WAC 182-08-198
When may a subscriber change health
plans? Subscribers may change health plans at the following
times:
(1) During annual open enrollment: Subscribers may
change health plans during the annual open enrollment. The
subscriber must submit the appropriate enrollment forms to
change health plan no later than the end 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: Subscribers may
change health plans outside of the annual open enrollment if a
special open enrollment event occurs. The change in
enrollment must be allowable under Internal Revenue Code (IRC)
and correspond to the event that creates the special open
enrollment for either the subscriber or the subscriber's
dependents or both. To make a health plan change, the
subscriber must submit the appropriate enrollment forms (and a
completed disenrollment form, if required) no later than sixty
days after the event occurs. Employees submit the enrollment
forms to their employing agency. All other subscribers submit
the enrollment forms to the PEBB program. Insurance coverage
in the new health plan will begin the first day of the month
following the later of the event date or the date the form is
received. 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,
insurance 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. 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 domestic partnership with
Washington's secretary of state;
(ii) Birth, adoption or when the subscriber has assumed a
legal obligation for total or partial support in anticipation
of adoption;
(iii) A child becoming eligible as an extended dependent
through legal custody or legal guardianship; or
(iv) A child becoming eligible as a dependent with a
disability;
(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 or a subscriber's dependent has a change
in employment status that affects the subscriber's or the
subscriber's dependent's eligibility for the employer
contribution toward group health coverage;
(d) Subscriber or a subscriber's dependent has a change
in residence that affects health plan availability. If the
subscriber moves and the subscriber's current health plan is
not available in the new location the subscriber must select a
new health plan. If the subscriber does not select a new
health plan, the PEBB program may change the subscriber's
health plan as described in WAC 182-08-196;
(e) Subscriber receives a court order or medical support
order requiring the subscriber, the subscriber's spouse, or
the subscriber's Washington state registered domestic partner
to provide insurance coverage for an eligible dependent (a
former spouse or former registered domestic partner is not an
eligible dependent);
(f) Subscriber or a subscriber's dependent becomes
eligible for state premium assistance through 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;
(g) Subscriber or a subscriber's dependent becomes
entitled to medicare, enrolls in or disenrolls from a medicare
Part D plan. If the subscriber's current health plan becomes
unavailable due to the subscriber's or a subscriber's
dependent's entitlement to medicare, the subscriber must
select a new health plan as described in WAC 182-08-196;
(h) Subscriber or a subscriber's dependent's current
health plan becomes unavailable because the subscriber or
enrolled dependent is no longer eligible for a health savings
account (HSA). HCA may require evidence that the subscriber
or subscriber's dependent is no longer eligible for an HSA;
(i) Subscriber experiences a disruption that could
function as a reduction in benefits for the subscriber or the
subscriber's dependent(s) due to a specific condition or
ongoing course of treatment. A subscriber may not change
their health plan if the subscriber's or an enrolled
dependent's physician stops participation with the
subscriber's health plan unless the PEBB program determines
that a continuity of care issue exists. The PEBB program
criteria used will include, but is not limited to, the
following in determining if a continuity of care issue exists:
(i) Active cancer treatment; or
(ii) Recent transplant (within the last twelve months);
or
(iii) Scheduled surgery within the next sixty days; or
(iv) Major surgery within the previous sixty days; or
(v) Third trimester of pregnancy; or
(vi) Language barrier.
If the employee is having premiums taken from payroll on
a pretax basis, a plan change will not be approved if it would
conflict with provisions of the salary reduction plan
authorized under RCW 41.05.300.
[Statutory Authority: RCW 41.05.160 and 2011 c 8. 11-22-036
(Order 11-02), § 182-08-198, filed 10/26/11, effective 1/1/12.
Statutory Authority: RCW 41.05.160. 10-20-147 (Order
10-02), § 182-08-198, filed 10/6/10, effective 1/1/11;
09-23-102 (Order 09-02), § 182-08-198, filed 11/17/09,
effective 1/1/10; 08-20-128 (Order 08-03), § 182-08-198, filed
10/1/08, effective 1/1/09; 08-09-027 (Order 08-01), §
182-08-198, filed 4/8/08, effective 4/9/08; 07-20-129 (Order
07-01), § 182-08-198, filed 10/3/07, effective 11/3/07. Statutory Authority: RCW 41.05.160 and 41.05.068. 06-23-165
(Order 06-09), § 182-08-198, filed 11/22/06, effective
12/23/06. Statutory Authority: RCW 41.05.160, 41.05.350, and 41.05.165. 05-16-046 (Order 05-01), § 182-08-198, filed
7/27/05, effective 8/27/05.]