Effective Date of Rule: Thirty-one days after filing.

     Purpose: Amendments to existing public employees benefits board (PEBB) rules are necessary to implement legislation enacted by the 2007 legislature, to implement federal and state law and to implement policy decisions adopted by the PEBB. In addition, the agency is making needed technical corrections and enhancing the clarity of PEBB rules throughout the three chapters 182-08, 182-12, and 182-16 WAC.

     Citation of Existing Rules Affected by this Order: Repealing WAC 182-12-190; and amending chapters 182-08, 182-12, and 182-16 WAC.

     Statutory Authority for Adoption: RCW 41.05.160.

      Adopted under notice filed as WSR 07-17-096 on August 16, 2007.

     Changes Other than Editing from Proposed to Adopted Version: The following describes any change other than editing from the proposed to the adopted version:

     The following proposed rules filed as WSR 07-17-096, in the supplemental rule-making notice, were withdrawn: WAC 182-08-180 The effective date of health plan enrollment will be retroactive to the loss of other coverage and WAC 182-12-171 The effective date of health plan enrollment will be the first of the month following the loss of other coverage.

     The following clarifying changes were made to proposed amendments in the final rules:

     WAC 182-08-015 and 182-12-109: The definition of "subscriber" was amended replacing "health plan" with "contracted vendors."

     WAC 182-08-196: Redundant language was removed and clarifying language inserted to make the rule clearer.

     WAC 182-08-197(3): Clarified language - "Employees who are later reemployed and become newly eligible for PEBB benefits enroll as described in subsections (1) and (2) of this section, with the following exceptions in which insurance coverage elections stay the same:"

     WAC 182-08-198 [(2)](h): "Salary reduction plan" replaces the outdated term "benefits contribution plan."

     WAC 182-12-171: Corrected language - "PEBB premium payments for retiree, COBRA or an extension of PEBB insurance coverage begin to accrue the first of the month after other of PEBB insurance coverage ends."

     WAC 182-12-128(4): Subsection (iii) is amended to read "the date when coverage was lost."

     WAC 182-12-200: Replaced the term "health plan" with the term "medical plan." The deferral rule was amended to be self-referential: "Continuous enrollment must be from the date the retiree deferred enrollment in was initially eligible for retiree insurance."

     WAC 182-12-260 (5)(a)(i): Amended to comply with state law and to respond to public comment: "For children enrolled in PEBB insurance coverage, the subscriber must provide evidence of the disability before within sixty days of the child's attainment of age twenty."

     WAC 182-12-265 (2)(c): The term "health plan" replaces the term "medical" in the last sentence. The final sentence was amended for clarity: "To enroll in a PEBB health plan, the dependent must provide satisfactory evidence of continuous enrollment in other medical coverage from the most recent open enrollment for which enrollment in PEBB coverage was waived."

     Number of Sections Adopted in Order to Comply with Federal Statute: New 0, Amended 3, Repealed 0; Federal Rules or Standards: New 0, Amended 0, Repealed 0; or Recently Enacted State Statutes: New 0, 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 1, Repealed 0.

     Number of Sections Adopted in Order to Clarify, Streamline, or Reform Agency Procedures: New 3, Amended 39, Repealed 1.

     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 0, Amended 0, Repealed 0.

     Date Adopted: October 3, 2007.

Jason Siems

Rules Coordinator

OTS-9818.5

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

WAC 182-08-010   Declaration of purpose.   The general purpose of this chapter is to establish a set of rules ((used by)) to administer the health care authority's (HCA) public employees benefits board (PEBB) ((for designing)) employee and retiree eligibility and ((insurance)) PEBB benefits ((and for administration of these insurance plans by the Washington State Health Care Authority (HCA))).

[Statutory Authority: Chapter 41.05 RCW. 96-08-042, § 182-08-010, filed 3/29/96, effective 4/29/96; Order 7228, § 182-08-010, filed 12/8/76.]

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

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

     "Comprehensive employer sponsored medical" includes insurance coverage continued by the employee or their dependent under COBRA.

     "Creditable coverage" means coverage that meets the definition of "creditable coverage" under RCW 48.66.020 (13)(a) and includes payment of medical and hospital benefits.

     "Defer" means to postpone enrollment or interrupt enrollment in PEBB ((sponsored)) medical insurance by a retiree or ((surviving dependent)) eligible survivor.

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

     "Effective date of enrollment" means the first date when 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.

     (("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 a medical ((and)) or dental ((coverage)) plan developed by the public employees benefits board and provided by a contracted vendor or self-insured plans administered by the HCA.

     "Insurance coverage" means any health plan, life ((or)) insurance, long-term care insurance, long-term disability insurance ((plan)), or property and casualty insurance 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, and retiree life insurance.

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

     (("PEBB plan" or)) "PEBB" means the public employees benefits board.

     "PEBB benefits" means one or more insurance coverage((s approved)) or other employee benefit administered by the ((public employees' benefits board for eligible enrollees and their dependents)) PEBB benefits services program within the HCA.

     "PEBB benefits services program" means the program within the health care authority which administers insurance and other benefits to eligible employees of the state (as defined in WAC 182-12-115), eligible retired and disabled employees of the state (as defined in WAC 182-12-171), and others as defined in RCW 41.05.011.

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

     "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 41.05.068. 06-23-165 (Order 06-09), § 182-08-015, filed 11/22/06, effective 12/23/06. Statutory Authority: RCW 41.05.160 and 41.05.165. 04-18-039, § 182-08-015, filed 8/26/04, effective 1/1/05; 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.]

[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.]

     Premium is due for the entire month of insurance 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.

     PEBB premiums will be refunded using the following method:

     (1) When a PEBB subscriber submits an enrollment change affecting eligibility, such as for example: Death, divorce, or when no longer a dependent as defined at 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)) indicated in WAC 182-12-148(3).

     (2) Notwithstanding subsection (1) of this section, the PEBB assistant administrator or designee may approve a refund which does not exceed twelve months of premium ((provided)) if 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 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.

     (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.))

[Statutory Authority: RCW 41.05.160 and 41.05.165. 04-18-039, § 182-08-180, filed 8/26/04, effective 1/1/05; 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.]

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

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

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

     (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)) canceled by HCA if the premium contributions are delinquent more than ninety days.

     (5) Washington state patrol officers disabled while performing their duties as determined by the chief of the Washington state patrol are eligible for the employer contribution for PEBB benefits as authorized in RCW 43.43.040. No other retiree or disabled employee is eligible for the employer contribution for PEBB benefits unless they are an eligible employee as defined in WAC 182-12-115.

[Statutory Authority: RCW 41.05.160 and 41.05.165. 04-18-039, § 182-08-190, filed 8/26/04, effective 1/1/05; 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.]

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

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

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

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

[Statutory Authority: RCW 41.05.160, 41.05.350, and 41.05.165. 05-16-046 (Order 05-01), § 182-08-196, filed 7/27/05, effective 8/27/05. 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.]

     (c) When employees continue insurance coverage under WAC 182-12-133 (1) or (2) and are reemployed into a benefits eligible position before the end of the maximum number of months allowed for continuing PEBB health plan enrollment. Employees who are eligible to continue optional life or optional long-term disability but discontinue that insurance coverage are subject to the insurance underwriting requirements if they apply for the insurance when they return to employment.

[Statutory Authority: RCW 41.05.160. 06-11-156 (Order 06-02), § 182-08-197, filed 5/24/06, effective 6/24/06. Statutory Authority: RCW 41.05.160, 41.05.350, and 41.05.165. 05-16-046 (Order 05-01), § 182-08-197, filed 7/27/05, effective 8/27/05.]

     (2) ((Enrollees)) Subscribers may change health plans outside of the annual open enrollment period under ((some)) the circumstances indicated below. To make a health plan change, the ((enrollee)) subscriber must send a completed enrollment form (and a completed disenrollment form, if required) to the PEBB benefits services program no later than sixty days after the event occurs. Enrollment in the new health plan(('s coverage)) will begin the first day of the month after the PEBB benefits services program receives the form(s). These are the circumstances:

     (a) Enrollees ((may change health plans if they)) move and their current health plan is not available in their new location. If the ((enrollee)) subscriber does not select a new health plan, the PEBB benefits services program ((will automatically)) may enroll them in the Uniform Medical Plan Preferred Provider Organization or Uniform Dental Plan.

     (b) Enrollees ((may change health plans if they)) move and a health plan that was not available to them before is available to them in the new location. The ((enrollee)) subscriber may only choose a newly available health plan.

     (c) ((Enrollees)) Subscribers may change health plans if a court order requires the ((enrollee)) subscriber to provide insurance coverage for an eligible spouse, ((same-sex)) qualified domestic partner, or child and the ((enrollee)) subscriber adds the dependent to their insurance coverage.

     (d) Seasonal employees whose off-season is during the annual open enrollment period may select a new health plan upon their return to work.

     (e) ((Employees)) Subscribers may change health plans when they enroll in PEBB retiree insurance coverage.

     (f) ((Enrollees)) Subscribers may change health plans when they or an eligible dependent becomes entitled to Medicare or enrolls in a Medicare Part D plan.

     (g) ((Enrollees)) Subscribers may not change their health plan if their or an enrolled dependent's physician stops participation with the ((enrollee's)) subscriber's health plan unless the PEBB appeals manager determines that a continuity of care issue exists. However, if the employee is having premiums taken from payroll on a pretax basis a plan change will not be approved if it would conflict with provisions of the salary reduction plan authorized under RCW 41.05.300. The PEBB appeals manager will use criteria that include but are not limited to the following in determining if a continuity of care issue exists:

     (i) Active cancer treatment; or

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

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

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

     (v) Third trimester of pregnancy; or

     (vi) Language barrier.

     (((h) Enrollees may change health plans if they reach their medical plan's lifetime maximum.))

[Statutory Authority: RCW 41.05.160 and 41.05.068. 06-23-165 (Order 06-09), § 182-08-198, filed 11/22/06, effective 12/23/06. Statutory Authority: RCW 41.05.160, 41.05.350, and 41.05.165. 05-16-046 (Order 05-01), § 182-08-198, filed 7/27/05, effective 8/27/05.]

[Statutory Authority: RCW 41.05.160 and 41.05.165. 04-18-039, § 182-08-200, filed 8/26/04, effective 1/1/05. 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.]

     (a) All materials describing PEBB ((plan)) benefits ((shall)) must be prepared by or approved by the HCA ((prior to)) before use.

     (b) Distribution or mailing of all ((plan)) benefit descriptions ((shall)) must be performed by or under the direction of the HCA.

     (c) All media announcements or advertising by a ((carrier)) contracted vendor which include any mention of the "public employees benefits board," "health care authority" or any reference to ((coverage)) benefits for "state employees or retirees" or any group of employees covered by PEBB ((plans)) benefits, must receive the advance written approval of the HCA.

     (2) Failure to comply with any or all of these requirements by a PEBB contracted ((carrier)) vendor or subcontractor may result in contract termination by the HCA, refusal to continue or renew a contract with the noncomplying party, or both.

[Statutory Authority: RCW 41.05.160 and 41.05.165. 03-17-031 (Order 02-07), § 182-08-220, filed 8/14/03, effective 9/14/03. Statutory Authority: Chapter 41.05 RCW. 96-08-042, § 182-08-220, filed 3/29/96, effective 4/29/96; 91-20-163, § 182-08-220, filed 10/2/91, effective 11/2/91; 86-16-061 (Resolution No. 86-3), § 182-08-220, filed 8/5/86.]

     (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 coverage((s)).

     (2)(a) Each employer group ((shall)) must 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)) must 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)) must sign an interlocal agreement with the HCA.

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

     (4) At least twenty days ((prior to)) before the premium due date, the HCA ((shall)) will 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)) must be submitted to the HCA ((prior to)) before the twentieth day of the month ((during which)) when 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)) must 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)) must 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)) must 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)) must 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)) Before termination for nonpayment of premium, the HCA ((shall cause)) will send 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)) canceled 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)) whose coverage is canceled 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 coverage((s)) 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.

[Statutory Authority: RCW 41.05.160 and 41.05.165. 04-18-039, § 182-08-230, filed 8/26/04, effective 1/1/05.]

OTS-9819.6

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

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

[Statutory Authority: RCW 41.05.160 and 41.05.165. 04-18-039, § 182-12-108, filed 8/26/04, effective 1/1/05.]

     "Administrator" means the administrator of the HCA or designee.

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

     "Comprehensive employer sponsored medical" includes insurance coverage continued by the employee or their dependent under COBRA.

     "Creditable coverage" means coverage that meets the definition of "creditable coverage" under RCW 48.66.020 (13)(a) and includes payment of medical and hospital benefits.

     "Defer" means to postpone enrollment or interrupt enrollment in PEBB ((sponsored)) medical ((coverage)) insurance by a retiree or ((surviving dependent)) eligible survivor.

     "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)) when 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 a medical ((and dental coverages)) or dental plan developed by the public employees benefits board and provided by a contracted vendor or self-insured plans administered by the HCA.

     "Insurance coverage" means any health plan, life insurance, ((or)) long-term care insurance, long-term disability insurance ((plan)), or property and casualty insurance 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, and retiree life insurance.

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

     (("PEBB plan" or)) "PEBB" means the public employees benefits board.

     "PEBB benefits" means one or more insurance coverage((s approved)) or other employee benefit administered by the ((public employees' benefits board for eligible enrollees and their dependents)) PEBB benefits services program within HCA.

     "PEBB benefits services program" means the program within the health care authority which administers insurance and other benefits to eligible employees of the state (as defined in WAC 182-12-115), eligible retired and disabled employees of the state (as defined in WAC 182-12-171), and others as defined in RCW 41.05.011.

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

     "Waive" means to interrupt enrollment or postpone enrollment in a PEBB ((sponsored)) health plan by an employee (as ((set forth)) 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 41.05.068. 06-23-165 (Order 06-09), § 182-12-109, filed 11/22/06, effective 12/23/06. Statutory Authority: RCW 41.05.160 and 41.05.165. 04-18-039, § 182-12-109, filed 8/26/04, effective 1/1/05.]

     (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 insurance coverage)) benefits. 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)) end PEBB ((insurance coverage)) benefits by January 1, 1996, or the expiration of the current collective bargaining agreements, whichever is later. Employees electing to ((terminate)) end PEBB ((coverage)) benefits have a one-time reenrollment option after a five year wait. Employees of a bargaining unit may ((terminate)) end PEBB benefit participation only as an entire bargaining unit. All administrative or managerial employees may ((terminate)) end 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)) 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 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 health plans must be the only employer sponsored health plans 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)) for PEBB insurance coverage is subject to the approval of the HCA.

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

     (e) The terms and conditions for the payment of the insurance premiums ((shall)) 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 must be the same as the requirements for dependents of the state employees and retirees as ((set forth)) in WAC 182-12-260.

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

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

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

     (a) All eligible employees of the entity must transfer to PEBB 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 health plans must be the only employer sponsored health plans 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)) for PEBB insurance coverage is subject to the approval of the HCA.

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

     (g) The legislative authority or the board of directors ((shall provide)) must give the HCA ((with)) written notice of its intent to ((terminate)) end PEBB ((plan)) insurance coverage participation ((no fewer than)) at least thirty days ((prior to)) before the effective date of termination. If a county, municipality, or political subdivision ((terminates)) ends coverage in PEBB insurance coverage, retired and disabled employees who began participating after September 15, 1991, are not eligible ((to participate in)) for PEBB insurance coverage beyond the mandatory extension requirements specified in WAC 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)) coverage provided all of the following requirements are met:

     (a) All eligible employees of the entity must transfer to PEBB 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)) for the PEBB 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 coverage. The PEBB health plans must be the only employer sponsored health plans available to eligible employees.

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

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

     (g) The school district or educational service district must ((provide)) give the HCA ((with)) written notice of its intent to ((terminate)) end PEBB ((plan)) insurance coverage participation ((no fewer than)) at least thirty days ((prior to)) before the effective date of termination, and may ((terminate)) end 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 health plans ((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. 04-18-039, § 182-12-111, filed 8/26/04, effective 1/1/05; 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.]

[Statutory Authority: RCW 41.05.160 and 41.05.165. 04-18-039, § 182-12-112, filed 8/26/04, effective 1/1/05.]

     A person whose employment situation can be described by more than one of the eligibility categories in subsections (1) through (7) of this section shall have his or her eligibility determined solely by the criteria of the one category that most closely describes his or her employment situation.

     (1) "Permanent employees." Those who work at least half-time per month and are expected to be employed for more than six months. These employees are eligible for benefits on their date of employment. Insurance coverage begins on the first day of the month following the date of employment. If the date of employment is the first working day of a month, insurance coverage begins on the date of employment.

     (2) "Nonpermanent employees." Those who work at least half-time and are expected to be employed for no more than six months. These employees are eligible for benefits on the first day of the seventh month of half-time or more employment. Insurance coverage begins on the first day of the seventh month following the date of employment.

     (3) "Career seasonal employees." Those who work at least half-time per month during a designated season for a minimum of three months but less than twelve months per year and who have an understanding of continued employment season after season. These employees are eligible for benefits on their date of employment. Insurance coverage begins on the first day of the month following the date of employment. If the date of employment is the first working day of a month, insurance coverage begins on the date of employment. Career seasonal employees who work at least half-time per month for a season that extends for nine or more months are eligible for the employer contribution during the break between seasons of employment. However, career seasonal employees who work at least half-time per month for less than nine months in a season are not eligible for the employer contribution during the break between seasons of employment but may be eligible to continue insurance coverage by self-paying premiums.

     (4) "Instructional year employees." Employees who work half-time or more on an instructional year (school year) or equivalent nine-month basis. These employees are eligible for benefits on their date of employment. Insurance coverage begins on the first day of the month following the date of employment. If the date of employment is the first working day of the month, insurance coverage begins on the date of employment. These employees are eligible to receive the employer contribution for insurance coverage during the off-season following each instructional year period of employment. The provisions of this subsection do not apply to persons employed on a quarter-to-quarter or semester-to-semester contract basis.

     (5)(a) "Part-time faculty" and "part-time academic employees." Employees who are employed on a quarter/semester to quarter/semester basis are eligible for insurance coverage ((beginning with)) starting the second consecutive quarter/semester of half-time or more employment at one or more state institutions of higher education including one or more college districts. These employees are eligible for benefits the first day of the second consecutive quarter/semester of half-time or more employment. Insurance coverage begins on the first day of the month following the beginning of the second quarter/semester of half-time or more employment. If the first day of the second consecutive quarter/semester is the first working day of the month, insurance coverage begins at the beginning of the second consecutive quarter/semester.

     ((For the purpose of determining)) To determine eligibility for part-time faculty and part-time academic employees, employers must:

     (i) Consider spring and fall as consecutive quarters/semesters when first establishing eligibility; and

     (ii) Determine "half-time or more employment" based on each institution's definition of "full-time"; and

     (iii) At the beginning of each quarter/semester notify, in writing, all current and newly hired part-time faculty and part-time academic employees of their potential right to benefits under this subsection; and

     (iv) Where concurrent employment at more than one state higher education institution is used to determine total employment of half-time or more, the employing institutions will arrange to prorate the cost of the employer insurance contribution based on the employment at each institution. However, if the employee would be eligible by virtue of employment at one institution, that institution will pay the entire cost of the employer contribution regardless of other higher education employment. In cases where the cost of the contribution is prorated between institutions, one institution will forward the entire contribution monthly to HCA.

     Part-time faculty and part-time academic employees employed at more than one state institution of higher education are responsible for notifying each employer quarterly, in writing, of the employee's multiple employment. In no case will retroactive insurance coverage be permitted or employer contribution paid to HCA if an employee ((fails to)) does not inform all of his((/)) or her employing institutions about employment at all institutions within the current quarter.

     Once enrolled, if a part-time faculty or part-time academic employee does not work at least a total of half-time in one or more state institutions of higher education, eligibility for the employer contribution ceases.

     (b) Part-time academic employees of community and technical colleges who have a reasonable expectation of continued employment at one or more college districts shall be eligible for the employer contribution for benefits during the period between the end of the spring quarter and the beginning of the fall quarter, or other quarter break period, if they meet the following conditions of this subsection (5)(b).

     Part-time academic employees who work half-time or more in each instructional year quarter of an academic year, or equivalent nine-month season, in a single college district or multiple college districts, as determined from the payroll records of the employing community or technical college district(s), are eligible for the employer contribution for health benefits during the quarter or off season period immediately following the end of one academic year or equivalent nine-month season.

     For ((the purposes of)) this subsection (5)(b):

     (i) "Academic employee" ((has the meaning set forth)) is defined in RCW 28B.50.489(3).

     (ii) "Academic year" means fall, winter, and spring quarters in a community or technical college, as determined from the payroll records of the employing college district or college districts.

     (iii) "Equivalent nine-month seasonal basis" means a nine consecutive month period of employment at half-time or more by a single college district or multiple college districts, as determined from the payroll records of the employing college district(s).

     (iv) "Health benefits" means the particular medical and/or dental coverage in place at the end of the academic year or equivalent nine-month season. Changes to health benefits may be made only as ((set forth)) allowed in chapter 182-08 WAC or during an annual open enrollment period.

     (c) Part-time academic employees who have established eligibility, as determined from the payroll records of the employing community or technical college districts, for employer contributions for benefits and who have worked an average of half-time or more in each of the two preceding academic years, through employment at one or more community or technical college districts, are eligible for continuation of employer contributions for the subsequent summer period between the end of the spring quarter and the beginning of the fall quarter.

     (d) Once a part-time academic employee meets the criteria in (c) of this subsection, the employee shall continue to receive uninterrupted employer contributions for benefits if the employee works at least ((three of the four)) two quarters of the academic year with an average academic year workload of half-time or more for three quarters of the academic year. Benefits provided under this subsection (5)(d) cease ((at the end of the academic year)) if this criteria is not met. Continuous benefits shall be reinstated once the employee reestablishes eligibility under (c) of this subsection.

     (e) As used in (c) and (d) of this subsection, "academic year" means the summer, fall, winter, and spring quarters. As used in this subsection, "academic employees" has the meaning provided in RCW 28B.50.489.

     (f) To be eligible for maintenance of benefits through averaging pursuant to (c) and (d) of this subsection, part-time academic employees must notify their employers of their potential eligibility.

     (6) "Appointed and elected officials." Legislators are eligible ((to apply for coverage)) for benefits on the date their term begins. All other elected and full-time appointed officials of the legislative and executive branches of state government are eligible ((to apply for coverage)) for benefits on the date their term begins or they take the oath of office, whichever occurs first. Insurance coverage for legislators begins on the first day of the month following the date their term begins. If the term begins on the first working day of the month, insurance coverage begins on the first day of their term. Insurance coverage begins for all other elected and full-time appointed officials of the legislative and executive branches of state government on the first day of the month following the date their term begins, or the first day of the month following the date they take the oath of office, whichever occurs first. If the term begins, or oath of office is taken, on the first working day of the month, insurance coverage begins on the date the term begins, or the oath of office is taken.

     (7) "Judges." Justices of the supreme court and judges of courts of appeals and the superior courts become eligible ((to apply for coverage)) for benefits on the date they take the oath of office. Insurance coverage begins on the first day of the month following the date their term begins, or the first day of the month following the date they take oath of office, whichever occurs first. If the term begins, or oath of office is taken, on the first working day of a month, insurance coverage begins on the date the term begins, or the oath of office is taken.

[Statutory Authority: RCW 41.05.160. 06-12-002 (Order 06-01), § 182-12-115, filed 5/25/06, effective 6/25/06; 05-17-132 (Order 04-04), § 182-12-115, filed 8/19/05, effective 9/2/05. Statutory Authority: RCW 41.05.160 and 41.05.165. 03-17-031 (Order 02-07), § 182-12-115, filed 8/14/03, effective 9/14/03. Statutory Authority: Chapter 41.05 RCW. 96-08-043, § 182-12-115, filed 3/29/96, effective 4/29/96; 92-08-003, § 182-12-115, filed 3/18/92, effective 3/18/92; 91-14-084, § 182-12-115, filed 7/1/91, effective 7/1/91. Statutory Authority: RCW 41.05.065(3). 90-12-037, § 182-12-115, filed 5/31/90, effective 7/1/90. Statutory Authority: RCW 41.05.065. 89-12-045 (Resolution No. 89-2), § 182-12-115, filed 6/2/89; 89-01-053 (Resolution No. 88-6), § 182-12-115, filed 12/15/88. Statutory Authority: RCW 41.05.010. 88-19-078 (Resolution No. 88-4), § 182-12-115, filed 9/19/88; 88-12-034 (Resolution No. 88-1), § 182-12-115, filed 5/26/88, effective 7/1/88. Statutory Authority: Chapter 41.05 RCW. 86-21-042 (Resolution No. 86-6), § 182-12-115, filed 10/10/86; 83-12-007 (Order 2-83), § 182-12-115, filed 5/20/83; 80-05-016 (Order 2-80), § 182-12-115, filed 4/10/80; 78-08-071 (Order 5-78), § 182-12-115, filed 7/26/78; Order 5646, § 182-12-115, filed 2/9/76.]

     If an employee terminates employment after becoming a plan participant and later on in the same plan year is hired into a new position that is eligible for PEBB ((insurance)) benefits, the employee may not resume participation in the PEBB medical flexible spending account until the beginning of the next plan year.

[Statutory Authority: RCW 41.05.160. 06-11-156 (Order 06-02), § 182-12-116, filed 5/24/06, effective 6/24/06. Statutory Authority: RCW 41.05.160, 41.05.350, and 41.05.165. 05-16-046 (Order 05-01), § 182-12-116, filed 7/27/05, effective 8/27/05.]

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

     (2) ((One insurance-)) An 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 or qualified domestic partner as stated in WAC 182-12-128. ((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)) Children eligible for ((coverage)) medical and dental 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))) (4) An employee employed in ((an insurance-)) a benefits 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)) PEBB benefits under the employer that:

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

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

[Statutory Authority: RCW 41.05.160 and 41.05.165. 04-18-039, § 182-12-123, filed 8/26/04, effective 1/1/05.]

     (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)) long-term disability.

     (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.)) An employee may waive medical or dental, or both, for any or all eligible dependents.

     (4) ((If the dental portion of the health plan coverage is waived, an otherwise eligible dependent may not enroll in PEBB dental coverage except)) Once health plan enrollment is waived, enrollment is only allowed 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:)) After losing other health insurance. The employee must provide evidence:

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

     (ii) ((The period between loss of the other dental and application for PEBB dental coverage is sixty days or less.)) Enrollment was continuous from the most recent PEBB open enrollment period; and

     (iii) The date when coverage was lost.

     Application to enroll in a PEBB health plan must be made no later than sixty days after the date the other health insurance was lost;

     (((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)) (c) After acquiring a new dependent. Application for enrollment must be made no later than sixty days after acquiring the new dependent through marriage, establishment of a qualified domestic partnership, birth, adoption or placement for adoption ((of a child)).

[Statutory Authority: RCW 41.05.160 and 41.05.165. 04-18-039, § 182-12-128, filed 8/26/04, effective 1/1/05.]

[Statutory Authority: RCW 41.05.160 and 41.05.165. 04-18-039, § 182-12-131, filed 8/26/04, effective 1/1/05.]

     (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 duty in the uniformed services as defined under the Uniformed Services Employment and Reemployment Rights Act (USERRA); ((however, self-payment of life insurance is limited to twelve months from the date the employee is called to active duty;)) or

     (f) The employee is on approved educational leave.

     (2) Part-time faculty and part-time academic employees may self-pay premium at the group rate between periods of eligibility for a maximum of eighteen months. ((Part-time faculty)) These employees 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)) twenty-nine 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.

     (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.

[Statutory Authority: RCW 41.05.160. 06-11-156 (Order 06-02), § 182-12-133, filed 5/24/06, effective 6/24/06. Statutory Authority: RCW 41.05.160 and 41.05.165. 04-18-039, § 182-12-133, filed 8/26/04, effective 1/1/05.]

[Statutory Authority: RCW 41.05.160 and 41.05.165. 04-18-039, § 182-12-136, filed 8/26/04, effective 1/1/05.]

[Statutory Authority: RCW 41.05.160 and 41.05.165. 04-18-039, § 182-12-138, filed 8/26/04, effective 1/1/05.]

[Statutory Authority: RCW 41.05.160 and 41.05.165. 04-18-039, § 182-12-141, filed 8/26/04, effective 1/1/05.]

[Statutory Authority: RCW 41.05.160 and 41.05.165. 04-18-039, § 182-12-146, filed 8/26/04, effective 1/1/05.]

     (a) For an appeal filed on or before June 30, 2005, the personnel appeals board 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 dismissal is upheld, all insurance coverage ((shall terminate)) will end at the end of the month in which the decision is entered, or the date to which premiums have been paid, whichever is earlier.

     (3)(a) If the 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 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, 41.05.350, and 41.05.165. 05-16-046 (Order 05-01), § 182-12-148, filed 7/27/05, effective 8/27/05. 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)) The employee must submit an election form to enroll or defer insurance coverage within sixty days after their employer paid or COBRA coverage ends. Employees who cancel PEBB health plan coverage or do not enroll in a PEBB health plan at retirement are only eligible to enroll if they have deferred enrollment and maintained comprehensive coverage as defined in WAC 182-12-200 or 182-12-205.

     (b) The ((retiring employee must submit an election form to enroll or defer health plan coverage within sixty days after 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) Public safety employees' retirement system;

     (iv) School employees' retirement system Plan 2;

     (v) State judges/judicial retirement system;

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

     (vii) Washington state patrol retirement system.

     (viii) 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), 41.37.200(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)) employee and enrolled dependents who are entitled to Medicare must enroll and maintain enrollment in both Medicare parts A and B if the employee retired after July 1, 1991. If the employee or an enrolled dependent becomes entitled to Medicare after enrollment in PEBB retiree insurance, they must enroll and maintain enrollment in Medicare.

     (2) Eligibility requirements. 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 submit an election form no later than sixty days after the date their PEBB employee life insurance terminates, providing their employee life insurance premium is not being waived by the life insurance carrier at the time they elect retiree life insurance)) (as defined in WAC 182-12-115) who end public employment after becoming vested in a Washington state-sponsored retirement plan (as defined in subsection (4) of this section) are eligible to continue PEBB insurance coverage as a retiree if they meet procedural and eligibility requirements. To be eligible to continue PEBB insurance coverage as a retiree the employee must be eligible to retire under a Washington state-sponsored retirement plan when their employer paid or COBRA coverage ends.

     Employees who do not meet their Washington state-sponsored retirement plan's age requirements when their employer paid or COBRA coverage ends, but who meet the age requirement within sixty days of coverage ending, may request that their eligibility be reviewed by the health care authority's appeals committee to determine eligibility (see WAC 182-16-030). Employees must meet other retiree insurance election procedural requirements.

     • Employees must immediately begin to receive a monthly retirement plan payment, with exceptions described below.

     • Employees who receive a lump-sum payment instead of a monthly retirement plan payment are only eligible if this is required by department of retirement systems because their monthly retirement plan payment is below the minimum payment that can be paid.

     • Employees who are members of a Plan 3 retirement, also called separated employees (defined in RCW 41.05.011(13)), are eligible if they meet their retirement plan's age requirement and length of service when PEBB employee insurance coverage ends. They do not have to receive a retirement plan payment.

     • Employees who are members of a Washington higher education retirement plan are eligible if they immediately begin to receive a monthly retirement plan payment, or meet their plan's age requirement, or are at least age fifty-five with ten years of state service.

     • Employees who are permanently and totally disabled are eligible if they start receiving or defer a monthly disability retirement plan payment.

     • Employees not retiring under the public employees' retirement system must meet the same age and years of service had the person been employed as a member of either public employees retirement system Plan 1 or Plan 2 for the same period of employment.

     • Employees who retire from a local government that participates in PEBB insurance coverage for their employees are eligible to continue PEBB insurance coverage as a retiree.

     (a) Local government employees. If the local government ends participation in PEBB insurance coverage, employees who enrolled after September 15, 1991, are no longer eligible for PEBB retiree insurance. These employees may continue PEBB health plan enrollment under COBRA (see WAC 182-12-146).

     (b) Washington state K-12 school district and educational service district employees for districts that do not participate in PEBB benefits. Employees of Washington state K-12 school districts and educational service districts who separate from employment after becoming vested in a Washington state-sponsored retirement system are eligible to enroll in PEBB health plans when retired or permanently and totally disabled.

     Except for employees who are members of a retirement Plan 3, employees who separate on or after October 1, 1993, must immediately begin to receive a monthly retirement plan payment from a Washington state-sponsored retirement system. Employees who receive a lump-sum payment instead of a monthly retirement plan payment are only eligible if department of retirement systems requires this because their monthly retirement plan payment is below the minimum payment that can be paid or they enrolled before 1995.

     Employees who are members of a Plan 3 retirement, also called separated employees (defined in RCW 41.05.011(13)), are eligible if they meet their retirement plan's age requirement and length of service when employer paid or COBRA coverage ends.

     Employees who separate from employment due to total and permanent disability who are eligible for a deferred retirement allowance under a Washington state-sponsored retirement system (as defined in chapter 41.32, 41.35 or 41.40 RCW) are eligible if they enrolled before 1995 or within sixty days following retirement.

     Employees who retired as of September 30, 1993, and began receiving a retirement allowance from a state-sponsored retirement system (as defined in chapter 41.32, 41.35 or 41.40 RCW) are eligible if they enrolled in a PEBB health plan not later than the HCA's open enrollment period for the year beginning January 1, 1995.

     (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.)) Elected state officials. Employees who are elected state officials (as defined under WAC 182-12-115(6)) who voluntarily or involuntarily leave public office are eligible to continue PEBB insurance coverage as a retiree if they meet procedural and eligibility requirements. They do not have to receive a retirement plan payment from a state-sponsored retirement system.

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

     • Higher education retirement plans;

     • Law enforcement officers' and fire fighters' retirement system;

     • Public employees' retirement system;

     • Public safety employees' retirement system;

     • School employees' retirement system;

     • State judges/judicial retirement system;

     • Teacher's retirement system; and

     • State patrol retirement system.

     (((5))) The two federal retirement systems, Civil Service Retirement System and Federal Employees' Retirement System, ((shall be)) are considered a Washington state-sponsored retirement system for Washington State University Extension employees ((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 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 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. 06-11-156 (Order 06-02), § 182-12-171, filed 5/24/06, effective 6/24/06. Statutory Authority: RCW 41.05.160, 41.05.350, and 41.05.165. 05-16-046 (Order 05-01), § 182-12-171, filed 7/27/05, effective 8/27/05. 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)) at least three years ((prior to)) before 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 benefits services 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.

[Statutory Authority: RCW 41.05.160, 41.05.350, and 41.05.165. 05-16-046 (Order 05-01), § 182-12-175, filed 7/27/05, effective 8/27/05.]