WSR 04-13-156

PROPOSED RULES

HEALTH CARE AUTHORITY


[ Order 04-01 -- Filed June 23, 2004, 9:37 a.m. ]

     Original Notice.

     Preproposal statement of inquiry was filed as WSR 04-07-079.

     Title of Rule and Other Identifying Information: Rules affecting the administration of and eligibility for Public Employees' Benefits Board (PEBB)-sponsored insurance coverages. HCA reviewed chapters 182-08 and 182-12 WAC, as well as WAC 182-16-040 and 182-16-050. Many of the amendments and new sections are proposed to clarify current rules or to communicate rules regarding administration of and eligibility for PEBB programs in a more user-friendly manner. Some of these amendments and new sections represent rules that had been codified in chapter 182-08 WAC and that will be readopted in chapter 182-12 WAC, and visa [vice] versa. The HCA proposes that these amendments will be effective January 1, 2005.

     Hearing Location(s): Health Care Authority, 676 Woodland Square Loop S.E., Meeting Room E101 A&B, Olympia, WA, on July 27, 2004, at 1:30 p.m.

     Date of Intended Adoption: August 4, 2004.

     Submit Written Comments to: Barbara Scott, 676 Woodland Square Loop S.E., Olympia, WA 98504-2684, e-mail bsco107@hca.wa.gov, fax (360) 923-2602, by July 27, 2004.

     Assistance for Persons with Disabilities: Contact Nikki Johnson by July 20, 2004, TTY (888) 923-5622 or (360) 923-2805.

     Purpose of the Proposal and Its Anticipated Effects, Including Any Changes in Existing Rules: HCA reviewed chapters 182-08 and 182-12 WAC and is proposing amendments and new sections in order to clarify administrative and eligibility rules affecting PEBB-sponsored insurance coverages for active and retired public employees. These proposed amendments and proposed new rules are intended to add logical structure and clearer language.

     WAC 182-08-180: HCA is proposing a change to PEBB rules to permit refunds of up to twelve months of adjusted premiums where extraordinary circumstances prevented notification of a change in eligibility.

     WAC 182-12-128: HCA is proposing a change to the length of time an employee, following a loss of other coverage, is allowed to make application for reenrollment in previously waived PEBB medical or dental coverage. The proposed change is consistent with other PEBB application periods and would extend the length of time from thirty-one to sixty days.

     WAC 182-12-133: This amendment would eliminate current limits on the number of months an employee may self-pay for coverage by the number of months the employee was covered under approved family and medical leave.

     WAC 182-12-138: This amendment would delete unnecessary and duplicative language that currently allows agencies to recover premiums paid to maintain employee coverage during approved family and medical leave if the employee does not return when the leave expires. This provision is included in the federal Family and Medical Leave Act and need not be repeated in state rules. Also, HCA is proposing to terminate coverage continued during family and medical leave if the employee is delinquent in paying employee premiums for affected coverage during the leave period.

     WAC 182-12-171 (7)(b): HCA is proposing a change to PEBB retiree rules to permit the PEBB Assistant Administrator to allow payment of missed or underpaid premiums where extraordinary circumstances preventing the payment of the premiums are demonstrated, rather than terminate the coverage.

     WAC 182-16-040: HCA is proposing amendments to support requirements of RCW 48.43.500(4).

     WAC 182-16-050: These amendments clarify PEBB appeals practices.

     Reasons Supporting Proposal: These proposed amendments and new proposed rules are designed to clarify administrative rules and eligibility affecting PEBB-sponsored insurance coverages.

     Statutory Authority for Adoption: RCW 41.05.160 and 41.05.165.

     Statute Being Implemented: RCW 41.05.021, 41.05.050, 41.05.065, 41.05.080, 41.05.085, 41.05.090, and 48.43.500.

     Rule is not necessitated by federal law, federal or state court decision.

     Name of Proponent: Pete Cutler, Acting Administrator, Health Care Authority, governmental.

     Name of Agency Personnel Responsible for Drafting and Implementation: Barbara Scott, Health Care Authority, 676 Woodland Square Loop S.E., Olympia, WA, (360) 923-2642; and Enforcement: Katie Rogers, Health Care Authority, 676 Woodland Square Loop S.E., Olympia, WA, (360) 923-2735.

     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 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 Health Care Authority rules unless requested by the Joint Administrative Rules Review Committee or applied voluntarily.

June 23, 2004

Melodie Bankers, Director

Legal and Contract Services

OTS-7307.3


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

WAC 182-16-040   Appeals -- Notice of appeal contents.   Any person aggrieved by a decision of the ((health care authority)) PEBB may appeal that decision by filing a notice of appeal with the ((health care authority's appeals committee)) PEBB. 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 should be covered (information or documentation submitted at a later date, unless specifically requested by ((the appeals committee)) PEBB, may not be considered in the appeal decision);

     (7) A copy of the ((plan's)) 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 or by mail, with the ((health care authority)) PEBB the original notice of appeal. The notice of appeal must be received by the ((health care authority)) PEBB within sixty days after the decision of the ((agency staff)) health carrier or insurer was mailed to the appealing party. The ((agency)) PEBB shall acknowledge receipt of the copies filed with the ((agency)) PEBB, within five days;

     (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)) PEBB will render a written decision within ((sixty)) thirty days ((of)) after receipt of the complete appeal file.

[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 WSR 97-21-128, filed 10/21/97, effective 11/21/97)

WAC 182-16-050   Appeals -- Hearings.   (1) If the ((health care authority's)) PEBB appeals ((committee)) officer upholds the original denial, the enrollee may request ((a)) an administrative hearing ((by)) in writing ((to the health care authority's appeals manager)). The ((health care authority)) HCA must receive the written request for a hearing within fifteen days ((of)) after the date the PEBB appeals ((committee's)) officer's decision was mailed to the ((appellant)) enrollee.

     (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 a request for an administrative appeal((s)).

     (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)) after conclusion 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.]

OTS-7308.3


AMENDATORY SECTION(Amending Order 02-07, filed 8/14/03, effective 9/14/03)

WAC 182-08-015   Definitions.   The following definitions apply throughout this ((Title 182 WAC)) chapter unless the context clearly indicates other meaning:

     (((1))) "Administrator" means the administrator of the health care authority (HCA) or designee.

     (((2))) "Board" means the public employees' benefits board established under provisions of RCW 41.05.055. ((The board is created within the HCA and the administrator of the HCA shall serve as the chair of the board.

     (3) "Open enrollment" means a time period designated by the administrator during which enrollees may apply to transfer their enrollment from one health plan to another, enroll in a medical plan if the enrollee had previously waived coverage or add dependents.

     (4) "Enrollee" means a person who meets all eligibility requirements defined in chapter 182-12 WAC, who is enrolled in a PEBB plan, and for whom applicable premium payments have been made.

     (5) "Subscriber" or "insured" means the enrollee who has been designated by the HCA as the individual to whom the HCA and the health plan will issue all notices, information, requests and premium bills on behalf of all enrolled family members.

     (6) "Effective date of enrollment" means the first date on which an enrollee is entitled to receive covered services.

     (7) "PEBB plan" means one or more insurance programs established by the public employees benefits board for eligible enrollees and their dependents.)) "Defer" means to postpone enrollment or interrupt enrollment in PEBB sponsored medical insurance by a retiree or surviving dependent.

     "Dependent" means a person who meets eligibility requirements set forth in WAC 182-12-260.

     "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.

     "Effective date of enrollment" means the first date on which an enrollee is entitled to receive covered benefits.

     "Extended dependent" means a dependent child who is not the child of an enrollee through birth, adoption, marriage, or a qualified same sex domestic partnership. Some examples of extended dependents include, but are not limited to, a grandchild or a niece or nephew for whom the enrollee is the legal guardian or the enrollee has legal custody.

     "Health carrier" has the meaning set forth at RCW 48.43.005(18) for purposes of administering this Title 182 WAC only, it includes the uniform medical plan and uniform dental plan.

     "Health plan" or "plan" means medical and dental coverage.

     "Insurance coverage" means any health plan, life or long-term disability insurance plan 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 and life insurance offered to employees on an optional basis.

     "Open enrollment" means a time period designated by the administrator during which enrollees may apply to transfer their enrollment from one health carrier to another, enroll in medical coverage if the enrollee had previously waived such coverage, or add dependents.

     "PEBB plan" or "PEBB benefits" means one or more insurance coverages approved by the public employees' benefits board for eligible enrollees and their dependents.

     "Subscriber" or "insured" means the employee, retiree, COBRA beneficiary or surviving dependent who has been designated by the HCA as the individual to whom the HCA and the health carrier will issue all notices, information, requests and premium bills on behalf of enrolled dependents.

     "Waive" means to interrupt enrollment or postpone enrollment in a PEBB sponsored health plan by an employee (as defined in WAC 182-12-115) or a dependent who meets eligibility requirements set forth in WAC 182-12-260.

[Statutory Authority: RCW 41.05.160 and 41.05.165. 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 02-07, filed 8/14/03, effective 9/14/03)

WAC 182-08-120   ((Employer contribution.)) How can the employer contribution be used?   The employers' contribution must be used solely to provide coverage for the basic life insurance benefit, a basic long-term disability benefit, medical coverage, and dental coverage, and to establish a reserve for any remaining balance. There is no employer contribution available for any other insurance coverages.

[Statutory Authority: RCW 41.05.160 and 41.05.165. 03-17-031 (Order 02-07), § 182-08-120, filed 8/14/03, effective 9/14/03. Statutory Authority: Chapter 41.05 RCW. 96-08-042, § 182-08-120, filed 3/29/96, effective 4/29/96; 86-16-061 (Resolution No. 86-3), § 182-08-120, filed 8/5/86; 83-22-042 (Resolution No. 6-83), § 182-08-120, filed 10/28/83; Order 3-77, § 182-08-120, filed 11/17/77; Order 7228, § 182-08-120, filed 12/8/76.]


AMENDATORY SECTION(Amending Order 02-07, filed 8/14/03, effective 9/14/03)

WAC 182-08-180   Premium payments and refunds.   PEBB premiums will be refunded using the following method:

     (1) ((Within ninety days after an event)) When a PEBB subscriber submits an enrollment change affecting eligibility, ((the subscriber or a dependent or beneficiary of a subscriber must notify HCA of any change in eligibility status,)) such as for example: Death, divorce, or when no longer a dependent as defined at ((WAC 182-12-119. Premium paid after such an event will be refunded in accordance with subsection (4) of this section.

     (2) Premiums miscalculated will be adjusted by returning the excess charged premium, if any, to the employer, subscriber, or beneficiary, as appropriate.)) WAC 182-12-260 no more than three months of accounting adjustments and any excess premium paid will be refunded to any individual or agency except as provided in WAC 182-12-148(3).

     (2) The PEBB assistant administrator or designee may approve a refund which does not exceed twelve months of premium provided both of the following occur:

     (a) The PEBB subscriber or a dependent or beneficiary of a subscriber submits a written appeal to the HCA; 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 ((producing)) 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.

     (((3))) (4) HCA errors will be adjusted by returning the excess premium paid, if any, to the employer, subscriber, or beneficiary, as appropriate.

     (5) Premium is due for the entire month of 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.

     (((4) Premium refunds requested by a subscriber or a dependent or beneficiary must be presented to HCA within ninety days of the event. Refunds will not be made for more than three months of premium. Examples of such events include, but are not limited to, divorce, death of an employee or retiree, or death of a dependent of an employee or retiree, or situations where premium was paid on behalf of enrollees or dependents.))

[Statutory Authority: RCW 41.05.160 and 41.05.165. 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 02-07, filed 8/14/03, effective 9/14/03)

WAC 182-08-190   ((Employer contribution.)) The employer contribution shall be set by the HCA and paid to the HCA for all eligible employees.   (((1))) Every department, division, or agency of state government, and such county, municipal or other political subdivision((s as are)), K-12 school district or educational service district that are covered under ((the)) PEBB ((plans)) insurance coverage, shall pay premium contributions to the HCA for insurance ((benefits)) coverage for all ((of its insurance-))eligible employees and their dependents.

     (((a))) (1) Employer contributions shall be set by the HCA and are subject to the approval of the governor.

     (((b))) (2) Employer contributions shall include an amount determined by the HCA to pay administrative costs to administer ((the plans)) insurance coverage for employees of these groups.

     (((c))) (3) Each eligible employee in pay status ((for)) eight or more hours during a calendar month ((or for)) and each eligible employee on ((family and medical)) leave under the federal Family and Medical Leave Act (FMLA) shall be eligible for the employer contribution. The entire employer contribution is due and payable to HCA even if medical coverage is waived.

     (((d))) (4) PEBB insurance coverage for any county, municipality or other political subdivision or any K-12 school district or educational service district may be terminated by HCA if the premium contributions are delinquent more than ninety days.

     (((2) For the period of July 1, 2002, to June 30, 2003, eligible state employees placed on temporary unpaid leave in order to implement the 2002 supplemental appropriations act are not required to have eight hours of pay status in order to maintain eligibility for the employer contribution for each month that they are on mandatory leave.))

[Statutory Authority: RCW 41.05.160 and 41.05.165. 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 02-07, filed 8/14/03, effective 9/14/03)

WAC 182-08-196   What happens if my health ((plan no longer available.)) carrier becomes unavailable?   Active employees and retirees for whom the chosen health ((plan)) carrier becomes unavailable must select a new health ((plan)) carrier within thirty-one days after notification by HCA. Any person that fails to select a new plan within the prescribed time period will be enrolled in the Uniform Medical Plan by default. Any person defaulted to the Uniform Medical Plan may not change the health ((plans)) carrier until the next open enrollment.

[Statutory Authority: RCW 41.05.160 and 41.05.165. 03-17-031 (Order 02-07), § 182-08-196, filed 8/14/03, effective 9/14/03.]


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

WAC 182-08-200   ((Payment of)) Which agency is responsible to pay the employer contribution for eligible employees changing agency employment((.))?   When an eligible employee's employment ceases with an agency at any time prior to the end of the month for which a premium contribution is due and that employee transfers to another agency, the losing agency is responsible for the payment of the contribution for that employee for that month. The receiving agency would not be liable for any employer contribution for that eligible employee until the month following the transfer.

[Statutory Authority: Chapter 41.05 RCW. 96-08-042, § 182-08-200, filed 3/29/96, effective 4/29/96; Order 3-77, § 182-08-200, filed 11/17/77.]


NEW SECTION
WAC 182-08-230   Employer groups.   This section applies to all employer groups, K-12 school districts and educational service districts participating in PEBB insurance coverages.

     (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 coverages.

     (2)(a) Each employer group shall 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 shall submit required documentation and meet all participation requirements set forth in the then-current Introduction to PEBB Coverage K-12 and Employer Groups booklet(s).

     (3)(a) Each employer group, K-12 school district or educational service district applying for participation in PEBB insurance coverage shall sign an interlocal agreement with the HCA.

     (b) Each interlocal agreement shall be renewed no less frequently than once in every two-year period.

     (4) At least twenty days prior to the premium due date, the HCA shall 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 shall be submitted to the HCA prior to the twentieth day of the month during which 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 shall be accompanied by a full explanation of the circumstances of the late notification.

     (5) An employer group, K-12 school district or educational service district shall 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) Each employer group, K-12 school district or educational service district shall 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 shall not withhold portions of the monthly premium due because it has failed to collect the entire employee share.

     (7) 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) Prior to termination for nonpayment of premium, the HCA shall cause a notice of overdue premium to be sent 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 shall have the right to a dispute resolution hearing in accordance with the terms of the interlocal agreement.

     (e) Employees terminated 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). Terminated employees shall 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 terminated 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) A disenrolled employer group, K-12 school district or educational service district may apply for reinstatement in PEBB insurance coverages 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) 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.

[]


REPEALER

     The following sections of the Washington Administrative Code are repealed:
WAC 182-08-095 Waiver of coverage for active employees.
WAC 182-08-125 PEBB-sponsored medical and dental benefit is limited to one enrollment per individual member.
WAC 182-08-160 Group coverage when not in pay status.
WAC 182-08-165 Other group coverage option.
WAC 182-08-175 Group coverage while on family and medical leave.
WAC 182-08-210 Termination of employer paid insurance benefit programs.

OTS-7309.3


NEW SECTION
WAC 182-12-108   Purpose.   The purpose of this chapter is to establish eligibility criteria of employee eligibility for and effective date of enrollment in the public employees' benefits board (PEBB) approved benefits.

[]


NEW SECTION
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.

     "Board" means the public employees' benefits board established under provisions of RCW 41.05.055.

     "Defer" means to postpone enrollment or interrupt enrollment in PEBB sponsored medical coverage by a retiree or surviving dependent.

     "Dependent" means a person who meets eligibility requirements set forth in WAC 182-12-260.

     "Effective date of enrollment" means the first date on which an enrollee is entitled to receive covered benefits.

     "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.

     "Extended dependent" means a dependent child who is not the child of an enrollee through birth, adoption, marriage, or a qualified same sex domestic partnership. Some examples of extended dependents include, but are not limited to, a grandchild or a niece or nephew for whom the enrollee is the legal guardian or the enrollee has legal custody.

     "Health carrier" has the meaning set forth at RCW 43.43.005(18) for purposes of administering this Title 182 WAC only, it includes the uniform medical plan and the uniform dental plan.

     "Health plan" or "plan" means medical and dental coverages.

     "Insurance coverage" means any health plan, life, or long-term disability insurance plan 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 and life insurance offered to employees on an optional basis.

     "Open enrollment" means a time period designated by the administrator during which enrollees may apply to transfer their enrollment from one health carrier to another, enroll in medical coverage if the enrollee had previously waived such coverage or add dependents.

     "PEBB plan" or "PEBB benefits" means one or more insurance coverages approved by the public employees' benefits board for eligible enrollees and their dependents.

     "Subscriber" or "insured" means the employee, retiree, COBRA beneficiary or surviving dependent who has been designated by the HCA as the individual to whom the HCA and the health carrier will issue all notices, information, requests and premium bills on behalf of enrolled dependents.

     "Waive" means to interrupt enrollment or postpone enrollment in a PEBB sponsored health plan by an employee (as set forth in WAC 182-12-115) or a dependent who meets eligibility requirements set forth in WAC 182-12-260.

[]


AMENDATORY SECTION(Amending Order 02-07, filed 8/14/03, effective 9/14/03)

WAC 182-12-111   Eligible entities and individuals.   The following entities and individuals shall be eligible to participate in PEBB insurance ((plans)) coverages 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 approved ((plans)) insurance coverage. 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 terminate PEBB insurance coverage by January 1, 1996, or the expiration of the current collective bargaining agreements, whichever is later. Employees electing to terminate PEBB coverage have a one-time reenrollment option after a five year wait. Employees of a bargaining unit may terminate PEBB participation only as an entire bargaining unit. All administrative or managerial employees may terminate 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 the purpose of purchasing insurance benefits, may participate in PEBB((-))sponsored ((benefits)) 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 ((plan)) insurance coverage as a unit. If the group meets the minimum size standards established by HCA, 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 ((medical)) health plan((s)) must be the only employer sponsored ((medical)) health plan((s)) 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 to participate in ((the)) PEBB ((plans)) insurance coverage is subject to the approval of the HCA.

     (d) The legislative authority or the board of directors must maintain its PEBB plan participation for a minimum of one full year, and may terminate participation only at the end of a plan year.

     (e) The terms and conditions for the payment of the insurance premiums shall be set forth in the provisions of the 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 ((defined)) set forth in WAC ((182-12-119)) 182-12-260.

     (g) The legislative authority or the board of directors shall provide the HCA with written notice of its intent to terminate PEBB plan participation no fewer than thirty days prior to the effective date of termination. If the employee organization terminates coverage in PEBB insurance ((plans)) coverage, retired and disabled employees who began participating after September 15, 1991, are not eligible to participate in PEBB insurance ((plans)) coverage beyond the mandatory extension requirements specified in WAC ((182-12-215)) 182-12-146.

     (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 ((programs)) coverage.

     (a) Vendors that do not enroll when first eligible may enroll only during the annual open enrollment period offered by the ((health care authority)) 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 ((programs)) 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 as ((defined)) set forth in WAC ((182-12-119)) 182-12-260.

     (4) Local governments: Employees of a county, municipality, or other political subdivision of the state may participate in PEBB insurance ((programs)) coverage provided all of the following requirements are met:

     (a) All eligible employees of the entity must transfer to PEBB ((plan)) insurance coverage as a unit. If the ((employer)) group meets the minimum size standards established by HCA, 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 ((medical)) health plan((s)) must be the only employer sponsored ((medical)) health plan((s)) 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 to participate in ((the)) PEBB ((plans)) insurance coverage is subject to the approval of the HCA.

     (d) The legislative authority or the board of directors must maintain its PEBB plan participation for a minimum of 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 set forth in the provisions of the 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 ((the)) state employees and retirees as ((defined)) set forth in WAC ((182-12-119)) 182-12-260.

     (g) The legislative authority or the board of directors shall provide the HCA with written notice of its intent to terminate PEBB plan participation no fewer than thirty days prior to the effective date of termination. If a county, municipality, or political subdivision terminates coverage in PEBB insurance ((plans)) coverage, retired and disabled employees who began participating after September 15, 1991, are not eligible to participate in PEBB insurance ((plans)) coverage beyond the mandatory extension requirements specified in WAC ((182-12-215)) 182-12-146.

     (5) K-12 school districts and educational service districts: Employees of school districts or educational service districts may participate in PEBB insurance programs provided all of the following requirements are met:

     (a) All eligible employees of the entity must transfer to PEBB ((plan)) insurance coverage as a unit. If the K-12 school district or educational service district meets the minimum size standards established by HCA, bargaining units may elect to participate separately from the whole group. For the purpose of enrolling by bargaining unit, all nonrepresented employees will be considered a single bargaining unit.

     (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. The application to participate in the PEBB ((plans)) insurance coverage is subject to the approval of the HCA.

     (c) The school district or educational service district must agree to participate in all PEBB insurance ((plans)) coverage. The PEBB ((medical)) health plan((s)) must be the only employer sponsored ((medical)) health plan((s)) available to eligible employees.

     (d) The school district or educational service district must maintain its PEBB plan participation for a minimum of one full year, and may terminate participation only at the end of the plan year.

     (e) Beginning September 1, 2003, the ((health care authority)) HCA will collect an amount equal to the composite rate charged to state agencies plus an amount equal to the employee premium by ((plan)) health carrier 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 ((plan)) health carrier 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 as ((defined)) set forth in WAC ((182-12-119)) 182-12-260.

     (g) The school district or educational district must provide the HCA with written notice of its intent to terminate PEBB plan participation no fewer than thirty days prior to the effective date of termination, and may terminate participation only at the end of a plan year.

     (6) 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 ((medical and dental)) health plan coverage 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 and 41.05.165. 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.]


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

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AMENDATORY SECTION(Amending Order 5-79, filed 12/27/79)

WAC 182-12-121   Does a change in position or job affect eligibility status((.))?   Employees who voluntarily move from an eligible to an otherwise noneligible position shall retain their eligibility for the employer contribution each month in which they are in pay status eight ((hours)) or more hours, provided, (1) the new position is one in which the employee is scheduled to work half time or more, and (2) the employee did not terminate state service before taking the new position. Layoff because of reduction in force is not considered termination of state service. Proviso (1) above does not apply to employees who are on reduction in force status.

[Statutory Authority: Chapter 41.05 RCW. 80-01-082 (Order 5-79), § 182-12-121, filed 12/27/79.]


NEW SECTION
WAC 182-12-123   Dual eligibility is prohibited.   Health plan coverage is limited to a single enrollment per individual.

     (1) Effective January 1, 2002, individuals that have more than one source of eligibility for enrollment in PEBB health coverage (called "dual eligibility") are limited to one enrollment.

     (2) One insurance-eligible employee may waive medical coverage for himself or herself and enroll as a spouse or dependent on the coverage of his or her eligible spouse. This waiver option is not available for other insurance coverages.

     (3) The following examples describe typical situations of dual eligibility. These are not the only situations where dual eligibility may arise. These examples are provided as illustrations only.

     (a) A husband and wife who are both insurance-eligible and employed by PEBB-participating employers, such as state agencies, may enroll only in a health plan as an employee but not also as a dependent. That is, the husband may enroll only under his employing agency and the wife may enroll only under her employing agency but not also as dependents of each other. In the alternative, one spouse may waive medical coverage as an employee and enroll as a dependent on the medical coverage of the other spouse.

     (b) A dependent child that is eligible for coverage under two or more parents or stepparents who are employed by PEBB-participating employers, may be enrolled as a dependent under the health plan coverage of one parent or stepparent, but not more than one.

     (c) An employee employed in an insurance-eligible position by more than one PEBB-participating employer may enroll only under one employer. The employee may choose to enroll in a health plan under the employer that:

     (i) Offers the most favorable cost-sharing arrangement; or

     (ii) Employed the employee for the longer period of time.

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NEW SECTION
WAC 182-12-128   May an employee waive enrollment in PEBB insurance coverage?   (1) Employees eligible for PEBB insurance coverage have the option of waiving health plan coverage if they are covered by other health plan coverage. If an employee waives health plan coverage, such coverage is automatically waived for all eligible dependents. An employee may choose to enroll only himself or herself, and waive either the medical or dental portion of the health plan coverage, or both, for any or all dependents. In order to waive enrollment, the employee must complete an enrollment form and list all enrollees for whom coverage is being waived.

     (2) An employee may only waive the medical portion of health plan coverage. The employee must remain enrolled in the dental, life and LTD insurance coverages.

     (3) If the medical portion of the health plan coverage is waived, an otherwise eligible enrollee may not rescind the waiver and reenroll in the medical portion of the health plan coverage except during the following times:

     (a) The next open enrollment period; or

     (b) Within sixty days of loss of other medical coverage if proof of enrollment in other comprehensive group medical coverage is submitted and demonstrates that:

     (i) Enrollment in other medical coverage was continuous from the most recent open enrollment period for which PEBB medical coverage was waived; and

     (ii) The period between loss of the other medical coverage and application for PEBB medical coverage is sixty days or less.

     (4) If the dental portion of the health plan coverage is waived, an otherwise eligible dependent may not enroll in PEBB dental coverage except during the following times:

     (a) The next open enrollment period; or

     (b) Within sixty days after loss of other dental coverage if proof of enrollment in other dental coverage is submitted and demonstrates that:

     (i) Enrollment in the other dental coverage was continuous from the most recent open enrollment period for which dental was waived; and

     (ii) The period between loss of the other dental and application for PEBB dental coverage is sixty days or less.

     (5) The employee and eligible dependents may have an additional opportunity to reenroll only as a result of addition of a new dependent due to marriage, birth, adoption, or placement for adoption, provided that advice of such enrollment is provided to HCA within thirty-one days after the marriage or within sixty days after the birth, adoption or placement for adoption of a child.

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NEW SECTION
WAC 182-12-131   When does employer paid insurance coverage end?   PEBB medical, dental and life insurance coverages for a terminated employee, spouse, qualified same sex domestic partner or dependent child ceases at 12:00 midnight, the last day of the month in which the employee or dependent is eligible. Basic long term disability coverage ceases at 12:00 midnight the date employment terminates or immediately upon the death of the employee.

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NEW SECTION
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 military duty; however, self-payment of life insurance is limited to twelve months from the date the employee is called to active duty;

     (f) The employee is on approved educational leave.

     (2) Part-time faculty may self-pay premium at the group rate between periods of eligibility for a maximum of eighteen months. Part-time faculty 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 group medical and dental coverage for a period of eighteen to thirty-six 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.

     (c) The employee reverts to a previously held position that is not eligible for benefits.

     (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 weeks, as provided in WAC 182-12-138.

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NEW SECTION
WAC 182-12-136   May an employee on approved educational leave waive PEBB health plan coverage?   In order to avoid duplication of group health plan coverage, the following shall apply to employees during any period of approved educational leave. Employees eligible for coverage provided in WAC 182-12-133 who obtain comprehensive health plan coverage under another group plan may waive continuance of such coverage for each full calendar month in which they maintain coverage under the other comprehensive group health plan. These employees have the right to reenroll in PEBB health plan coverage effective the first day of the month after the date the other comprehensive group health plan coverage terminates, provided proof of such other comprehensive group health plan coverage is provided to the HCA upon application for reenrollment.

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NEW SECTION
WAC 182-12-138   If an employee is approved family and medical leave, what PEBB insurance coverage may be continued?   Employees on leave under the federal Family and Medical Leave Act (FMLA) may 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 also continue current optional life and long-term disability. All employee premium amounts associated with insurance coverage must be paid monthly as they become due. If premiums are more than sixty days delinquent, insurance coverage will be terminated as of the last day of the month of fully paid coverage.

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NEW SECTION
WAC 182-12-141   If I revert from an eligible position to an ineligible position what happens to my insurance coverage?   Employees who revert to a position that is ineligible for employer contribution toward insurance coverage may continue health plan coverage by self-paying premium for up to eighteen months (and in some cases up to twenty-nine months) under provisions of the federal Consolidated Omnibus Budget Reconciliation Act (COBRA).

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NEW SECTION
WAC 182-12-146   PEBB health plan coverage under COBRA.   Enrollees and eligible dependents who become ineligible for health plan coverage and who qualify for continued coverage under the Consolidated Omnibus Budget Reconciliation Act (COBRA) may continue their plan coverage by self-payment of plan premiums in accordance with COBRA statutes and regulations.

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NEW SECTION
WAC 182-12-148   May an employee continue PEBB insurance coverage during their appeal of dismissal?   (1) Employees awaiting hearing of a dismissal action before 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.

     (2) If the hearing board or court upholds the dismissal, 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 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 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.

     (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.

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NEW SECTION
WAC 182-12-171   Eligible retirees.   (1) Eligible employees who terminate public employment after becoming vested in a Washington state sponsored retirement system are eligible to continue PEBB sponsored insurance coverage as a retiree provided the following requirements are met:

     (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 must submit an application form to enroll or defer health plan coverage within sixty days after active employer 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 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), RCW 41.32.762(1), RCW 41.32.870(1), RCW 41.35.410(1), RCW 41.35.670(1), RCW 41.40.625(1) or RCW 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 sixty days after the date their active PEBB life insurance terminates and their premium is not being waived for any PEBB life insurance coverage at the time of application for 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 Federal Civil Service 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 sixty days after retirement, or who terminate PEBB retiree coverage within 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. 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.

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AMENDATORY SECTION(Amending Order 2-80, filed 4/10/80)

WAC 182-12-190   ((Retirees changing medical plans)) May a retiree change health carriers at retirement((.))?   Retirees eligible to continue their ((medical)) insurance coverage after retirement may elect to change ((medical plans)) healthcarriers at the time of retirement.

[Statutory Authority: Chapter 41.05 RCW. 80-05-016 (Order 2-80), § 182-12-190, filed 4/10/80; Order 4-77, § 182-12-190, filed 11/17/77.]


AMENDATORY SECTION(Amending Order 01-00, filed 8/9/01, effective 9/9/01)

WAC 182-12-200   May a retiree((s may change enrollment in approved)) who is enrolled in PEBB sponsored or Washington state K-12 school district sponsored health plan coverage defer enrollment in PEBB retiree health plans((.))?   A retiree, whose spouse is enrolled as an eligible employee in a PEBB or Washington state school district((-))sponsored health plan, may defer enrollment in PEBB retiree ((medical and dental plans)) health plan coverage and enroll in the spouse's PEBB or school district((-))sponsored health plan coverage. If a retiree defers enrollment in ((a)) PEBB retiree medical ((plan)) coverage, enrollment must also be deferred for dental coverage. The retiree and eligible dependents may subsequently enroll in ((a)) PEBB retiree medical coverage, or medical and dental((, plan(s))) coverage if the retiree was continuously enrolled under the spouse's PEBB or school district((-))sponsored health plan coverage from the date the retiree was initially eligible for retiree insurance coverage:

     (1) During any open enrollment period determined by the HCA; or

     (2) Within sixty days ((of)) after the date the spouse ceases to be enrolled in a PEBB or school district((-))sponsored health plan as an eligible employee; or

     (3) Within sixty days of the date ((of)) after the retiree's loss of eligibility as a dependent under the spouse's PEBB or school district((-))sponsored health plan coverage.

[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.]


NEW SECTION
WAC 182-12-205   Retirees may defer enrollment in PEBB health plan coverage at or following retirement.   (1) Beginning January 1, 2001, retirees may defer enrollment in health plan coverage at or following retirement if they are covered under:

     (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 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 a PEBB Retiree Medical and Dental Coverage form to the HCA requesting deferment of coverage. The notice of deferral must be received by the HCA 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 a PEBB Retiree Medical and Dental Coverage form and satisfactory evidence of continuous enrollment in comprehensive employer sponsored coverage to the HCA:

     (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 a PEBB Retiree Medical and Dental Coverage form and satisfactory evidence of continuous enrollment in a federal retiree medical plan to the HCA:

     (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.

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NEW SECTION
WAC 182-12-211   If department of retirement systems makes a formal determination of retroactive eligibility, may the retiree enroll in PEBB sponsored insurance coverage?   (1) When the Washington state department of retirement systems (DRS) makes a formal determination that a person is retroactively eligible for pension benefits, that person may apply for PEBB retiree health plan coverage only if application is made within sixty days after the date of notice from DRS.

     (2) All premium due from the date of eligibility established by DRS or the date of the DRS decision letter, at the option of the retiree, must be sent with the application to HCA.

     (3) The administrator may make an exception to the date PEBB retiree benefits commence or payment of premiums; however, such requests must demonstrate extraordinary circumstances beyond the control of the retiree.

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NEW SECTION
WAC 182-12-250   Insurance eligibility for surviving dependents of emergency service personnel killed in the line of duty.   Surviving dependents of emergency service personnel who were killed in the line of duty on or after January 1, 1998, are eligible to participate in health plan coverage administered by the HCA.

     (1) This section applies to the dependents of emergency service personnel "killed in the line of duty" as determined consistent with Title 51 RCW by the department of labor and industries.

     (2) "Emergency service personnel" means law enforcement officers, fire fighters and reserve officers, fire fighters as defined in RCW 41.26.030 and RCW 41.24.010.

     (3) "Surviving dependent" means:

     (a) A lawful spouse or ex-spouse as defined in RCW 41.26.162; and

     (b) Dependent children. The term "children" includes unmarried natural children, stepchildren and legally adopted children under the age of twenty or under the age of twenty-four for a dependent student attending high school or registered at an accredited secondary school, college, university, vocational school, or school of nursing. Disabled dependents as defined in RCW 41.26.030(7) are eligible at any age.

     (4) Premium rates will be subsidized consistent with rates established by PEBB for non-Medicare retirees under RCW 41.05.022 and for Medicare-entitled retirees under RCW 41.05.085.

     (5) Surviving dependents that are Medicare-entitled must enroll in both parts A and B of Medicare.

     (6) The surviving dependent must send a completed enrollment application to PEBB no later than sixty days after:

     (a) The last day of any coverage extended by the employing agency of the emergency service employee who died in the line of duty; or

     (b) The last day of coverage extended through the Consolidated Omnibus Budget Reconciliation Act (COBRA) from any employing agency.

     (7) Surviving dependents must choose one of the following two options for maintaining eligibility for participation under PEBB health plan coverage:

     (a) Enroll in PEBB health plan coverage:

     (i) Enrollment in the medical portion of PEBB health plan coverage is required.

     (ii) Enrollment in the dental portion of PEBB health plan coverage is optional. Once enrolled in dental coverage the person must maintain enrollment in dental coverage for a minimum of two years before dental coverage can be dropped.

     (iii) Dental only coverage is not available.

     (b) Defer enrollment:

     (i) Surviving dependents may defer enrollment in PEBB health plan coverage if they are enrolled in employer sponsored medical through their employment.

     (ii) Surviving dependents may enroll in PEBB health plan coverage when their employer sponsored coverage ends. Proof of continuous enrollment in other comprehensive employer sponsored coverage must be submitted with the application for enrollment to the HCA within sixty days after the date that their coverage ended.

     (8) Enrollees may change their health carrier selection during open enrollment. In addition to open enrollment, enrollees may change health carriers if they move out of their health carrier's service area or into a service area where a health carrier that was not previously offered is now available.

     (9) Surviving dependents will forfeit their right to enroll in PEBB health plan coverage if they:

     (a) Do not make application to PEBB before the date specified in subsection (6) of this section; or

     (b) Do not maintain continuous comprehensive employer sponsored medical coverage during the deferral period, as provided in subsection (7)(b)(i) of this section.

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NEW SECTION
WAC 182-12-260   Eligible dependents defined.   The following are eligible as dependents under the PEBB eligibility rules:

     (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. Dependent student eligibility continues year-round for those who attend three of the four school quarters or two semesters and 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 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 under PEBB health plan coverage as a registered student. Proof of such disability must be furnished prior to the dependent's attainment of age twenty or loss of eligibility for student coverage, and as periodically requested thereafter.

     (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 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.

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NEW SECTION
WAC 182-12-265   What options for continuing insurance coverage are available to widows, widowers and dependent children if the employee or retiree dies?   (1) Dependents that lose eligibility due to the death of an eligible employee may continue health plan coverage under a retiree plan provided they immediately begin receiving a monthly retirement benefit from any state of Washington sponsored retirement system.

     (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).

     (d) The Federal Civil Service 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 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 sixty days after the retiree's death.

     (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 form approved by PEBB within 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 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 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 prior to reenrollment in a PEBB health plan.

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NEW SECTION
WAC 182-12-270   What options are available to dependents that cease to meet the definition of dependent in WAC 182-12-260?   Dependents may continue enrollment in PEBB health plan coverage by self-paying premiums following their loss of eligibility. Options for continuing coverage are based on the reason that eligibility was lost.

     (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 no longer meet the definition of dependent as defined under COBRA may continue coverage for a maximum of thirty-six months.

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REPEALER

     The following sections of the Washington Administrative Code are repealed:
WAC 182-12-110 Purpose.
WAC 182-12-117 Eligible retirees.
WAC 182-12-118 Insurance eligibility for surviving dependents of emergency service personnel killed in the line of duty.
WAC 182-12-119 Eligible dependents.
WAC 182-12-124 Determination by department of retirement systems of retroactive eligibility for PEBB pension.
WAC 182-12-132 Deferring coverage at or following retirement.
WAC 182-12-145 Insurance eligibility for higher education.
WAC 182-12-215 Continued PEBB medical/dental coverage under COBRA.
WAC 182-12-220 Eligibility during appeal of dismissal.
WAC 182-12-230 Employer groups.

Legislature Code Reviser 

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