WSR 97-17-106

PROPOSED RULES

HEALTH CARE AUTHORITY

[Filed August 20, 1997, 11:22 a.m.]

Original Notice.

Preproposal statement of inquiry was filed as WSR 96-22-016.

Title of Rule: Chapter 182-08 WAC, Health Care Authority PEBB administration and PEBB eligibility rules.

Purpose: Establishes rules for determining benefits, eligibility, enrollment processes and for administering the Washington State Public Employee Benefits Board (PEBB).

Statutory Authority for Adoption: RCW 41.05.160.

Statute Being Implemented: Chapter 41.05 RCW.

Summary: Updates required due to recent federal legislation requiring special enrollment opportunities.

Reasons Supporting Proposal: Federal legislation.

Name of Agency Personnel Responsible for Drafting: Mich'l Needham, Health Care Authority, 923-2735; Implementation and Enforcement: Sharon Thompson, Health Care Authority, 923-2640.

Name of Proponent: Health Care Authority, governmental.

Rule is necessary because of federal law, HIPAA federal regulation.

Explanation of Rule, its Purpose, and Anticipated Effects: Public Employees Benefits Board (PEBB) eligibility rules. Updates required due to recent federal legislation requiring special enrollment opportunities.

Proposal Changes the Following Existing Rules: Additional special enrollment period under certain circumstances.

No small business economic impact statement has been prepared under chapter 19.85 RCW. Not required. The Joint Administrative Rules Review Committee has not requested the filing of a small business economic impact statement, and costs to businesses will be negligible.

RCW 34.05.328 does not apply to this rule adoption. Section 201, chapter 403, Laws of 1995, do not apply to the Health Care Authority unless requested by the Joint Administrative Rules Review Committee or applied voluntarily.

Hearing Location: Attorney General Conference Center, RoweSix, Building One, 4224 6th Avenue S.E., Lacey, WA 98504, on September 23, 1997, at 1:00 p.m.

Assistance for Persons with Disabilities: Contact Nikki Woehl by September 19, 1997, (360) 923-2805.

Submit Written Comments to: Elin Meyer, FAX (360) 923-2606, by September 30, 1997.

Date of Intended Adoption: October 18, 1997.

August 20, 1997

Elin Meyer

Rules Coordinator

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

WAC 182-08-095 Waiver of coverage. (1) State employees: Employees eligible for PEBB health care coverage have the option of waiving medical coverage for themselves and any or all dependents if they are covered by another medical plan. In order to waive medical coverage, the employee must complete an enrollment form that identifies the individuals for whom coverage is being waived. If an employee waives medical coverage for him/herself, coverage is automatically waived for all eligible dependents. An employee may choose to enroll only him/herself, and waive medical coverage for any or all dependents.

Employees and dependents whose medical coverage is waived will remain enrolled in a PEBB dental plan. Employees will also remain enrolled in PEBB life and long term disability coverage.

If PEBB medical coverage is waived, an otherwise eligible person may not enroll in a PEBB plan until the next open enrollment period, or within 31 days of loss of other medical coverage. Proof of other medical coverage is required to demonstrate that: 1) Coverage was continuous from the date PEBB coverage was waived; and 2) the period between loss of coverage and application for PEBB coverage is 31 days or less. The employee and dependents may have an additional opportunity to enroll in the event of acquisition of a new dependent as a result of marriage, birth, adoption, or placement for adoption, provided that enrollment is requested within 31 days of marriage or within 60 days of birth, adoption or placement for adoption.

(2) K-12 employees: Employees eligible for PEBB health care coverage have the option of waiving medical coverage for themselves and any or all dependents. In order to waive medical coverage, the employee must complete an enrollment form that identifies the individuals for whom coverage is being waived. If an employee waives medical coverage for him/herself, coverage is automatically waived for all eligible dependents. An employee may choose to enroll only him/herself, and waive medical coverage for any or all dependents.

Employees and dependents whose medical coverage is waived will remain enrolled in a PEBB dental plan if the district/unit participates in the dental plan. Employees will also remain enrolled in life and long term disability coverage if the district/unit participates in those plans.

If PEBB medical coverage is waived, an otherwise eligible person may not enroll in a PEBB plan until the next school district renegotiation period, or upon approval of the participating school district and the HCA. Approval of the HCA will require proof of other medical coverage to demonstrate that: 1) Coverage was continuous from the date PEBB coverage was waived; and 2) the period between loss of coverage and application for PEBB coverage is 31 days or less. The employee and dependents may have an additional opportunity to enroll in the event of acquisition of a new dependent as a result of marriage, birth, adoption, or placement for adoption, provided that enrollment is requested within 31 days of marriage or within 60 days of birth, adoption or placement for adoption.

(3) Political subdivision employees: Political subdivision employees may not waive PEBB medical coverage for themselves, but may waive medical coverage for their dependents if the dependents are covered by another medical plan. In order to waive medical coverage for dependents, the employee must complete an enrollment form that identifies the individuals for whom coverage is being waived.

Dependents whose medical coverage is waived will remain enrolled in their PEBB dental plan.

If PEBB medical coverage is waived, an otherwise eligible dependent may not enroll in a PEBB medical plan until the next open enrollment period, or within 31 days of loss of other medical coverage. Proof of other medical coverage is required to demonstrate that: 1) Coverage was continuous from the date PEBB coverage was waived; and 2) the period between loss of coverage and application for PEBB coverage is 31 days or less. The employee and dependents may have an additional opportunity to enroll in the event of acquisition of a new dependent as a result of marriage, birth, adoption, or placement for adoption, provided that enrollment is requested within 31 days of marriage or within 60 days of birth, adoption or placement for adoption.

[Statutory Authority: Chapter 41.05 RCW. 96-08-042, 182-08-095, filed 3/29/96, effective 4/29/96.]

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

WAC 182-08-160 Group coverage when not in pay status. Employees covered by a PEBB health plan have options for providing continued coverage for themselves and their dependents during temporary or permanent loss of eligibility. With the exception of approved family and medical leave, employees not in pay status for at least 8 hours per month are ineligible to receive the employer premium contribution:

(1) When an employee loses eligibility as an active employee, PEBB group coverage, except long-term disability, may be continued at the group premium rate by self-paying premiums for medical coverage only, or for medical and dental combined, or for dental only, and on life insurance for a maximum of 29 months. With respect to medical and dental coverage, the maximum time shall be reduced by the number of months of self-pay allowed under COBRA and the number of employer-paid months allowed under family and medical leave. Part-time faculty may self-pay for group coverage between periods of active employee eligibility for a maximum of 18 months. If an employee is temporarily not in pay status for any of the following reasons, he or she may continue PEBB group coverage by self-paying the premium:

(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 awaiting hearing for a dismissal action

(e) The employee is applying for disability retirement

(2) The federal Consolidated Omnibus Budget Reconciliation Act of 1985 (COBRA) gives enrollees the right to continue group coverage for a period of 18 to 36 months.

(3) The Family and Medical Leave Act of 1993 gives the enrollee the opportunity to extend eligibility with employer contribution toward premium for up to 12 weeks, see WAC ((182-08-080)) 182-08-175.

(4) Enrollees have the right to convert to individual medical coverage when continuation of group medical coverage is no longer possible.

(5) The dependents of employees also have options for continuing coverage for themselves following loss of eligibility.

(6) Employees who revert to a previously held position and do not regain pay status during the last month in which their employer contribution is made may continue their PEBB-sponsored health and life coverage, by self-paying premium for up to 18 months (and in some cases up to 29 months).

(7) If a dependent(s) loses eligibility due to the death of the employee, the dependent(s) may continue coverage under a retiree plan provided the dependent(s) will immediately begin receiving a monthly benefit from any state of Washington-sponsored retirement system. The employee's spouse may continue coverage indefinitely; other dependents may continue coverage until they lose eligibility under PEBB rules. Application for surviving dependent coverage must be made within 60 days from the death of the employee. If a dependent is not eligible for a monthly retirement income benefit, or a lump-sum payment because the monthly pension payment would be less than $50, the dependent may be eligible for continued coverage under COBRA.

(8) An employee may retain long-term disability coverage by self-payment of premium up to twenty-four months during an authorized leave without pay, but only if such leave is an approved educational leave.

[Statutory Authority: Chapter 41.05 RCW. 96-08-042, 182-08-160, filed 3/29/96, effective 4/29/96; 93-23-065, 182-08-160, filed 11/16/93, effective 12/17/93; 86-16-061 (Resolution No. 86-3), 182-08-160, filed 8/5/86; 83-22-042 (Resolution No. 6-83), 182-08-160, filed 10/28/83; 80-01-082 (Order 5-79), 182-08-160, filed 12/27/79; 78-03-021 (Order 3-78), 182-08-160, filed 2/14/78; Order 7228, 182-08-160, filed 12/8/76.]

AMENDATORY SECTION (Amending WSR 93-23-065, filed 11/16/93, effective 12/17/93)

WAC 182-08-175 Group coverage while on family and medical leave. Employees on leave under the federal Family and Medical Leave Act of 1993, and regulations implementing that act, shall continue to receive up to twelve weeks of employer-paid group medical, dental, basic life, and basic long-term disability insurance while on family and medical leave and may self-pay their optional life and long-term disability. If an employee fails to return to work after expiration of family and medical leave for a reason other than the continuation, recurrence, or onset of a serious health condition or other circumstance beyond the control of the employee, the employer may recover the premiums paid to maintain the employee's insurance coverage from the employee.