Washington Administrative Code › Title 182 - Health Care Authority › PUBLIC EMPLOYEES BENEFITS BOARD (PEBB) PROGRAM › Chapter 182-16 - Appeals practice and procedure › Part I - GENERAL PROVISIONS › Section 182-16-020 - 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 employing agency, as well as supplemental accidental death and
					 dismemberment insurance offered to and paid for by employees for themselves and
					 their dependents.
"Appellant" means a person who requests a brief
					 adjudicative proceeding with the PEBB appeals unit about the action of the
					 employing agency, the HCA, or its contracted vendor.
"Authority" or "HCA" means the Washington state health care
					 authority.
"Board" means the public employees benefits board
					 established under provisions of
					 RCW
					 41.05.055.
"Brief adjudicative proceeding" means the process described
					 in
					 RCW
					 34.05.482 through
					 34.05.494
					 and in WAC
					 182-16-2000
					 through
					 182-16-2160.
"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 PEBB 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 PEBB benefits.
"Denial" or "denial notice" means an action by, or
					 communication from, an employing agency, contracted vendor, or the PEBB program
					 that aggrieves a subscriber, a dependent, or an applicant, with regard to PEBB
					 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
					 182-12-260,
					 except that "surviving spouses, state registered domestic partners, and
					 dependent children" of emergency service personnel who are killed in the line
					 of duty is defined in WAC
					 182-12-250.
"Dependent care assistance program" or "DCAP" means a
					 benefit plan whereby state 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" means 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.
"Employee" for the public employees benefits board program
					 includes all employees of the state, whether or not covered by civil service;
					 elected and appointed officials of the executive branch of government,
					 including full-time members of boards, commissions, or committees; justices of
					 the supreme court and judges of the court of appeals and the superior courts;
					 and members of the state legislature. Pursuant to contractual agreement with
					 the authority, "employee" may also include:
(a) Employees of a county, municipality, or
				  other political subdivision of the state and members of the legislative
				  authority of any county, city, or town who are elected to office after February
				  20, 1970, if the legislative authority of the county, municipality, or other
				  political subdivision of the state submits application materials to the
				  authority to provide any of its insurance programs by contract with the
				  authority, as provided in
				  RCW
				  41.04.205 and
				  41.05.021(1)(g);
(b) employees of employee organizations
				  representing state civil service employees, at the option of each such employee
				  organization;
(c) through December
				  31, 2019, employees of a school district or represented employees of an
				  educational service district if the authority agrees to provide any of the
				  school districts' or educational service districts' insurance programs by
				  contract with the authority as provided in
				  RCW
				  28A.400.350;
(d) employees of a tribal government, if the
				  governing body of the tribal government seeks and receives the approval of the
				  authority to provide any of its insurance programs by contract with the
				  authority, as provided in
				  RCW
				  41.05.021(1)(f) and (g); (e)
				  employees of the Washington health benefit exchange if the governing board of
				  the exchange established in
				  RCW
				  43.71.020 seeks and receives approval of the
				  authority to provide any of its insurance programs by contract with the
				  authority, as provided in
				  RCW
				  41.05.021(1)(g) and (n); (f)
				  through December 31, 2019, employees of a charter school established under
				  chapter 28A.710 RCW; and (g) through December 31, 2023, nonrepresented
				  employees of an educational service district. "Employee" does not include:
				  Adult family home providers; unpaid volunteers; patients of state hospitals;
				  inmates; employees of the Washington state convention and trade center as
				  provided in
				  RCW
				  41.05.110; students of institutions of higher
				  education as determined by their institution; and any others not expressly
				  defined as employees under
				  RCW
				  41.05.011 or by the authority under this
				  chapter.
"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.
"Employer group" means those counties, municipalities,
					 political subdivisions, the Washington health benefit exchange, tribal
					 governments, employee organizations representing state civil service employees,
					 and through December 31, 2019, school districts and charter schools, and
					 through December 31, 2023, educational service districts obtaining employee
					 benefits through a contractual agreement with the authority to participate in
					 benefit plans developed by the public employees benefits board as described in
					 WAC
					 182-08-245.
"Employing agency" for the public employees benefits board
					 program means a division, department, or separate agency of state government,
					 including an institution of higher education; a county, municipality, or other
					 political subdivision; and a tribal government covered by chapter 41.05
					 RCW.
"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.
"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: PEBB 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
					 182-16-3000
					 through
					 182-16-3200.
"HCA hearing representative" means a person who is
					 authorized to represent the PEBB 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 or dental, or
					 both, 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.
"Institutions of higher education" means the state public
					 research universities, the public regional universities, The Evergreen State
					 College, the community and technical colleges, and the state board for
					 community and technical colleges.
"Life insurance" means basic life insurance paid for by the
					 employing agency, as well as supplemental life insurance or supplemental
					 dependent life insurance offered to and paid for by employees for themselves
					 and their dependents. Life insurance for eligible retirees includes retiree
					 term life insurance offered to and paid for by retirees.
"Limited purpose flexible spending arrangement" or "limited
					 purpose FSA" means a benefit plan whereby eligible state 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 PEBB program.
"Medical flexible spending arrangement" or "medical FSA"
					 means a benefit plan whereby eligible state 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.
"PEBB benefits" means one or more insurance coverages or
					 other employee benefits administered by the PEBB program within the health care
					 authority.
"PEBB insurance coverage" means any health plan, life
					 insurance, accidental death and dismemberment insurance, long-term disability
					 (LTD) insurance, long-term care insurance, or property and casualty insurance
					 administered as a PEBB benefit.
"PEBB program" means the program within the HCA that
					 administers insurance and other benefits for eligible employees (as described
					 in WAC
					 182-12-114)
					 , eligible retired employees (as described in WAC
					 182-12-171,
					 182-12-180,
					 and
					 182-12-211)
					 , eligible survivors (as described in WAC
					 182-12-180,
					 182-12-250,
					 and
					 182-12-265)
					 , eligible dependents (as described in WAC
					 182-12-250
					 and
					 182-12-260)
					 , and others as defined in
					 RCW
					 41.05.011.
"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 public
					 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.
"Public employee" has the same meaning as employee.
" Reviewing officer or officers" means one or more
					 delegates from the director that consider appeals relating to the
					 administration of PEBB benefits by the PEBB program.
"Salary reduction plan" means a benefit plan whereby public
					 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.
"Service" or "serve" means the process described in WAC
					 182-16-058.
"State agency" means an office, department, board,
					 commission, institution, or other separate unit or division, however
					 designated, of the state government. It includes the legislature, executive
					 branch, and agencies or courts within the judicial branch, as well as
					 institutions of higher education, and any unit of state government established
					 by law.
"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 employee, retiree, continuation
					 coverage enrollee, or survivor who has been determined eligible by the PEBB
					 program, employer group, or state agency, is enrolled in PEBB benefits, and is
					 the individual to whom the PEBB 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.
"Tribal government" means an Indian tribal government as
					 defined in Section 3(32) of the Employee Retirement Income Security Act of 1974
					 (ERISA), as amended, or an agency or instrumentality of the tribal government,
					 that has government offices principally located in this state.
Statutory
					 Authority:
					 RCW
					 41.05.160 and
					 2012 2nd sp.s. c
					 3 . WSR 13-22-019 (Admin. 2013-01), §
											182-16-020, filed 10/28/13,
					 effective 1/1/14. Statutory Authority:
					 RCW
					 41.05.160. WSR 12-20-022 (Order 2012-01),
					 §
											182-16-020, filed 9/25/12,
					 effective 11/1/12. Statutory Authority:
					 RCW
					 41.05.160 and
					 2011 c
					 8 . WSR 11-22-036 (Order 11-02), §
											182-16-020, filed 10/26/11,
					 effective 1/1/12. Statutory Authority:
					 RCW
					 41.05.160. WSR 09-23-102 (Order 09-02),
					 §
											182-16-020, filed 11/17/09,
					 effective 1/1/10; WSR 08-20-128 (Order 08-03), §
											182-16-020, filed 10/1/08,
					 effective 1/1/09; WSR 07-20-129 (Order 07-01), §
											182-16-020, filed 10/3/07,
					 effective 11/3/07. Statutory Authority: RCW 41.05.010 and
					 34.05.250. WSR 91-14-025, §
											182-16-020, filed 6/25/91,
					 effective 7/26/91. WSR 13-21-033, §
											182-16-020, filed 10/9/2013,
					 effective 11/9/2013