Washington Administrative Code › Title 182 - Health Care Authority › PUBLIC EMPLOYEES BENEFITS BOARD (PEBB) PROGRAM › Chapter 182-08 - Procedures › Section 182-08-015 - Definitions

Current through Register Vol. 24-14, July 15, 2024
The following definitions apply throughout this chapter
				  unless the context clearly indicates other 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.
"Affordable Care Act" means the federal Patient Protection
				  and Affordable Care Act,
				  P.L.
				  111-148, as amended by the federal Health Care and
				  Education Reconciliation Act of 2010,
				  P.L.
				  111-152, or federal regulations or guidance issued
				  under the Affordable Care Act.
"Annual open enrollment" means an annual event set aside for
				  a period of time by the HCA when subscribers may make changes to their health
				  plan enrollment and salary reduction elections for the following plan year.
				  During the annual open enrollment, subscribers may transfer from one health
				  plan to another, enroll or remove dependents from coverage, enroll in coverage,
				  or waive enrollment (see definition of "waive" in this section). Employees
				  eligible to participate in the salary reduction plan may enroll in or change
				  their election under the dependent care assistance program (DCAP), the medical
				  flexible spending arrangement (FSA), or limited purpose FSA. They may also
				  enroll in or opt out of the premium payment plan.
"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.
"Calendar days" or "days" means all days including Saturdays,
				  Sundays, and all state legal holidays as set forth in
				  RCW
				  1.16.050.
"Consolidated Omnibus Budget Reconciliation Act" or "COBRA"
				  means continuation coverage as administered under
				  42
				  U.S.C. Secs. 300bb-1 through
				  300bb-8.
"Continuation coverage" means the temporary continuation of
				  PEBB benefits available to enrollees under the Consolidated Omnibus Budget
				  Reconciliation Act (COBRA),
				  42
				  U.S.C. Secs. 300bb-1 through
				  300bb-8, the
				  Uniformed Services Employment and Reemployment Rights Act (USERRA),
				  38 U.S.C. Secs.
				  4301 through
				  4335,
				  or the public employees benefits board's policies.
"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.
"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 insurance coverage by a retiree or an eligible survivor.
"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 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.
"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" for the public employees benefits board program
				  means the state of Washington.
"Employer-based group health plan" means group medical and
				  group dental related to a current employment relationship. It does not include
				  medical or dental coverage available to retired employees, individual market
				  medical or dental coverage, or government-sponsored programs such as medicare
				  or medicaid.
"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 contribution" means the funding amount paid to the
				  HCA by a state agency or employer group for its eligible employees as described
				  under WAC
				  182-12-114
				  and
				  182-12-131.
"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.
"Employer group rate surcharge" means the rate surcharge
				  described in
				  RCW
				  41.05.050(2).
"Employer-paid coverage" means PEBB insurance coverage for
				  which an employer contribution is made by a state agency or an employer group
				  for employees eligible under WAC
				  182-12-114
				  and
				  182-12-131.
				  It also means SEBB insurance coverage for which an employer contribution is
				  made by a SEBB organization, or basic benefits described in
				  RCW
				  28A.400.270(1) for which an
				  employer contribution is made by an educational service district.
"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.
"Exchange" means the Washington health benefit exchange
				  established in
				  RCW
				  43.71.020, and any other health benefit
				  exchange established under the Affordable Care Act.
"Exchange coverage" means coverage offered by a qualified
				  health plan through an exchange.
"Faculty" means an academic employee of an institution of
				  higher education whose workload is not defined by work hours but whose
				  appointment, workload, and duties directly serve the institution's academic
				  mission, as determined under the authority of its enabling statutes, its
				  governing body, and any applicable collective bargaining agreement.
"Forms" or "form" means both paper forms and forms completed
				  electronically.
"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.
"Insignificant shortfall" means a premium balance owed that
				  is less than or equal to the lesser of $50 or 10 percent of the premium
				  required by the health plan as described in Treasury Regulation
				  26 C.F.R.
				  54.4980B-8.
"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.
"Large claim" means a claim for more than $25,000 in allowed
				  costs for services in a quarter.
"Layoff," for purposes of this chapter, means a change in
				  employment status due to an employer's lack of funds or an employer's
				  organizational change.
"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.
"Ongoing large claim" means a claim where the patient is
				  expected to need ongoing case management into the next quarter for which the
				  expected allowed cost is greater than $25,000 in the quarter.
"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.
"Plan year" means the time period established by the
				  authority.
"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 premium 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.
"Public employee" has the same meaning as employee.
"Qualified health plan" means a medical plan that is
				  certified to be offered through an exchange.
"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.
"Special open enrollment" means a period of time when
				  subscribers may make changes to their health plan enrollment and salary
				  reduction elections outside of the annual open enrollment period when specific
				  life events occur. During the special open enrollment subscribers may change
				  health plans and enroll or remove dependents from coverage. Additionally,
				  employees may enroll in or waive enrollment (see definition of "waive" in this
				  section). Employees eligible to participate in the salary reduction plan may
				  enroll in or revoke their election under the DCAP, medical FSA, limited purpose
				  FSA, or the premium payment plan and make a new election. For special open
				  enrollment events related to specific PEBB benefits, see WAC
				  182-08-198,
				  182-08-199,
				  182-12-128,
				  and
				  182-12-262.
"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.
"Supplemental coverage" means any life insurance or
				  accidental death and dismemberment (AD&D) insurance coverage purchased by
				  the employee in addition to the coverage provided by the employing
				  agency.
"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.
"Waive" means an eligible employee affirmatively declining
				  enrollment in PEBB medical because the employee is enrolled in other
				  employer-based group medical, a TRICARE plan, or medicare as allowed under WAC
				  182-12-128.
				  An employee on approved educational leave who obtains another employer-based
				  group health plan may waive enrollment as allowed under WAC
				  182-12-136.
				  An employee may waive enrollment in PEBB medical to enroll in SEBB medical only
				  if they are enrolled in SEBB dental and SEBB vision. An employee who waives
				  enrollment in PEBB medical to enroll in SEBB medical also waives enrollment in
				  PEBB dental.
Statutory
				  Authority:
				  RCW
				  41.05.160 and
				  2012 2nd sp.s. c
				  3 . WSR 13-22-019 (Admin. 2013-01), §
										182-08-015, filed 10/28/13,
				  effective 1/1/14. Statutory Authority:
				  RCW
				  41.05.160. WSR 12-20-022 (Order 2012-01),
				  §
										182-08-015, 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), §
										182-08-015, filed 10/26/11,
				  effective 1/1/12. Statutory Authority:
				  RCW
				  41.05.160. WSR 10-20-147 (Order 10-02),
				  §
										182-08-015, filed 10/6/10,
				  effective 1/1/11; WSR 09-23-102 (Order 09-02), §
										182-08-015, filed 11/17/09,
				  effective 1/1/10; WSR 08-20-128 (Order 08-03), §
										182-08-015, filed 10/1/08,
				  effective 1/1/09; WSR 07-20-129 (Order 07-01), §
										182-08-015, filed 10/3/07,
				  effective 11/3/07. Statutory Authority:
				  RCW
				  41.05.160 and
				  41.05.068. WSR 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. WSR 04-18-039, §
										182-08-015, filed 8/26/04,
				  effective 1/1/05; WSR 03-17-031 (Order 02-07), §
										182-08-015, filed 8/14/03,
				  effective 9/14/03. Statutory Authority:
				  Chapter
				  41.05 RCW. WSR 96-08-042,
				  §
										182-08-015, filed 3/29/96,
				  effective 4/29/96. WSR 13-21-033, §
										182-08-015, filed 10/9/2013,
				  effective 11/9/2013