1. Rules, Appeals, Students, and Layoffs
Health Care Authority
PEBB Outreach and Training
PPMS Meeting – 2/27/2009

2. Agenda Overview of New Rules Appeals Process Student Certification
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 Appeals process
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
Appeals process
New and amended rules clarify and formalize a process that is already in place
WAC through

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
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 and FMLA Act

5. Overview of New Rules Special open enrollment Student certification
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 , , ,
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

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

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

8. 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

9. 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

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 )
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
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 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

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 )
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

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 )
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
Employee’s new dependent, age 20 through 23, attending high school or registered as a student (see WAC )
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

24. Dependent Not Currently Enrolled
Dependent age 20 through 23 becomes eligible as a student because they go back to school (see WAC )
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 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 Insurance
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.

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 employer’s procedures, rules, and collective bargaining agreements
(WAC and )
Layoff/RIF employees transferring to an agency where layoff procedures are not applicable must qualify as a newly eligible employee (WAC )

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 Employment Ending
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

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 1-800-200-1004 The PEBB Program customer service:
PEBB website:

38. Questions