PDFWAC 182-08-235

Employer group application process.

This section applies to employer groups for the public employees benefits board (PEBB) program as defined in WAC 182-08-015. An employer group may apply to obtain PEBB insurance coverage through a contract with the health care authority (HCA).
(1) Employer groups with less than 500 employees must apply at least 60 days before the requested coverage effective date. Employer groups with 500 or more employees but with less than 5,000 employees must apply at least 90 days before the requested effective date.
Employer groups with 5,000 or more employees must apply at least 120 days before the requested coverage effective date.
To apply, employer groups must submit the documents and information described in subsection (2) of this section to the PEBB program as follows:
(a) Counties, municipalities, political subdivisions, and tribal governments with fewer than 5,000 employees are required to provide the documents and information described in subsection (2)(a) through (f) of this section;
(b) Counties, municipalities, political subdivisions, and tribal governments with 5,000 or more employees will have their application approved or denied through the evaluation criteria described in WAC 182-08-240 and are required to provide the documents and information described in subsection (2)(a) through (d), (f), and (g) of this section; and
(c) All employee organizations representing state civil services employees and the Washington health benefit exchange, regardless of the number of employees, will have their application approved or denied through the evaluation criteria described in WAC 182-08-240 and are required to provide the documents and information described in subsection (2)(a) through (d), (f), and (g) of this section.
(2) Documents and information required with application:
(a) A letter of application that includes the information described in (a)(i) through (iv) of this subsection:
(i) A reference to the group's authorizing statute;
(ii) A description of the organizational structure of the group and a description of the employee bargaining unit or group of nonrepresented employees for which the group is applying;
(iii) Tax identification number; and
(iv) A statement of whether the group is applying to obtain only medical or all available PEBB insurance coverages.
(b) A resolution from the group's governing body authorizing the purchase of PEBB insurance coverage.
(c) A signed governmental function attestation document that attests to the fact that employees for whom the group is applying are governmental employees whose services are substantially all in the performance of essential governmental functions.
(d) A member level census file for all of the employees for whom the group is applying. The file must be provided in the format required by the authority and contain the following demographic data, by member, with each member classified as employee, spouse or state registered domestic partner, or child:
(i) Employee ID (any identifier which uniquely identifies the employee; for dependents the employee's unique identifier must be used);
(ii) Age;
(iii) Birth sex;
(iv) First three digits of the member's zip code based on residence;
(v) Indicator of whether the employee is active or retired, if the group is requesting to include retirees; and
(vi) Indicator of whether the member is enrolled in coverage.
(e) Historical claims and cost information that include the following:
(i) Large claims history for 24 months by quarter that excludes the most recent three months;
(ii) Ongoing large claims management report for the most recent quarter provided in the large claims history;
(iii) Summary of historical plan costs; and
(iv) The director or the director's designee may make an exception to the claims and cost information requirements based on the size of the group, except that the current health plan does not have a case management program, then the primary diagnosis code designated by the authority must be reported for each large claimant. If the code indicates a condition which is expected to continue into the next quarter, the claim is counted as an ongoing large claim. If historical claims and cost information as described in (e)(i) through (iii) of this subsection are unavailable, the director or the director's designee may make an exception to allow all of the following alternative requirements:
• A letter from their carrier indicating they will not or cannot provide claims data.
• Provide information about the health plan most employees are enrolled in by completing the actuarial calculator authorized by the PEBB program.
• Current premiums for the health plan.
(f) If the application is for a subset of the group's employees (e.g., bargaining unit), the group must provide a member level census file of all employees eligible under their current health plan who are not included on the member level census file in (d) of this subsection. This includes retired employees participating under the group's current health plan. The file must include the same demographic data by member.
(g) Employer groups described in subsection (1)(b) and (c) of this section must submit to an actuarial evaluation of the group provided by an actuary designated by the PEBB program. The group must pay for the cost of the evaluation. This cost is nonrefundable. A group that is approved will not have to pay for an additional actuarial evaluation if it applies to add another bargaining unit within two years of the evaluation. Employer groups of this size must provide the following:
(i) Large claims history for 24 months, by quarter that excludes the most recent three months;
(ii) Ongoing large claims management report for the most recent quarter provided in the large claims history;
(iii) Executive summary of benefits;
(iv) Summary of benefits and certificate of coverage; and
(v) Summary of historical plan costs.
Exception:
If the current health plan does not have a case management program then the primary diagnosis code designated by the authority must be reported for each large claimant. If the code indicates a condition which is expected to continue into the next quarter, the claim is counted as an ongoing large claim.
(3) The authority may automatically deny a group application if the group fails to provide the required information and documents described in this section.
[Statutory Authority: RCW 41.05.021, 41.06.065 [ 41.05.065], and 41.05.160. WSR 24-18-076 (Admin #2024-01.01), § 182-08-235, filed 8/29/24, effective 1/1/25. Statutory Authority: RCW 41.05.021 and 41.05.160. WSR 23-14-015 (Admin #2023-01), § 182-08-235, filed 6/23/23, effective 1/1/24; WSR 22-13-158 (Admin #2022-01), § 182-08-235, filed 6/21/22, effective 1/1/23; WSR 20-16-062 (Admin #2020-03), § 182-08-235, filed 7/28/20, effective 1/1/21. Statutory Authority: RCW 41.05.021, 41.05.160, and PEBB policy resolutions. WSR 19-17-073 (Admin #2019-01), § 182-08-235, filed 8/20/19, effective 1/1/20; WSR 18-20-117 (Admin #2018-02), § 182-08-235, filed 10/3/18, effective 1/1/19; WSR 17-19-077 (Order 2017-01), § 182-08-235, filed 9/15/17, effective 1/1/18. Statutory Authority: RCW 41.05.021, 41.05.160, 2016 c 67, and PEBB policy resolutions. WSR 16-20-080, § 182-08-235, filed 10/4/16, effective 1/1/17. Statutory Authority: RCW 41.05.160, 2015 c 116, and PEBB policy resolutions. WSR 15-22-099 (PEBB Admin # 2015-01 Rev 1), § 182-08-235, filed 11/4/15, effective 1/1/16. Statutory Authority: RCW 41.05.160 and 2013 2nd sp.s. c 4. WSR 14-20-058 (PEBB Admin 2014-02), § 182-08-235, filed 9/25/14, effective 1/1/15. Statutory Authority: RCW 41.05.160 and 2012 2nd sp.s. c 3. WSR 13-22-019 (Admin. 2013-01), § 182-08-235, filed 10/28/13, effective 1/1/14. Statutory Authority: RCW 41.05.160. WSR 12-20-022 (Order 2012-01), § 182-08-235, filed 9/25/12, effective 11/1/12.]