Washington Administrative Code › Title 182 - Health Care Authority › SCHOOL EMPLOYEES BENEFITS BOARD (SEBB) PROGRAM › Chapter 182-32 - Appeals practices and procedures › Part I - GENERAL PROVISIONS › Section 182-32-020 - Definitions

Current through Register Vol. 24-14, July 15, 2024
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.
"Brief adjudicative proceeding" means the process described
					 in
					 RCW
					 34.05.482 through
					 34.05.494
					 and in WAC
					 182-32-2000
					 through
					 182-32-2160.
"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;
* Fax: 360-763-4709; or
* 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.