Current through Register Vol. 24-18, September 15, 2024
(1)
During the annual
open enrollment: A subscriber may change health plans during the school
employees benefits board (SEBB) annual open enrollment period. The subscriber
must submit the required enrollment forms to change their health plan. A school
employee submits the enrollment forms to their SEBB organization. Any other
subscriber submits the enrollment forms to the SEBB program. The required
enrollment forms must be received no later than the last day of the annual open
enrollment. Enrollment in the new health plan will begin January 1st of the
following year.
(2)
During a
special open enrollment: A subscriber may revoke their health plan
election and make a new election outside of the annual open enrollment if a
special open enrollment event occurs. A special open enrollment event must be
an event other than a school employee gaining initial eligibility for SEBB
benefits as described in WAC
182-31-040 or regaining
eligibility for SEBB benefits as described in WAC
182-30-080. The change in
enrollment must be allowable under Internal Revenue Code (IRC) and Treasury
regulations, and correspond to and be consistent with the event that creates
the special open enrollment for the subscriber, the subscriber's dependent, or
both.
A subscriber may not change their health plan during a
special open enrollment if their state registered domestic partner or state
registered domestic partner's child is not a tax dependent. A subscriber may
change their health plan as described in subsection (1) of this section.
To make a health plan change, a subscriber must submit the
required enrollment forms. The forms must be received no later than 60 days
after the event occurs. A school employee submits the enrollment forms to their
SEBB organization. Any other subscriber submits the enrollment forms to the
SEBB program. In addition to the required forms, a subscriber must provide
evidence of the event that created the special open enrollment. New health plan
coverage will begin the first day of the month following the later of the event
date or the date the form is received. If that day is the first of the month,
the change in enrollment begins on that day. If the special open enrollment is
due to the birth, adoption, or assumption of legal obligation for total or
partial support in anticipation of adoption of a child, health plan coverage
will begin the month in which the birth, adoption, or assumption of legal
obligation for total or partial support in anticipation of adoption occurs. If
the special open enrollment is due to the enrollment of an extended dependent
or a dependent with a disability, the change in health plan coverage will begin
the first day of the month following the later of the event date or the
eligibility certification. Any one of the following events may create a special
open enrollment:
(a) Subscriber
acquires a new dependent due to:
(i) Marriage
or registering a state registered domestic partnership;
(ii) Birth, adoption, or when the subscriber
has assumed a legal obligation for total or partial support in anticipation of
adoption; or
(iii) A child becoming
eligible as an extended dependent through legal custody or legal
guardianship.
(b)
Subscriber or a subscriber's dependent loses other coverage under a group
health plan or through health insurance coverage, as defined by the Health
Insurance Portability and Accountability Act (HIPAA);
(c) Subscriber has a change in employment
status that affects the subscriber's eligibility for the employer contribution
toward their employer-based group health plan;
(d) Subscriber has a change in employment
location that affects medical plan availability. If the subscriber changes
employment locations and the subscriber's current medical plan is no longer
available, the subscriber must select a new medical plan as described in WAC
182-30-085(3).
If the subscriber has one or more new medical plans available, the subscriber
may select to enroll in a newly available plan.
(e) The subscriber's dependent has a change
in their own employment status that affects their eligibility or their
dependent's eligibility for the employer contribution under their
employer-based group health plan;
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Note:
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As used in (e) of this subsection "employer
contribution" means contributions made by the dependent's current or former
employer toward health coverage as described in Treasury Regulation
26 C.F.R.
54.9801-6.
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(f)
Subscriber or a subscriber's dependent has a change in residence that affects
health plan availability.
(i) If the
subscriber has a change in residence and the subscriber's current medical plan
is no longer available, the subscriber must select a new medical plan, as
described in WAC
182-30-085(3).
(ii) If the subscriber or the subscriber's
dependent has a change in residence and the subscriber's current dental plan
does not have available providers within 50 miles of the subscriber or the
subscriber's dependent's new residence, the subscriber may select a new dental
plan.
(g) A court order
requires the subscriber or any other individual to provide insurance coverage
for an eligible dependent of the subscriber (a former spouse or former state
registered domestic partner is not an eligible dependent);
(h) Subscriber or a subscriber's dependent
enrolls in coverage under medicaid or a state children's health insurance
program (CHIP), or the subscriber or a subscriber's dependent loses eligibility
for coverage under medicaid or CHIP;
(i) Subscriber or a subscriber's dependent
becomes eligible for state premium assistance subsidy for SEBB health plan
coverage from medicaid or CHIP;
(j)
Subscriber or a subscriber's dependent enrolls in coverage under medicare, or
the subscriber or a subscriber's dependent loses eligibility for coverage under
medicare. If the subscriber's current medical plan becomes unavailable due to
the subscriber's or a subscriber's dependent's enrollment in medicare, the
subscriber must select a new medical plan as described in WAC
182-30-085(2);
(k) Subscriber or a subscriber's dependent's
current medical plan becomes unavailable because the subscriber or enrolled
dependent is no longer eligible for a health savings account (HSA). The
authority may require evidence that the subscriber or subscriber's dependent is
no longer eligible for an HSA;
(l)
Subscriber or a subscriber's dependent experiences a disruption of care for
active and ongoing treatment that could function as a reduction in benefits for
the subscriber or the subscriber's dependent. The subscriber may not change
their health plan election if the subscriber's or dependent's physician stops
participation with the subscriber's health plan unless the SEBB program
determines that a continuity of care issue exists. The SEBB program will
consider but not limit its consideration to the following:
(i) Active cancer treatment such as
chemotherapy or radiation therapy;
(ii) Treatment following a recent organ
transplant;
(iii) A scheduled
surgery;
(iv) Recent major surgery
still within the postoperative period; or
(v) Treatment for a high-risk
pregnancy.
(m) The SEBB
program determines that there has been a substantial decrease in the providers
available under a SEBB medical plan.
(3) If the school employee is having premiums
taken from payroll on a pretax basis, a medical plan change will not be
approved if it would conflict with provisions of the salary reduction plan
authorized under
RCW
41.05.300.
