Current through Register Vol. 24-18, September 15, 2024
This section applies to employer groups as defined in WAC
182-30-020. An employer group may
apply to obtain school employees benefits board (SEBB) insurance coverage
through a contract with the health care authority (HCA).
(1) Employer groups with less than 500 school
employees must apply at least 60 days before the requested coverage effective
date. Employer groups with 500 or more school employees but with less than
5,000 school employees must apply at least 90 days before the requested
effective date.
Employer groups with 5,000 or more school employees must
apply at least 120 days before the requested coverage effective date.
To apply, employer groups must submit the documents and
information described in subsection (2) of this section to the SEBB program as
follows:
(a) Tribal schools are
required to provide the documents and information described in subsection
(2)(a) through (f) of this section; and
(b) All employee organizations representing
school employees, regardless of the number of school employees, will have their
application approved or denied through the evaluation criteria described in WAC
182-30-210 and are required to provide the documents and information described
in subsection (2)(a) through (d), (f), and (g) of this section.
(2) Documents and information
required with application:
(a) A letter of
application that includes the information described in (a)(i) through (iv) of
this subsection:
(i) A reference to the
group's authorizing statute;
(ii) A
description of the organizational structure of the group and a description of
the employee bargaining unit or group of nonrepresented employees for which the
group is applying;
(iii) Tax
identification number; and
(iv) A
statement of whether the group is applying to obtain only medical or all
available SEBB insurance coverages.
(b) A resolution from the group's governing
body authorizing the purchase of SEBB insurance coverage.
(c) A signed governmental function
attestation document that attests to the fact that employees for whom the group
is applying are governmental employees whose services are substantially all in
the performance of essential governmental functions.
(d) A member level census file for all of the
school employees for whom the group is applying. The file must be provided in
the format required by the authority and contain the following demographic
data, by member, with each member classified as school employee, spouse or
state registered domestic partner, or child:
(i) Employee ID (any identifier which
uniquely identifies the school employee; for dependents the school employee's
unique identifier must be used);
(ii) Age;
(iii) Birth sex;
(iv) First three digits of the member's zip
code based on residence;
(v)
Indicator of whether the school employee is active or retired, if the group is
requesting to include retirees; and
(vi) Indicator of whether the member is
enrolled in coverage.
(e) Historical claims and cost information
that include the following:
(i) Large claims
history for 24 months by quarter that excludes the most recent three
months;
(ii) Ongoing large claims
management report for the most recent quarter provided in the large claims
history;
(iii) Summary of
historical plan costs; and
(iv) The
director or the director's designee may make an exception to the claims and
cost information requirements based on the size of the group, except that the
current health plan does not have a case management program, then the primary
diagnosis code designated by the authority must be reported for each large
claimant. If the code indicates a condition which is expected to continue into
the next quarter, the claim is counted as an ongoing large claim. If historical
claims and cost information as described in (e)(i) through (iii) of this
subsection are unavailable, the director or the director's designee may make an
exception to allow all of the following alternative requirements:
* A letter from their carrier indicating they will not or
cannot provide claims data.
* Provide information about the health plan most school
employees are enrolled in by completing the actuarial calculator authorized by
the SEBB program.
* Current premiums for the health plan.
(f) If the application is for a
subset of the group's school employees (e.g., bargaining unit), the group must
provide a member level census file of all school employees eligible under their
current health plan who are not included on the member level census file in (d)
of this subsection. This includes retired school employees participating under
the group's current health plan. The file must include the same demographic
data by member.
(g) Employer groups
described in subsection (1)(b) of this section must submit to an actuarial
evaluation of the group provided by an actuary designated by the SEBB program.
The group must pay for the cost of the evaluation. This cost is nonrefundable.
A group that is approved will not have to pay for an additional actuarial
evaluation if it applies to add another bargaining unit within two years of the
evaluation. Employer groups of this size must provide the following:
(i) Large claims history for 24 months, by
quarter that excludes the most recent three months;
(ii) Ongoing large claims management report
for the most recent quarter provided in the large claims history;
(iii) Executive summary of
benefits;
(iv) Summary of benefits
and certificate of coverage; and
(v) Summary of historical plan costs.
|
Exception:
|
If the current health plan does not have a case
management program, then the primary diagnosis code designated by the authority
must be reported for each large claimant. If the code indicates a condition
which is expected to continue into the next quarter, the claim is counted as an
ongoing large claim.
|
(3) The authority may automatically deny a
group application if the group fails to provide the required information and
documents described in this section.
