INTERPRETIVE OR POLICY STATEMENT
HEALTH CARE AUTHORITY
(Public Employees Benefits Board)
[Filed December 3, 2019, 2:45 p.m.]
Notice of Administrative Policy Statements
The following is a list of administrative policies published by the public employees benefits board (PEBB) program. These policies are effective January 1, 2020. You can download the complete policy statements on the PEBB rules and policies page hca.wa.gov/pebb-rules.
The following policies were amended:
Policy 11-1: Providing a notice to an employee and an employer.
To clarify the requirements of an employer-to-employee and employee-to-employer notice, as stated in RCW 41.05.009
(2) and 41.05.065
(4)(c)(iii), (iv), and (v).
Policy 11-3: Correcting employing agency and contracted vendor enrollment errors. This policy clarifies the requirements placed on an employing agency or contracted vendor when they correct their own enrollment errors as described in WAC 182-08-187.
Policy 15-1: Determining eligibility for a seasonal employee and maintenance of the employer contribution through the off-season. This policy clarifies seasonal employee eligibility for PEBB benefits and the employer contribution.
Policy 17-1: Determining faculty eligibility for summer/short class sessions. To clarify a higher education institution's role in defining faculty for the purposes of PEBB benefits.
Policy 19-1: Termination due to loss of eligibility or enrollment error. This policy applies whenever coverage for a subscriber or a subscriber's dependent is terminated due to loss of eligibility, or because a subscriber or dependent was enrolled when they were not eligible for coverage.
Addendum 19-1A: Termination due to loss of eligibility or enrollment error: Employee.
Addendum 19-1B: Termination due to loss of eligibility or non-payment: Self-pay subscriber.
Policy 21-1: Exemption from the retiree deferral form requirement. This policy exempts certain retirees from the "deferral form requirement" under WAC 182-12-171 (1)(d) and 182-12-205 (4)(a).
Policy 31-1: Verifying dependent eligibility before enrollment. This policy clarifies which documents the PEBB program considers valid for dependent verification and identifies which accounts are included in the dependent verification process.
Policy 31-2: Use of PEBB premium surcharge attestation help sheet and spousal plan calculator tools.
This policy provides direction when a PEBB program subscriber enrolled in PEBB medical, but not enrolled in medicare Part A and Part B and in the medicare risk pool as described in RCW 41.05.080
(3), is determining if a premium surcharge will be applied for a spouse or state-registered domestic partner enrolled in PEBB medical.
Policy 33-1: Verifying legal union's residency status.
This policy clarifies which documents the PEBB program considers valid for establishing state residency for subscribers who are in a legal union as defined in RCW 26.04.260
that is substantially equivalent to marriage in Washington State.
Policy 36-1: Certifying eligibility for a dependent child with a disability who is age twenty-six or older. This policy applies whenever a subscriber requests to enroll or continue enrollment for a dependent child with a disability who is age twenty-six or older to their PEBB program subscriber account.
Policy 37-1: Certifying eligibility for an extended dependent child. This policy applies when a subscriber submits the required forms to enroll an extended dependent child in the subscriber's PEBB benefits.
Policy 45-2: Special Open Enrollment (SOE). This policy applies whenever a subscriber requests an enrollment change or election change outside of the PEBB program annual open enrollment period.
Addendum 45-2A: Special Open Enrollment (SOE) matrix: Summary of permitted election changes.
Policy 56-1: Continuation coverage and retiree insurance coverage reinstatement for subscribers with mental or physical impairment or incapacitation. This policy applies whenever a subscriber (or another party acting on behalf of the subscriber) requests reinstatement of continuation coverage or retiree insurance coverage due to non-payment of premiums, or applicable premium surcharges, for reason of mental or physical impairment or incapacitation.
This policy establishes the methodology that the PEBB program will use to make a determination of mental or physical impairment or incapacitation for the purpose of reinstatement of coverage terminated due to nonpayment of premiums, or applicable premium surcharges.
Policy 56-2: Election period tolling for applicants with mental or physical impairment or incapacitation. This policy applies whenever an applicant (or another party acting on behalf of the applicant) requests tolling of the continuation coverage, retiree insurance coverage, new employee eligibility, annual open enrollment, or special open enrollment election period for reason of mental or physical impairment or incapacitation.
This policy establishes the methodology that the PEBB program will use to make a determination of mental or physical impairment or incapacitation for the purpose of tolling the election period of continuation coverage, retiree insurance coverage, new employee eligibility, annual open enrollment, or special open enrollment.
This policy provides timing requirements to request tolling of the election period for reason of mental or physical impairment or incapacity.
Policy 60-1: Required appeals related documents when the PEBB program conducts a brief adjudicative proceeding. This policy clarifies what particular documents are required from an employing agency or third-party administrator when the PEBB program is conducting a brief adjudicative proceeding at the request of one of its employees or subscribers.
Policy 90-1: Allowable mid-year employer group terminations. This policy clarifies when employer group participation may terminate mid-year.
Policy 90-2: What authority do employer groups need before contracting with the health care authority (HCA) for participation in public employees benefits board (PEBB) for insurance coverage? To clarify what authority is required from employer groups as part of the application process for benefits with HCA and the PEBB program.
Policy 90-3: Determining if an employer group requesting eligibility standards different from public employees benefits board (PEBB) program rules shall be approved. This policy clarifies the criteria used by HCA to approve or deny requests by employer groups for eligibility standards that are different eligibility standards than standards used by the PEBB program.
Policy 91-1: Requesting a reasonable alternative for completing wellness incentive program requirements or avoiding the tobacco use premium surcharge. This policy applies when a subscriber who is eligible to participate in the PEBB wellness incentive program is seeking a reasonable alternative to a wellness incentive program requirement in order to receive a wellness incentive as described in WAC 182-12-300.
This policy also applies when an enrollee on a PEBB medical plan is seeking a reasonable alternative so that a subscriber can avoid paying the tobacco use premium surcharge as described in WAC 182-08-185 (1)(c)(iii).
Policy 91-2: Tobacco as it relates to religious or ceremonial use. This policy applies whenever a PEBB subscriber is attesting to an enrolled member's tobacco use status. The purpose of the policy is to clarify the exception for the religious or ceremonial use of tobacco.
Policy 91-3: Washington wellness worksite designation program incentive requirements. This policy provides a set of requirements for state agencies to use when offering wellness incentives under the Washington wellness worksite designation program.
Policy 93-2: PEBB program payment plans. This policy describes the process through which a subscriber or a subscriber's legal representative may request a payment plan and the criteria the HCA will use when authorizing a payment plan.
Policy 94-1: Accessing PEBB program salary reduction plan document. This policy clarifies where a subscriber may access the PEBB program's salary reduction plan document.
Policy 94-2: Accessing PEBB program wellness plan document. This policy clarifies where a subscriber may access the PEBB program's wellness plan document.
To receive a hard copy of the policy statements, contact Stella Ng at P.O. Box 42684, Olympia, WA 98504-2684, or at 360-725-0852, or Rob Parkman at 360-725-0883.