The following definitions apply throughout this chapter unless the context clearly indicates another meaning:
"Accidental death and dismemberment insurance" or "AD&D" means basic accidental death and dismemberment (AD&D) insurance paid for by the SEBB organization, as well as supplemental accidental death and dismemberment insurance offered to and paid for by school employees for themselves and their dependents.
"Appellant" means a person who requests a brief adjudicative proceeding with the SEBB appeals unit about the action of the SEBB organization, the HCA, or its contracted vendor.
"Authority" or "HCA" means the Washington state health care authority.
"Board" means the school employees benefits board established under provisions of RCW
41.05.740.
"Business days" means all days except Saturdays, Sundays, and all state legal holidays as set forth in RCW
1.16.050.
"Calendar days" or "days" means all days including Saturdays, Sundays, and all state legal holidays as set forth in RCW
1.16.050.
"Continuance" means a change in the date or time of when a brief adjudicative proceeding or formal administrative hearing will occur.
"Contracted vendor" means any person, persons, or entity under contract or agreement with the HCA to provide goods or services for the provision or administration of SEBB benefits. The term "contracted vendor" includes subcontractors of the HCA and subcontractors of any person, persons, or entity under contract or agreement with the HCA that provide goods or services for the provision or administration of SEBB benefits.
"Denial" or "denial notice" means an action by, or communication from, a school employees benefits board (SEBB) organization, contracted vendor, or the SEBB program that aggrieves a subscriber, a dependent, or an applicant, with regard to SEBB benefits including, but not limited to, actions or communications expressly designated as a "denial," "denial notice," or "cancellation notice."
"Dependent" means a person who meets eligibility requirements in WAC
182-31-140.
"Dependent care assistance program" or "DCAP" means a benefit plan whereby school employees may pay for certain employment related dependent care with pretax dollars as provided in the salary reduction plan under chapter
41.05 RCW pursuant to 26 U.S.C. Sec. 129 or other sections of the Internal Revenue Code.
"Director" means the director of the authority.
"Dispositive motion" is a motion made to a presiding officer, reviewing officer, or hearing officer to decide a claim or case in favor of the moving party without further proceedings.
"Documents" means papers, letters, writings, electronic mail, electronic files, or other printed or written items.
"Employer-based group medical" means group medical related to a current employment relationship. It does not include medical coverage available to retired employees, individual market medical coverage or government-sponsored programs such as medicare or medicaid.
"Enrollee" means a person who meets all eligibility requirements defined in chapter
182-31 WAC or WAC
182-30-130, who is enrolled in SEBB benefits, and for whom applicable premium payments have been made.
"File" or "filing" means the act of delivering documents to the office of the presiding officer, reviewing officer, or hearing officer. A document is considered filed when it is received by the authority or its designee. A document may be filed by one or more of the following:
• Personal delivery to the authority at Cherry Street Plaza, 626 8th Avenue S.E., Olympia, Washington 98501;
• First class, registered, or certified mail to the authority to the following mailing address:
Health Care Authority
Attn: SEBB Appeals Unit
P.O. Box 45504
Olympia, WA 98504-5504;
• Submission online through the designated submission portal.
The identified methods are the exclusive methods for a document to be filed, and submission of documents by any other fashion to the authority shall not constitute filing unless agreed to in advance by the authority.
"Final order" means an order that is the final health care authority decision.
"Formal administrative hearing" means a proceeding before a hearing officer that gives an appellant an opportunity for an evidentiary hearing as described in RCW
34.05.413 through
34.05.476 and WAC
182-32-3000 through
182-32-3200.
"HCA hearing representative" means a person who is authorized to represent the SEBB program in a formal administrative hearing. The person may be an assistant attorney general or authorized HCA employee.
"Health plan" means a plan offering medical, vision, dental, or any combination of these coverages, developed by the board and provided by a contracted vendor or self-insured plans administered by the HCA.
"Hearing officer" means an impartial decision maker who presides at a formal administrative hearing, and is:
• A director-designated HCA employee; or
• When the director has designated the office of administrative hearings (OAH) as a hearing body, an administrative law judge employed by the OAH.
"Life insurance" means any basic life insurance paid for by the SEBB organization, as well as supplemental life insurance or supplemental dependent life insurance offered to and paid for by school employees for themselves and their dependents.
"Limited purpose flexible spending arrangement" or "limited purpose FSA" means a benefit plan whereby eligible school employees may reduce their salary before taxes to pay for dental and vision expenses not reimbursed by insurance as provided in the salary reduction plan established under chapter
41.05 RCW pursuant to 26 U.S.C Sec. 125 or other sections of the Internal Revenue Code.
"Long-term disability insurance" or "LTD insurance" means employer-paid long-term disability insurance and employee-paid long-term disability insurance offered by the SEBB program.
"Medical flexible spending arrangement" or "medical FSA" means a benefit plan whereby eligible school employees may reduce their salary before taxes to pay for medical expenses not reimbursed by insurance as provided in the salary reduction plan established under chapter
41.05 RCW pursuant to 26 U.S.C. Sec. 125 or other sections of the Internal Revenue Code.
"PEBB" means the public employees benefits board.
"Prehearing conference" means a proceeding scheduled and conducted by a hearing officer to address issues in preparation for a formal administrative hearing.
"Premium payment plan" means a benefit plan whereby school employees may pay their share of group health plan premiums with pretax dollars as provided in the salary reduction plan under chapter
41.05 RCW pursuant to 26 U.S.C. Sec. 125 or other sections of the Internal Revenue Code.
"Premium surcharge" means a payment required from a subscriber, in addition to the subscriber's medical premium contribution, due to an enrollee's tobacco use or an enrolled subscriber's spouse or state registered domestic partner choosing not to enroll in their employer-based group medical when:
• The spouse's or state registered domestic partner's share of the medical premiums is less than 95 percent of the additional cost an employee would be required to pay to enroll a spouse or state registered domestic partner in the public employees benefits board (PEBB) Uniform Medical Plan (UMP) Classic; and
• The benefits have an actuarial value of at least 95 percent of the actuarial value of PEBB UMP Classic benefits.
"Presiding officer" means an impartial decision maker who conducts a brief adjudicative proceeding and is a director-designated HCA employee.
"Reviewing officer or officers" means one or more delegates from the director that consider appeals relating to the administration of SEBB benefits by the SEBB program.
"Salary reduction plan" means a benefit plan whereby school employees may agree to a reduction of salary on a pretax basis to participate in the dependent care assistance program, medical flexible spending arrangement, limited purpose flexible spending arrangement, or premium payment plan offered pursuant to 26 U.S.C. Sec. 125 or other sections of the Internal Revenue Code.
"School employee" means:
• All employees of school districts and charter schools established under chapter
28A.710 RCW;
• Represented employees of educational service districts; and
• Effective January 1, 2024, all employees of educational service districts.
"School employees benefits board organization" or "SEBB organization" means a public school district or educational service district or charter school established under chapter
28A.710 RCW that is required to participate in benefit plans provided by the school employees benefit board.
"SEBB" means the school employees benefits board.
"SEBB benefits" means one or more insurance coverages or other employee benefits administered by the SEBB program within the HCA.
"SEBB insurance coverage" means any health plan, life insurance, accidental death and dismemberment insurance, or long-term disability insurance administered as a SEBB benefit.
"SEBB program" means the program within the HCA that administers insurance and other benefits for eligible school employees (as described in WAC
182-31-040 or
182-30-130), and eligible dependents (as described in WAC
182-31-140).
"State registered domestic partner," has the same meaning as defined in RCW
26.60.020(1) and substantially equivalent legal unions from other jurisdictions as defined in RCW
26.60.090.
"Subscriber" means the school employee or continuation coverage enrollee who has been determined eligible by the SEBB program or SEBB organizations, is enrolled in SEBB benefits, and is the individual to whom the SEBB program and contracted vendors will issue all notices, information, requests, and premium bills on behalf of an enrollee.
"Tobacco products" means any product made with or derived from tobacco that is intended for human consumption, including any component, part, or accessory of a tobacco product. This includes, but is not limited to, cigars, cigarettes, pipe tobacco, chewing tobacco, snuff, and other tobacco products. It does not include e-cigarettes or United States Food and Drug Administration (FDA) approved quit aids.
"Tobacco use" means any use of tobacco products within the past two months. Tobacco use, however, does not include the religious or ceremonial use of tobacco.
