order 07-01, filed 10/3/07, effective 11/3/07)

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

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

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

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

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

     (d) The employee is applying for disability retirement;

     (e) The employee is called to active duty in the uniformed services as defined under the Uniformed Services Employment and Reemployment Rights Act (USERRA); 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.]


AMENDATORY SECTION(Amending Order 07-01, filed 10/3/07, effective 11/3/07)

WAC 182-12-138   If an employee is approved for family and medical leave, what insurance coverage may be continued?   Employees on approved leave under the federal Family and Medical Leave Act (FMLA) may continue to receive up to ((twelve)) twenty-six weeks of employer-paid medical, dental, basic life, and basic long-term disability insurance ((while on family and medical leave and)). These employees may also continue current optional life and long-term disability. ((All)) The employee's employing agency is responsible for determining if the employee is eligible for leave under FMLA and the duration of such leave. The employee must pay the premium amounts associated with insurance coverage ((must be paid)) monthly as ((they)) premiums become due. If premiums are more than sixty days delinquent, insurance coverage will end as of the last day of the month ((of fully)) for which a full premium is paid ((coverage)).

[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.]


AMENDATORY SECTION(Amending Order 07-01, filed 10/3/07, effective 11/3/07)

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

     (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.

Employees who ((cancel PEBB health plan coverage or)) do not enroll in a PEBB health plan at retirement are only eligible to enroll if they have deferred enrollment and maintained comprehensive coverage as ((defined)) identified in WAC 182-12-200 or 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.]


AMENDATORY SECTION(Amending Order 07-01, filed 10/3/07, effective 11/3/07)

WAC 182-12-175   May a local government entity or tribal government entity applying for participation in PEBB insurance coverage include their retirees in the transfer unit?   Local government or tribal government entities applying for participation in PEBB insurance coverage under WAC 182-12-111 (4) and (6), may request inclusion of retired employees who are covered under their retiree health plan at the time of application. The PEBB benefits services program will use the following criteria for approval of these requests for inclusion of retirees.

     (1) The local government 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.]


AMENDATORY SECTION(Amending Order 07-01, filed 10/3/07, effective 11/3/07)

WAC 182-12-200   May a retiree who is enrolled as a dependent in a PEBB health plan or a Washington state K-12 school district sponsored health plan defer enrollment in a PEBB retiree health plan?   Retirees who are enrolled in a PEBB or Washington state K-12 school district sponsored medical plan as a dependent may defer enrollment in a PEBB retiree health plan. Retirees who defer enrollment in medical cannot remain enrolled in dental. Retirees who defer may later enroll themselves and their dependents in PEBB retiree medical, or medical and dental, if they provide evidence of continuous enrollment in a PEBB or K-12 school district sponsored medical plan. Continuous enrollment must be from the date the retiree deferred enrollment in retiree insurance. Retirees may enroll:

     (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.]


AMENDATORY SECTION(Amending Order 08-01, filed 4/8/08, effective 4/9/08)

WAC 182-12-205   May a retiree defer enrollment in a PEBB health plan at or after retirement?   Except as stated in subsection (1)(c) of this section and for adult dependents as defined in WAC 182-12-260 (4)(d), if ((a)) retirees defer((s)) enrollment in a PEBB health plan, they also defer enrollment for all eligible dependents. Retirees may not defer their retiree term life insurance, even if they have other life insurance.

     (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.]


AMENDATORY SECTION(Amending Order 07-01, filed 10/3/07, effective 11/3/07)

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

[Statutory Authority: RCW 41.05.160. 07-20-129 (Order 07-01), § 182-12-209, filed 10/3/07, effective 11/3/07.]


AMENDATORY SECTION(Amending Order 07-01, filed 10/3/07, effective 11/3/07)

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

     (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.]


AMENDATORY SECTION(Amending Order 07-01, filed 10/3/07, effective 11/3/07)

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

     (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.

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

     (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.]


AMENDATORY SECTION(Amending Order 08-01, filed 4/8/08, effective 4/9/08)

WAC 182-12-262   When may subscribers enroll, waive or remove eligible dependents?   (1) Subscribers may enroll or waive eligible dependents when the subscriber becomes eligible and enrolls in PEBB insurance coverage. If enrolled, the dependent's effective date will be the same as the subscriber's effective date. Unless a dependent is independently eligible for PEBB ((insurance)) health plan coverage, the subscriber must be enrolled to enroll their dependent.


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).

     (2) Subscribers may enroll eligible dependents during the annual open enrollment with ((insurance)) health plan coverage beginning January of the following year.

     (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.]


AMENDATORY SECTION(Amending Order 07-01, filed 10/3/07, effective 11/3/07)

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

     (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.]


AMENDATORY SECTION(Amending Order 07-01, filed 10/3/07, effective 11/3/07)

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

     (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.

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

[Statutory Authority: RCW 41.05.160. 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.]


AMENDATORY SECTION(Amending Order 07-01, filed 10/3/07, effective 11/3/07)

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

     "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.]


AMENDATORY SECTION(Amending Order 07-01, filed 10/3/07, effective 11/3/07)

WAC 182-16-030   ((Appeals of decisions of the agency or its agent -- Applicability.)) How can an employee or an employee's dependent appeal a decision made by an employing agency about eligibility or enrollment in benefits?   ((Except as provided by RCW 48.43.530 and 48.43.535, any person aggrieved by a decision of the health care authority or its agent may appeal that decision.

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

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

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

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

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

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

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

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

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

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

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

     The employing agency may only reverse eligibility or enrollment decisions based on circumstances that arose due to delays caused by the employing agency or error(s) made by the employing agency.

     (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.]


NEW SECTION
WAC 182-16-032   How can a retiree or self-pay enrollee appeal a decision made by the PEBB benefits services program regarding eligibility, enrollment or premium payments?   Any retiree or self-pay enrollee aggrieved by a decision made by the PEBB benefits services program with regard to public employee benefit eligibility, enrollment, or premium payments may appeal the decision to the PEBB appeals committee.


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.

     The PEBB appeals manager must receive the notice of appeal within sixty 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.

     (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.

[]


NEW SECTION
WAC 182-16-034   How can a PEBB enrollee appeal a decision regarding the administration of a PEBB medical plan, insured dental plan, life insurance, long-term care insurance, long-term disability insurance, or property or casualty insurance?   Any PEBB enrollee aggrieved by a decision regarding the administration of a PEBB medical plan, insured dental plan, life insurance, long-term care insurance, long-term disability insurance, or property and casualty insurance may do so by following the appeal provisions of those plans. Those appeals are not subject to this chapter, except for eligibility, enrollment and premium payment determinations. Employees and their dependents should refer to WAC 182-16-030 for eligibility, enrollment and premium payment appeals. Retirees, self-pay enrollees, and their dependents should refer to WAC 182-16-032 for eligibility, enrollment and premium payment appeals.

[]


NEW SECTION
WAC 182-16-036   How can an enrollee appeal a decision regarding the administration of benefits offered under the state's salary reduction plan?   (1) Any enrollee aggrieved by a decision regarding the medical FSA and DCAP offered under the state's salary reduction plan may appeal that decision to the third-party administrator contracted to administer the plan.

     (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.

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NEW SECTION
WAC 182-16-037   How can an enrollee appeal a decision by the agency's self-insured dental plan?   Any enrollee aggrieved by a decision by the agency's self-insured dental 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 agency's self-insured dental plan. The contents of the notice of appeal are to be provided in accordance with WAC 182-16-040.

     (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.

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NEW SECTION
WAC 182-16-038   How can an entity or organization appeal a decision to deny its participation in PEBB?   Any entity or organization whose application to participate in PEBB benefits has been denied may appeal the decision to the PEBB appeals committee. For rules regarding eligible entities, see WAC 182-12-111. 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.

     (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.

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AMENDATORY SECTION(Amending Order 07-01, filed 10/3/07, effective 11/3/07)

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

     (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.]


AMENDATORY SECTION(Amending Order 07-01, filed 10/3/07, effective 11/3/07)

WAC 182-16-050   ((Appeals -- Hearings.)) How can an enrollee or entity get a hearing if aggrieved by a decision made by the PEBB appeals committee?   (1) ((If the appealing party is not satisfied with the decision of the health care authority's)) Any party aggrieved by a decision of the PEBB appeals committee, ((the appealing party)) may request an administrative hearing.

     (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.]

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