Current through Register Vol. 24-18, September 15, 2024
School employees benefits board (SEBB) insurance coverage
premiums and applicable premium surcharges for all subscribers are due as
described in this section, except when a SEBB organization is correcting its
enrollment error as described in WAC
182-30-060(4)
or (5).
(1)
Premium payments. SEBB
insurance coverage premiums and applicable premium surcharges for all
subscribers become due the first of the month in which SEBB insurance coverage
is effective.
Premiums and applicable premium surcharges are due from the
subscriber for the entire month of SEBB insurance coverage and will not be
prorated during any month.
(a) For
subscribers not eligible for the employer contribution that are electing to
enroll in continuation coverage as described in WAC
182-31-090,
182-31-100,
182-31-120,
or
182-31-130,
the first premium payment and applicable premium surcharges are due to the
health care authority (HCA) or the contracted vendor no later than 45 days
after the election period ends as described within the Washington
Administrative Code applicable to the subscriber. Premiums and applicable
premium surcharges associated with continuing SEBB medical must be made to the
HCA as well as premiums associated with continuing SEBB dental or vision
insurance coverage. Premiums associated with life insurance coverage and
accidental death and dismemberment (AD&D) coverage must be made to the
contracted vendor. Following the first premium payment, premiums and applicable
premium surcharges must be paid as premiums become due.
(b) For school employees who are eligible for
the employer contribution, premiums and applicable premium surcharges are due
to the SEBB organization or contracted vendor. If a school employee elects
supplemental coverage or employee-paid long-term disability (LTD) insurance, or
is enrolled in employee-paid LTD insurance, as described in WAC
182-30-080(1)(a)
or (3)(a) or is enrolled in employee-paid LTD
insurance as described in WAC
182-30-080(1)(b)
the school employee is responsible for payment of premiums from the month the
supplemental coverage or employee-paid LTD insurance begins.
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Exception:
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A school employee who is on a leave of absence and
maintains eligibility for the employer contribution, will have their premiums
waived for their employee-paid LTD insurance for the first 90 days. For this
purpose, "leave of absence" is defined as a paid or unpaid temporary or
indefinite administrative leave, involuntary leave, sick leave, or insurance
continued under the federal Family and Medical Leave Act, or paid family and
medical leave program as described in WAC
182-31-110.
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(c)
Unpaid or underpaid premiums or applicable premium surcharges for all
subscribers must be paid, and are due from the SEBB organization, subscriber,
or a subscriber's legal representative to the HCA or the contracted vendor. For
subscribers not eligible for the employer contribution, monthly premiums or
applicable premium surcharges that remain unpaid for 30 days will be considered
delinquent. A subscriber is allowed a grace period of 30 days from the date the
monthly premiums or applicable premium surcharges become delinquent to pay the
unpaid premium balance or applicable premium surcharges. If a subscriber, who
is not eligible for the employer contribution, has monthly premiums or
applicable premium surcharges remain unpaid for 60 days from the original due
date, the subscriber's SEBB insurance coverage will be terminated retroactive
to the last day of the month for which the monthly premiums and any applicable
premium surcharges were paid. If it is determined by the HCA that payment of
the unpaid balance in a lump sum would be considered a hardship, the HCA may
develop a reasonable payment plan up to 12 months in duration with the
subscriber or the subscriber's legal representative upon request.
(d) Monthly premiums or applicable premium
surcharges due from a subscriber who is not eligible for the employer
contribution will be considered unpaid if one of the following occurs:
(i) No payment of premiums or applicable
premium surcharges are received by the HCA or the contracted vendor and the
monthly premiums or applicable premium surcharges remain unpaid for 30 days;
or
(ii) Premium payments or
applicable premium surcharges received by the HCA or the contracted vendor are
underpaid by an amount greater than an insignificant shortfall and the monthly
premiums or applicable premium surcharges remain underpaid for 30 days past the
date the monthly premiums or applicable premium surcharges were due.
(2)
Premium
refunds. SEBB insurance coverage premiums and applicable premium
surcharges will be refunded using the following methods:
(a) When a subscriber submits an enrollment
change affecting subscriber or dependent eligibility, HCA may allow up to three
months of accounting adjustments. HCA will refund to the individual or the SEBB
organization any excess premiums and applicable premium surcharges paid during
the 60 day adjustment period, except as indicated in WAC
182-31-120.
(b) If a SEBB subscriber, dependent, or
beneficiary submits a written appeal as described in WAC
182-32-2010,
and provides clear and convincing evidence of extraordinary circumstances, such
that the subscriber could not timely submit the necessary information to
accomplish an allowable enrollment change within 60 days after the event that
created a change of premiums, the SEBB director, the SEBB director's designee,
or the SEBB appeals unit may:
(i) Approve a
refund of premiums and applicable premium surcharges that does not exceed 12
months of premiums; and
(ii)
Approve the enrollment change that was originally requested and which forms the
basis for the refund.
(c) If a federal government entity determines
that an enrollee is retroactively enrolled in coverage (for example, medicare)
the subscriber or beneficiary may be eligible for a refund of premiums and
applicable premium surcharges paid during the time they were enrolled under the
federal program if approved by the SEBB director or the SEBB director's
designee.
(d) HCA errors will be
corrected by returning all excess premiums and applicable premium surcharges
paid by the SEBB organization, subscriber, or beneficiary.
(e) SEBB organization errors will be
corrected by returning all excess premiums and applicable premium surcharges
paid by the school employee or beneficiary as described in WAC
182-30-060(4)
and (5).
