Rules, Appeals, Students, and Layoffs

1
Rules, Appeals, Students, and Layoffs

• Health Care Authority
• PEBB Outreach and Training
• PPMS Meeting 2/27/2009

2
Agenda

• Overview of New Rules
• Adult Dependents Appeals Process Dependents
  with Disabilities FMLA Special Open
  Enrollment Student Certification Tribal
  Government Participation
• Appeals Process
• Student Certification
• Overview of Layoffs
• Questions

3
Overview of New Rules

• Adult dependents
• A qualified dependent, age 20 through 24,
  unmarried
• Self-pay rates apply, subscriber responsible for
  the full cost of coverage
• Dependent must enroll in the same medical and
  dental plans as the subscriber unless dependent
  lives outside plan area
• WAC 182-12-260
• Appeals process
• New and amended rules clarify and formalize a
  process that is already in place
• WAC 182-16-030 through 182-16-050

4
Overview of New Rules

• Dependents with disabilities clarification
• Subscriber must provide evidence that the
  condition occurred
• Before the child reached the age of 20 or,
• That dependent would have met student eligibility
  rules when condition occurred
• WAC 182-12-260
• FMLA amendment
• Employees who are a spouse, son, daughter,
  parent, or next-of-kin may take up to 26 weeks
  of leave to care for a member of the armed forces
  undergoing treatment as an outpatient, or on the
  temporary disability retired list for serious
  injury or illness
• WAC 182-12-138 and FMLA Act

5
Overview of New Rules

• Special open enrollment
• Subscribers may make changes to the medical and
  dental coverage outside of annual open enrollment
  if they have a qualifying event that triggers a
  special open enrollment
• Appropriate forms must be submitted to the
  personnel, payroll, or benefits office within 60
  days of the event
• WAC 182-08-198, 182-12-128, 182-12-205,
  182-12-262
• Student certification
• Clarifies continuous coverage to dependents
  turning 20 whose birthday falls during an
  off-quarter
• Also clarifies when a student is eligible for
  off-season coverage
• WAC 182-12-260

6
Overview of New Rules

• Tribal government participation
• Tribal governments may now participate in PEBB
  coverage
• Follow same enrollment and eligibility rules as
  all subscribers
• WAC 182-12-111

7
Appeals Process

• When is it an Appeal?
• The Appeal Process
• New Forms
• Plan Appeals
• Account Adjustments

8
When is it an Appeal?

• Its an appeal if there is a disagreement between
  the employer and the employee about enrollment or
  eligibility
• If there is no disagreement, it is not an appeal
  and the change should be handled internally
• Corrections may be made in PAY1 as far back as 90
  days (lower limit date)
• Corrections beyond 90 days should be sent to PEBB
  via FUZE for keying
• Please dont make a partial correction leaving
  the remainder for us that doesnt work well in
  the system

9
The Appeals Process

• An employee disagrees with an employers decision
  about eligibility or enrollment
• The employee submits a request for review to the
  employer, in writing, within 30 days of the
  denial
• When the employer receives the request for
  review, the agency
• Has at least one or more staff, not involved in
  the initial decision, make a review of the
  request
• The employer completes an Employer Decision
  Notice within 30 days of receiving the request

10
The Appeals Process

• A copy of the Employer Decision Notice is sent
  to
• Your agency administrator or designee
• The employee
• The PEBB appeals manager (attached to a FUZE
  email)
• Your agency administrator or designee has 15 days
  to overturn the decision. If the decision is
  overturned, a new copy of the decision is sent
  to
• Your Personnel, Payroll, or HR office
• The employee
• The PEBB appeals manager (attached to a FUZE
  email)
• If the administrator does not overturn the
  decision, no additional action or paperwork is
  required.

11
The Appeals Process

• If the employee does not agree with the final
  agency decision
• The employee may submit a Notice of Appeal to the
  PEBB Appeals Committee within 30 days of the date
  on the Employer Decision Notice
• The PEBB Appeals Committee has 30 days to review
  the appeal and make a decision
• The employee and employer will be notified, in
  writing, of the decision

12
The Appeals Process

• If the employee does not agree with the PEBB
  Appeals Committee decision
• The employee may request an administrative
  hearing, in writing, within 30 days of the
  postmark on the appeals committee decision
• The administrator or designee will render a
  decision within 90 days after the hearing
• A copy of the decision will be sent to the
  employer and employee

13
The Appeals Process
14
The Appeals Process
15
New Forms
Request for Review
Employer Decision Notice
Notice of Appeal
16
Plan Appeals

• If an employee disagrees with the decision of
  one of the insurance plans, the employee may
• Appeal to the plan following the appeal
  procedures in the plans Certificate of Coverage
• If the employee disagrees with the decision
  made by ASIFlex (FSA and DCAP), the employee
  may
• Appeal to ASIFlex following the appeal
  procedures in the ASIFlex Enrollment Guide
• If the employee does not agree with the
  decision of the ASIFlex Administrator, the
  employee may then follow the procedures to
  appeal to the PEBB Appeals Committee

17
Account Adjustments

• Account adjustments are not appeals since there
  is no disagreement between the employee and the
  employer
• Employees do not need to go through the appeals
  process in cases where the employing agency has
  decided there was an agency error
• Employing agencies may only reverse eligibility
  or enrollment decisions based on circumstances
  that arose due to documented delays
• An example of a documented delay would be a
  copy of the enrollment form with a date
  indicating the employee met enrollment deadlines

18
Account Adjustments

• Agencies may key reversals in PAY1 that
  occurred within the last 90 days (lower limit
  date)
• Reversals over 90 days must be submitted to
  PEBB through FUZE for keying
• Please do not key back as far as you can and
  then contact us to key back to the actual
  effective date of the change
• Contact us first and we will make the entire
  effective date change for you

19
Student Certification

• Dependents currently enrolled in PEBB coverage
• Dependents not currently enrolled in PEBB
  coverage
• Missed deadlines
• Off-season coverage
• Coverage ends

20
Dependent Currently Enrolled

• Dependent currently enrolled in PEBB coverage,
  turning 20, and attending high school or
  registered as a student (see WAC 182-12-260)
• Employee must submit a Student Certification
  form within 60 days of the first of the month
  following the dependents birthday
• Form may be submitted directly to PEBB for
  certification

21
Dependent Currently Enrolled

• Dependent currently certified as a student, age
  20 through 23
• Employee required to recertify student annually
• Employee must submit a Student Certification
  form at least 30 days prior to coverage ending
• PEBB will notify employee when recertification
  is necessary

22
Dependent Not Currently Enrolled

• Dependent of newly eligible employee, age 20
  through 23, and attending high school or
  registered as a student (see WAC 182-12-260)
• Employee must submit a Student Certification
  form within 31 days of their initial date of
  eligibility
• Key student in PAY1, send copy of Student
  Certification form to PEBB for certification
• Coverage will begin on the first day of the
  month the dependent becomes eligible as a student

23
Dependent Not Currently Enrolled

• Employees new dependent, age 20 through 23,
  attending high school or registered as a student
  (see WAC 182-12-260)
• Employee must submit an Enrollment/Change form
  and a Student Certification form within 60 days
  of acquiring the new dependent
• Key student in PAY1, send copy of Student
  Certification form to PEBB for certification
• Coverage will begin on the first day of the
  month the dependent becomes the employees
  dependent

24
Dependent Not Currently Enrolled

• Dependent age 20 through 23 becomes eligible as
  a student because they go back to school (see
  WAC 182-12-260)
• Employee must submit a Student Certification
  form within 60 days of the start of the
  quarter/semester for which the dependent
  registers
• An Enrollment/Change form is required if the
  dependent has never been enrolled in PEBB
  coverage
• If dependent has never been enrolled, key the
  dependent in PAY1 and send a copy of the Student
  Certification form to PEBB for certification
• Coverage will begin on the first day of the
  month the quarter/semester begins for which the
  dependent is registered

25
Missed Deadlines

• If an employee misses the deadline to enroll
  their student, the employee must wait for
• Annual open enrollment, or
• Special open enrollment, triggered by a
  qualifying event

26
Off-Season Coverage

• Students are eligible to maintain eligibility
  when not registered for courses through the
  summer or off quarter/semester, as long as, the
  dependent meets all other eligibility
  requirements and
• The dependent attended 3 consecutive quarters
  or two consecutive semesters before the off
  quarter/semester, or
• The dependent is enrolled in PEBB coverage,
  turning age 20 or renewing student certification
  and is expected to register for three
  consecutive quarters or two consecutive semesters
  after the off quarter/semester

27
Coverage Ends

• PEBB coverage ends
• The last month of the quarter/semester in which
  the student is eligible
• If student is eligible for the off-season,
  coverage ends at the end of the off-season
• The last day of the month in which the student
  turns 24
• The 3 month period after graduation (graduation
  successful completion of studies to earn a
  degree or certificate)

28
Layoffs and Terminations

• Benefits
• Medical, Dental, Life, LTD, FSA, DCAP, Auto/Home,
  and Long-Term Care
• Options to continue coverage
• Continued employment
• Self-Pay Coverage
• Retiree Coverage
• What to expect
• Employee Resources

29
PEBB Benefits
Auto/Home and Long-Term Care may continue as
before. If using payroll deduction for Auto/Home
contact Liberty Mutual to make other payment
arrangements.
30
Options to continue coverage

• The employee has options to continue most
  coverage
• The options depend on the situation

31
Overview of Options

• Continued employment through reversion, reduction
  in hours, or transfer
• Access benefits as an eligible dependent on a
  spouse, qualified domestic partner, or parents
  account
• Continue coverage on a self-pay basis
• Access benefits through retiree coverage

32
Option Continued Employment

• Layoff/RIF employees are eligible for the
  employer contribution as long as they are in pay
  status for eight hours or more per month.
  Employees may
• Revert to a previously held position
• Revert to a different position
• Have current position hours reduced, or
• Transfer to another agency as outlined in their
  employers procedures, rules, and collective
  bargaining agreements
• (WAC 182-08-190 and 182-12-121)
• Layoff/RIF employees transferring to an agency
  where layoff procedures are not applicable must
  qualify as a newly eligible employee (WAC
  182-12-115)

33
Option Dependent Coverage

• Spouse, qualified domestic partner, or parent
  must complete an Employee Enrollment/Change form
  and any necessary dependent certifications to add
  an eligible dependent
• If employment is ending, life insurance coverage
  may be transferred to spouse or qualified
  domestic partner, up to plan maximums, within 31
  days
• If Layoff/RIF, may continue life insurance on a
  self-pay basis

34
Option Self-Pay

• Layoff/RIF
• Eligible for PEBB Leave Without Pay coverage
• Continue medical, dental, and life insurance
  coverage for up to 29 months
• Employment Ending
• Eligible for COBRA
• Continue medical and dental coverage for up to 18
  months
• For qualified domestic partners and children of
  qualified domestic partners not eligible for
  COBRA
• PEBB Extension of Coverage
• Continue medical and dental coverage for up to 18
  months

35
Option Retiree Coverage

• Must be eligible to retire (as per retirement
  plan)
• May use continuation of coverage to bridge to
  retirement
• Continue medical and dental coverage
• May have option to enroll in retiree life
  insurance coverage

36
What to expect

• A Continuation of Coverage Packet in the mail
• The employee has 60 days from the
• postmark date to enroll in coverage
• The employee may enroll eligible
• dependents
• Self-pay rates apply

37
Employee Resources

• The PEBB Program customer service
• 1-800-200-1004
• PEBB website
• www.pebb.hca.wa.gov

38
Questions