Purpose: The Health Care Authority is adopting amendments and new sections to chapters 182-08, 182-12 and 182-16 WAC in order to clarify administrative and eligibility rules affecting PEBB-sponsored insurance coverage; clarify the PEBB appeal process; and effectuate changes enacted by the 2005 legislature in chapters 143 and 195, Laws of 2005.

     Citation of Existing Rules Affected by this Order: Amending WAC 182-08-196, 182-12-148, 182-12-171, 182-12-205, 182-12-260, 182-12-265, 182-12-270, 182-16-040, and 182-16-050.

     Statutory Authority for Adoption: RCW 41.05.160 and 41.05.350.

     Other Authority: RCW 41.05.165.

      Adopted under notice filed as WSR 05-13-093 on June 16, 2005.

     Changes Other than Editing from Proposed to Adopted Version: The words "who are eligible for PEBB insurance benefits" is added to the new section WAC 182-12-116. The words "within the sixty day period" is added to he last sentence of WAC 182-12-205(7).

     Number of Sections Adopted in Order to Comply with Federal Statute: New 0, Amended 0, Repealed 0; Federal Rules or Standards: New 0, Amended 1, Repealed 0; or Recently Enacted State Statutes: New 1, Amended 2, Repealed 0.

     Number of Sections Adopted at Request of a Nongovernmental Entity: New 0, Amended 0, Repealed 0.

     Number of Sections Adopted on the Agency's Own Initiative: New 0, Amended 0, Repealed 0.

     Number of Sections Adopted in Order to Clarify, Streamline, or Reform Agency Procedures: New 4, Amended 9, Repealed 0.

     Number of Sections Adopted Using Negotiated Rule Making: New 0, Amended 0, Repealed 0;      Pilot Rule Making: New 0, Amended 0, Repealed 0; or Other Alternative Rule Making: New 13, Amended 0, Repealed 0.

     Date Adopted: July 25, 2005.

Cyndi L. Presnell

Rules Coordinator

OTS-8094.1

AMENDATORY SECTION(Amending WSR 04-18-039, filed 8/26/04, effective 1/1/05)

WAC 182-08-196   What happens if my health carrier becomes unavailable?   ((Active)) Employees and retirees for whom the chosen health carrier becomes unavailable due to a change in service area, the health carrier no longer contracting, or the retiree's entitlement to Medicare must select a new health ((carrier)) plan within ((thirty-one)) sixty days after notification by ((HCA)) the PEBB program.

     ((Any person)) (1) Employees that fail((s)) to select a new health plan within the prescribed time period will be enrolled in the health carrier's successor plan if one is available or will be enrolled in the Uniform Medical Plan and the Uniform Dental Plan with existing dependent enrollment by default.

     (2) Retirees and surviving dependents eligible under WAC 182-12-250 or 182-12-265 that fail to select a new health plan within the prescribed time period will be enrolled in the health carrier's successor plan if one is available or will be enrolled in the Uniform Medical Plan and the Uniform Dental Plan, except that retirees enrolled in Medicare Part A and B and who enroll in Medicare Part D may be defaulted to a PEBB-sponsored Medicare plan that does not include a pharmacy benefit.

     Any ((person)) employee or retiree defaulted to a carrier's successor plan, the Uniform Medical Plan or the Uniform Dental Plan may not change ((the)) health ((carrier)) plans until the next open enrollment except as set forth in WAC 182-08-198.

     (3) Enrollees continuing PEBB health plan coverage as provided in 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 program or their health plan coverage will terminate as of the last day of the month in which the plan is no longer available.

[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.]

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     (2) Enrollees may change health plans outside of the annual open enrollment period if one of the following events occur, provided the request to change health plans is made no later than sixty days after the event occurs.

     (a) The enrollee moves and the health plan they are enrolled in is not available in their new location. If the enrollee fails to select a new health plan they will be automatically defaulted to the Uniform Medical Plan or Uniform Dental Plan.

     (b) The enrollee moves and a health plan that was not available to them before is available to them in the new location. The enrollee may choose to enroll in the newly available health plan.

     (c) A court order requires the enrollee to provide coverage for an eligible spouse, same-sex domestic partner, or child and the enrollee adds the dependent to the coverage.

     (d) The enrollee is a seasonal employee who is off during the annual open enrollment period. In this case the enrollee may select a new health plan upon their return to work.

     (e) The employee retires. Employees may change health plans at the time that they apply for PEBB-sponsored retiree coverage.

     (f) The enrollee's physician stops participation with the enrollee's health plan and it is determined by the PEBB appeals manager that a continuity of care issue exists. The PEBB appeals manager shall use the following criteria in determining if continuity of care issues exist:

     (i) Active cancer treatment, (i.e., chemotherapy and/or radiation);

     (ii) Recent transplant (within the last twelve months);

     (iii) Scheduled surgery within the next sixty days; or

     (iv) Major surgery within the previous sixty days; or

     (v) Third trimester of pregnancy.

     (g) It is determined by the PEBB appeals manager that there is a language barrier issue (e.g., a Vietnamese speaking provider discontinues participation in a plan and no other Vietnamese speaking provider is available within the subscriber's area that is contracting with that plan and/or within the travel range of the subscriber).

     (h) The enrollee reaches their medical plan maximum.

     (3) For enrollees making a health plan change during the annual open enrollment, the plan change must be made no later than the last day of the open enrollment period and the plan change is effective the first day of January following the open enrollment.

     (4) For enrollees making a health plan change outside of open enrollment, the health plan change must be made no later than sixty days after the triggering event and the plan change is effective the first day of the month following the date the change request is received by the PEBB program.

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OTS-8095.3

NEW SECTION
WAC 182-12-116   Who is eligible to participate in the PEBB flexible spending account program?   State agency employees, including those employed by all state higher education institutions, the higher education coordinating board, and the state board for community and technical colleges, who are eligible for PEBB insurance benefits as defined in WAC 182-12-115 are eligible to participate in the PEBB flexible spending account program.

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     (a) For an appeal filed on or before June 30, 2005, the personnel appeals board((, higher education personnel board or any court may continue their insurance coverage by self-payment of premium on the same terms as an employee who is granted leave without pay)) or any court.

     (b) For an appeal filed on or after July 1, 2005, the personnel resources board, an arbitrator, a grievance or appeals committee established under a collective bargaining agreement for union represented employees.

     (2) If the ((hearing board or court upholds the)) dismissal is upheld, all insurance coverage shall terminate at the end of the month in which the ((board or court's)) decision is entered, or the date to which premiums have been paid, whichever is earlier.

     (3)(a) If the ((hearing)) board, arbitrator, committee, or court sustains the employee in the appeal and directs reinstatement of employer paid insurance coverage retroactively, the employer must forward to HCA the full employer contribution for the period directed by the ((hearing)) board, arbitrator, committee, or court and collect from the employee the employee's share of premiums due, if any.

     (b) HCA will refund to the employee any premiums the employee paid that may be provided for as a result of the reinstatement of the employer contribution only if the employee makes retroactive payment of any employee contribution amounts associated with the insurance coverage. In the alternative, at the request of the employee, HCA may deduct the employee's contribution from the refund of any premiums self-paid by the employee during the appeal period.

     (c) All optional life and long term disability insurance which was in force at the time of dismissal shall be reinstated retroactively only if the employee makes retroactive payment of premium for any such optional coverage which was not continued by self-payment during the appeal process. If the employee chooses not to pay the retroactive premium, evidence of insurability will be required to restore such optional coverage.

[Statutory Authority: RCW 41.05.160 and 41.05.165. 04-18-039, § 182-12-148, filed 8/26/04, effective 1/1/05.]

     (a) If the retiree or enrolled dependent(s) is entitled to Medicare and the retiree retired after July 1, 1991, the Medicare-entitled retiree or Medicare-entitled dependent must enroll in both Medicare Parts A and B; and

     (b) The ((person)) retiring employee must submit an ((application)) election form to enroll or defer health plan coverage within sixty days after ((active)) their employer paid or continuous Consolidated Omnibus Budget Reconciliation Act (COBRA) coverage ends and is eligible for retiree benefits under one or more of the programs described in (c), (d), (e), (f), or (g) of this subsection;

     (c) Except as provided in (c)(vii) of this subsection, the person immediately upon termination begins receiving a monthly retirement income benefit from one or more of the following retirement systems:

     (i) Law enforcement officers' and fire fighters' retirement system Plan 1 or 2;

     (ii) Public employees' retirement system Plan 1 or 2;

     (iii) School employees' retirement system Plan 2;

     (iv) State judges/judicial retirement system;

     (v) Teachers' retirement system Plan 1 or 2; or

     (vi) Washington state patrol retirement system.

     (vii) Provided, however, that a lump-sum payment may be received in lieu of a monthly retiree income benefit payment under RCW 41.26.425(1), 41.32.762(1), 41.32.870(1), 41.35.410(1), 41.35.670(1), 41.40.625(1) or 41.40.815(1).

     (d) The person is at least fifty-five years of age with at least ten years of state of Washington service credit and a member of one of the following retirement systems:

     (i) Public employees' retirement system Plan 3;

     (ii) School employees' retirement system Plan 3; or

     (iii) Teachers' retirement system Plan 3.

     (e) The person is a member of a state of Washington higher education retirement plan, and is:

     (i) At least fifty-five years of age with at least ten years service; or

     (ii) At least sixty-two years of age; or

     (iii) Immediately begins receiving a monthly retirement income benefit.

     (f) If not retiring under the public employees' retirement system, the person would have been eligible for a monthly retirement income benefit because of age and years of service had the person been employed under the provisions of public employees' retirement system Plan 1 or Plan 2 for the same period of employment.

     (g) The person is an elected official as defined under WAC 182-12-115(6) who has voluntarily or involuntarily left a public office, whether or not the person receives a benefit from a state retirement system.

     (2) Eligible employees who participate in PEBB sponsored life insurance as an active employee and meet qualifications for retiree insurance coverage as provided in subsection (1) of this section are eligible for PEBB sponsored retiree life insurance if they ((apply to the HCA within)) submit an election form no later than sixty days after the date their ((active)) PEBB employee life insurance terminates ((and)), providing their employee life insurance premium is not being waived ((for any PEBB)) by the life insurance ((coverage)) carrier at the time ((of application for)) they elect retiree life insurance.

     (3) The following retired and disabled school district and educational service district employees are eligible to participate in health plan coverage only, provided they meet all of the enrollment criteria stated below and, if they are entitled to Medicare, are also enrolled in both Medicare Parts A and B:

     (a) Persons receiving a retirement allowance under chapter 41.32, 41.35 or 41.40 RCW as of September 30, 1993, and who enroll in PEBB health plan coverage not later than the end of the open enrollment period established by the authority for the plan year beginning January 1, 1995;

     (b) Persons who separate from employment with a school district or educational service district due to a total and permanent disability and are eligible to receive a deferred retirement allowance under chapter 41.32, 41.35 or 41.40 RCW. Such persons must enroll in PEBB health plan coverage not later than the end of the open enrollment period established by the HCA for the plan year beginning January 1, 1995, or sixty days following retirement, whichever is later.

     (4) With the exception of the Washington state patrol, retirees and disabled employees are not eligible for an employer premium contribution.

     (5) The two federal retirement systems, Civil Service Retirement System and Federal ((Civil Service)) Employees Retirement System, shall be considered a Washington state sponsored retirement system for Washington State University ((cooperative)) Extension ((service)) employees who ((hold a federal civil service appointment and who)) are covered under the PEBB insurance coverage at the time of retirement or disability.

     (6) Employees who do not elect enrollment in PEBB retiree insurance coverage ((within)) no later than sixty days immediately after termination of employment for retirement, or immediately after continuous Consolidated Omnibus Budget Reconciliation Act (COBRA) coverage ends, or who terminate PEBB retiree coverage ((within)) no later than sixty days after retirement, or who terminate PEBB retiree coverage after retirement, are not eligible to reenroll in PEBB retiree insurance coverage unless they retired and deferred PEBB retiree coverage pursuant to WAC 182-12-205 or retired and deferred PEBB retiree coverage pursuant to WAC 182-12-200.

     (7)(a) If a retiree's insurance coverage terminates for any reason, coverage will not be reinstated at a later date. Examples of termination include, but are not limited to, any one or more of the following:

     (i) Failure to continue to meet eligibility requirements;

     (ii) Fraud, intentional misrepresentation or withholding of information the enrollee knew or should have known was material or necessary to accurately determine eligibility or the correct premium;

     (iii) Failure to provide information requested by the due date or knowingly providing false information;

     (iv) Abusive or offensive conduct repeatedly directed to an HCA employee, a health plan or other HCA contractor providing coverage on behalf of the PEBB program, its employees, or other persons; or

     (v) Intentional misconduct.

     (b) If a retiree fails to pay the premium when due or an underpayment of premium is made, PEBB sponsored insurance coverage will terminate on the last day of the month for which the last full premium was received.

     (c) Notwithstanding (a) of this subsection, the PEBB assistant administrator or designee may approve reinstatement of insurance coverage if the retiree or their dependent or beneficiary submits a written appeal and provides proof that extraordinary circumstances made it virtually impossible to make the payment and the retiree agrees to make payment in accordance with the terms of an agreement with the HCA. No insurance coverage will be reinstated more than three times.

     (8) Enrollees may not enroll in retiree dental coverage unless they also enroll in retiree medical coverage.

     (9) In order to continue retiree term life insurance, an election must be made within sixty days after retirement and premiums must be paid whether or not the retiree is otherwise employed. Election of retiree term life insurance may not be waived or deferred during periods of other coverage or otherwise.

[Statutory Authority: RCW 41.05.160 and 41.05.165. 04-18-039, § 182-12-171, filed 8/26/04, effective 1/1/05.]

     (1) The local government retiree health plan must have existed for a minimum of three years prior to the date of application for participation in PEBB health plans.

     (2) Eligibility for coverage under the local 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 retiree health plan.

     (4) To protect the integrity of the risk pool, if total local government retiree enrollment exceeds ten percent of the total PEBB retiree population, the PEBB program may:

     (a) Stop approving inclusion of retirees with local government unit transfers; or

     (b) May adopt a new rating methodology reflective of the cost of covering local 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 transferring to PEBB health plan coverage must meet retiree eligibility as outlined in chapter 182-12 WAC.

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     (a) Comprehensive employer sponsored medical coverage as an ((active)) employee or as the spouse or same sex domestic partner of an ((active)) employee; or

     (b) As a retiree or as the spouse or as the same sex domestic partner of ((an employee's)) a retiree's retirement insurance from a federal retiree plan.

     (2) If a retiree defers enrollment in PEBB health plan coverage, coverage is automatically waived for all eligible dependents.

     (3) Election of retiree term life insurance coverage may not be deferred during periods of other coverage or otherwise.

     (4) In order to defer health plan coverage, a retiree must submit the appropriate ((enrollment)) form(((s))) to the ((HCA)) PEBB program requesting deferment of coverage. The notice of deferral must be received by ((the HCA)) PEBB benefit services prior to the date coverage is deferred or within sixty days after the date the retiree is eligible to apply for PEBB sponsored retiree benefits.

     (5) Retirees may reenroll in PEBB coverage following the end of a deferral period under conditions listed below.

     (a) Retirees who defer PEBB health plan coverage while enrolled in employer sponsored medical coverage, may reenroll in PEBB health plan coverage by submitting the appropriate ((enrollment)) form(s) and satisfactory evidence of continuous enrollment in comprehensive employer sponsored coverage to the ((HCA)) PEBB program:

     (i) During an annual open enrollment period; or

     (ii) No later than sixty days after the last day of the employer sponsored coverage.

     (b) Retirees who defer PEBB health plan coverage while enrolled as a retiree or dependent of a retiree in a federal retiree plan will have a one-time opportunity to reenroll in PEBB health plan coverage by submitting the appropriate ((enrollment)) form(s) and satisfactory evidence of continuous enrollment in a federal retiree medical plan to the ((HCA)) PEBB program:

     (i) During an annual open enrollment period; or

     (ii) No later than sixty days after the date their federal retiree coverage ends.

     (c) PEBB health plan enrollment will be effective the first day of the month following the date employer sponsored coverage or coverage under a federal retiree plan ended, except that reenrollment in PEBB insurance coverage during the annual open enrollment will become effective the first day of January following the open enrollment period.

[Statutory Authority: RCW 41.05.160 and 41.05.165. 04-18-039, § 182-12-205, filed 8/26/04, effective 1/1/05.]

     (1) Lawful spouse.

     (2) A same sex domestic partner qualified through the declaration certificate issued by PEBB.

     (3) Dependent children through age nineteen. The term "children" includes 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 same sex domestic partner, or children specified in a court order or divorce decree. Married children who qualify as dependents of the subscriber under the Internal Revenue Code, and extended dependents approved by PEBB are included. To qualify for PEBB approval, the subscriber must demonstrate legal custody for the child with a court order, and the child:

     (a) Must be living with the subscriber in a parent-child relationship; and

     (b) Must not be a foster child for whom support payments are made to the subscriber through the state department of social and health services (DSHS) foster care program.

     (4) Dependent children age twenty through age twenty-three and who are registered students at an accredited secondary school, college, university, vocational school, or school of nursing.

     (a) Dependent student coverage begins the first day of the month in which the quarter/semester for which the dependent is registered begins and ends the last day of the month in which the dependent stops attending or in which the quarter/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 ((and)).

     (b) Dependent student coverage continues during the three month period following graduation provided the subscriber is covered, at the same time, the dependent has not reached age twenty-four, and the dependent meets all other eligibility requirements.

     (5) Dependent children of any age with disabilities, developmental disabilities, mental illness or mental retardation who are incapable of self-support, provided such condition occurs prior to age twenty or during the time the dependent was ((covered)) eligible as a student under ((PEBB health plan coverage as a registered student)) subsection (4) of this section. The subscriber must provide proof ((of)) that such disability ((must be furnished)) occurred prior to the dependent's attainment of age twenty or ((loss of)) during the time the dependent satisfies eligibility for student coverage under subsection (4) of this section, and as periodically requested thereafter by the PEBB program.

     (a) The subscriber must notify the PEBB program, in writing, no later than sixty days after the date that a dependent 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 dependent may be eligible to continue PEBB coverage under provisions of WAC 182-12-270.

     (ii) Children age twenty and older that become capable of self-support do not regain eligibility under subsection (5) of this section if they later become incapable of self-support.

     (6) Dependent parents.

     (a) Dependent parents covered under a PEBB medical plan before July 1, 1990, may continue enrollment on a self-pay basis as long as:

     (i) The parent maintains continuous coverage in PEBB sponsored medical coverage;

     (ii) The parent qualifies under the Internal Revenue Code as a dependent of an eligible subscriber;

     (iii) The subscriber who claimed the parent as a dependent continues enrollment in PEBB insurance coverage; and

     (iv) The parent is not covered by any other group medical coverage.

     (b) Dependent parents that are eligible under (a) of this subsection may be enrolled with a different health carrier than that selected by the eligible subscriber; however, dependent parents may not add additional dependents to their coverage.

     (7) The enrollee must notify the PEBB program, in writing, no later than sixty days after the date that a dependent no longer qualifies under subsection (1), (2), (3), (4) or (6) of this section. The subscriber must notify the PEBB program in writing no later than sixty days after the date a dependent no longer qualifies under subsection (5) of this section. A PEBB continuation of coverage election notice will only be available if the PEBB program is notified in writing within the sixty-day period.

[Statutory Authority: RCW 41.05.160 and 41.05.165. 04-18-039, § 182-12-260, filed 8/26/04, effective 1/1/05.]

     (a) The employee's spouse or qualified same sex domestic partner may continue coverage until death.

     (b) Other dependents may continue coverage until they lose eligibility under PEBB rules.

     (c) If a surviving dependent 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 may continue health plan coverage under provisions of the federal Consolidated Omnibus Budget Reconciliation Act (COBRA) or WAC 182-12-270.

     (d) The ((Federal)) 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 ((cooperative)) extension service employees ((who held a federal civil service appointment and)) who were covered under PEBB insurance coverage at the time of death.

     (2) Dependents that lose eligibility due to the death of a PEBB eligible retiree may continue health plan coverage under a retiree plan.

     (a) The retiree's spouse or qualified same sex domestic partner may continue coverage until death.

     (b) Other dependents may continue coverage until they lose eligibility under PEBB rules.

     (c) Dependents that are waiving PEBB ((insurance)) health plan coverage at the time of the retiree's death are eligible to enroll or defer PEBB retiree coverage ((if they submit evidence of continuous enrollment in other comprehensive medical coverage within)). A form to enroll or defer PEBB health plan coverage must be hand-delivered or mailed to PEBB benefit services no later than sixty days after the retiree's death. To enroll in PEBB health plan coverage, the dependent must provide satisfactory evidence that enrollment in other health plan coverage was continuous from the most recent open enrollment period for which PEBB coverage was waived.

     (3) Surviving spouses or eligible dependent 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 PEBB sponsored health plan coverage 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 same-sex domestic partner may continue health plan coverage until death.

     (b) Other dependents may continue coverage until they lose eligibility under PEBB rules.

     (4) Application for surviving dependent coverage must be made in writing on an ((enrollment)) election form approved by PEBB ((within)) no later than sixty days after the date of death of the employee or retiree. Coverage is retroactive to the date the employee or retiree insurance coverage terminated subject to the payment of premium. In order to avoid duplication of group medical coverage, surviving dependents may defer enrollment in PEBB health plan coverage for each full calendar month in which they maintain coverage under other employer sponsored comprehensive medical coverage. Notice of intent to defer PEBB coverage must be sent in writing to ((the HCA within)) PEBB benefit services no later than sixty days after the date of death of the subscriber.

     (5) Surviving dependents that defer coverage while enrolled in an employer sponsored comprehensive medical plan must submit an application to reenroll in PEBB coverage ((within)) no later than sixty days after the last day of coverage under the employer sponsored medical plan. Satisfactory evidence of continuous enrollment in an employer sponsored comprehensive medical coverage will be required by the ((HCA)) PEBB program prior to reenrollment in a PEBB health plan.

[Statutory Authority: RCW 41.05.160 and 41.05.165. 04-18-039, § 182-12-265, filed 8/26/04, effective 1/1/05.]

     (1) Dependents that lose eligibility due to the death of an employee or retiree may be eligible to continue coverage under provisions of WAC 182-12-265.

     (2) Dependents of a lawful marriage that lose eligibility because they no longer meet the definition of dependent as defined in WAC 182-12-260 are eligible to continue coverage under provisions of the federal Consolidated Omnibus Budget Reconciliation Act (COBRA); or

     (3) Dependents of a qualified same sex domestic partnership that lose eligibility because they no longer meet the definition of dependent as defined ((under COBRA)) in WAC 182-12-260 may continue under an extension of PEBB coverage for a maximum of thirty-six months.

     No extension of PEBB coverage will be offered unless PEBB benefits services 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 and 41.05.165. 04-18-039, § 182-12-270, filed 8/26/04, effective 1/1/05.]

OTS-8096.1

AMENDATORY SECTION(Amending WSR 97-21-128, filed 10/21/97, effective 11/21/97)

WAC 182-16-040   Appeals -- Notice of appeal contents.   Except as provided by RCW 48.43.530 and 48.43.535, any person aggrieved by a decision of the health care authority's PEBB program may appeal that decision by filing a notice of appeal with the ((health care authority's)) PEBB program's appeals ((committee)) manager. The notice of appeal must contain:

     (1) The name and mailing address of the enrollee;

     (2) The name and mailing address of the appealing party;

     (3) The name and mailing address of the appealing party's representative, if any;

     (4) A statement identifying the specific portion of the decision being appealed making it clear what it is that is believed to be unlawful or unjust;

     (5) A clear and concise statement of facts in support of appealing party's position;

     (6) Any and all information or documentation that the aggrieved person would like considered and feels substantiates why the ((claim or request for coverage)) decision should be ((covered)) reversed (information or documentation submitted at a later date, unless specifically requested by the appeals ((committee)) manager, may not be considered in the appeal decision);

     (7) A copy of the ((plan's)) PEBB program's or health carrier's response to the issue the appellant has raised;

     (8) The type of relief sought;

     (9) A statement that the appealing party has read the notice of appeal and believes the contents to be true, followed by his((/)) or her signature and the signature of his((/)) or her representative, if any;

     (10) The appealing party shall file((, personally)) the original notice of appeal with PEBB benefit services using hand delivery, electronic mail or ((by)) United States Postal Service mail((, with the health care authority the original notice of appeal)). The notice of appeal must be received by ((the health care authority)) PEBB benefit services within sixty days after the decision of the ((agency)) PEBB staff was mailed to the appealing party. The ((agency)) PEBB appeals manager shall acknowledge receipt of the copies filed with ((the agency)) PEBB benefit services;

     (11) ((Within thirty days after receipt of notice of appeal, the agency shall notify the appellant of any obvious errors or omissions, and request any additional information.

     (12))) The appeals ((committee)) officer will render a written decision within ((sixty)) thirty working days ((of)) after receipt of the complete notice of appeal.

[Statutory Authority: RCW 41.05.160. 97-21-128, § 182-16-040, filed 10/21/97, effective 11/21/97. Statutory Authority: RCW 41.05.010 and 34.05.250. 91-14-025, § 182-16-040, filed 6/25/91, effective 7/26/91.]

     (2) The agency shall set the time and place of the hearing and give not less than seven days notice to all parties and persons who have filed written petitions to intervene.

     (3) The administrator or his((/)) or her designee shall preside at all hearings resulting from the filings of appeals.

     (4) All hearings shall be conducted in compliance with these rules, chapter 34.05 RCW and chapter 10-08 WAC as applicable.

     (5) Within ninety days of the hearing, 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 all parties and persons who have intervened.

[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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