Rules, Appeals, Students, and Layoffs

Health Care AuthorityPEBB Outreach and TrainingPPMS Meeting – 2/27/2009

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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

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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

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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

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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

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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

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Appeals Process

• When is it an Appeal?

• The Appeal Process

• New Forms

• Plan Appeals

• Account Adjustments

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When is it an Appeal?

• It’s 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 don’t make a partial correction leaving the remainder for us – that doesn’t work well in the system

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The Appeals Process

• An employee disagrees with an employer’s 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

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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.

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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

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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

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Employerdenies enrollment/

eligibility

The Appeals Process

Employee

Employee files a written

Request for Review within 30 days of

denial (form on the PEBB website)

Employing Agency

Initialdecision

must be reviewedby one or more

staff, not involvedin the initial

decision

Employer completes an Employer Decision Notice within 30 days

of the date of the Request for Review.

A copy is sent to:

PEBB Appeals Manager

Agency Administratoror Designee

EmployeeEmploying Agency

Attached to a FUZE email

Attached to a FUZE email

Agencydesignee has

15 days from thedate on the Employer

Decision Notice tooverturn the decision.

If overturned, send new decision

to:

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The Appeals Process

Employee has 30 days from the date on the Employer Decision

Notice to submit a Notice of Appeal to the PEBB Appeals

Committee (form on PEBB website)

PEBB Appeals Committee

PEBB Appeals Committee will

review the appeal within 30 days. A

written response will be sent to the

employee.

Employee

Employee has 30 days from the postmark on

the decision to request, in writing, an

Administrative Hearing

The PEBBadministrator

or designee will render a decision within 90 days

of the hearing.

A copy of the decision will be

sent to the employee and the

employer.

Employee

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New Forms

Request for Review

Employer Decision Notice

Notice of Appeal

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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

plan’s 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

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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

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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

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Student Certification

• Dependents currently enrolled in PEBB coverage

• Dependents not currently enrolled in PEBB coverage

• Missed deadlines

• Off-season coverage

• Coverage ends

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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

dependent’s birthday– Form may be submitted directly to PEBB for certification

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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

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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

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Dependent Not Currently Enrolled

• Employee’s 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 employee’s dependent

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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

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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

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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

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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)

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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

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PEBB Benefits

PEBB Benefits When they will end if you take no action

Medical and Dental Insurance

Midnight, the last day of the month in which employment ends

Life InsuranceMidnight, the last day of the month in which employment ends

Basic Long-Term Disability

Midnight, the date employment ends

Optional Long-Term Disability

Midnight, the last day of the month in which employment ends or the last day in which a required premium payment was made

Flexible Spending Account (FSA) & Dependent Care Assistance Program (DCAP)

Participation ends on the last day of the month you make a contribution through payroll deduction

*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.

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Options to continue coverage

• The employee has options to continue most coverage

• The options depend on the situation

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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

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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 employer’s

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)

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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

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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

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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

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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

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Employee Resources

• The PEBB Program customer service:

1-800-200-1004

• PEBB website:

www.pebb.hca.wa.gov

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Questions