182-16-2010  <<  182-16-2020 >>   182-16-2030

(Effective until January 1, 2020)

WAC 182-16-2020

How can a current or former employee or an employee's dependent appeal a decision made by a state agency about eligibility, premium surcharge, or enrollment in benefits?

(1) An eligibility, premium surcharge, or enrollment decision made by a state agency may be appealed by submitting a written request for administrative review to the state agency. The state agency must receive the request for administrative review no later than thirty days after the date of the denial notice. The contents of the request for administrative review are to be provided as described in WAC 182-16-2070.
(a) Upon receiving the request for administrative review, the state agency shall perform a complete review of the denial by one or more staff who did not take part in the decision resulting in the denial. As part of the administrative review, the state agency may hold a formal meeting or formal administrative hearing, but is not required to do so.
(b) The state agency shall render a written decision within thirty days of receiving the request for administrative review. The written decision shall be sent to the employee or employee's dependent who submitted the request for administrative review and must include a description of appeal rights. The state agency shall also send a copy of the state agency's written decision to the state agency's administrator (or designee) and to the public employees benefits board (PEBB) appeals unit. If a state agency fails to render a written decision within thirty days of receiving the written request for administrative review, the request for administrative review may be considered denied and the original underlying state agency decision may be appealed to the PEBB appeals unit by following the process in this section.
(c) The state agency may reverse eligibility, premium surcharge, or enrollment decisions based only on circumstances that arose due to delays caused by the state agency or errors made by the state agency.
(2) Any current or former employee or employee's dependent who disagrees with the state agency's decision in response to a written request for administrative review, as described in subsection (1) of this section, may request a brief adjudicative proceeding to be conducted by the authority by submitting a written request to the PEBB appeals unit.
(a) The PEBB appeals unit must receive the request for a brief adjudicative proceeding no later than thirty days after the date of the state agency's written decision on the request for administrative review. The contents of the request for a brief adjudicative proceeding are to be provided as described in WAC 182-16-2070.
(i) The PEBB appeals unit shall notify the appellant in writing when the request for a brief adjudicative proceeding has been received.
(ii) Once the PEBB appeals unit receives a request for a brief adjudicative proceeding, the PEBB appeals unit will send a request for documentation and information to the applicable state agency. The state agency will then have two business days to respond to the request and provide the requested documentation and information. The state agency will also send a copy of the documentation and information to the employee, former employee, or the employee's dependent.
(iii) The brief adjudicative proceeding will be conducted by a presiding officer designated by the director.
(b) If an employee fails to timely request a brief adjudicative proceeding to appeal the state agency's written decision within thirty days by following the process in (a) of this subsection, the state agency's prior written decision becomes the health care authority's final decision.
[Statutory Authority: RCW 41.05.021 and 41.05.160. WSR 18-22-033 (Admin #2018-03), § 182-16-2020, filed 10/29/18, effective 1/1/19.]
(Effective January 1, 2020)

WAC 182-16-2020

Appealing a decision made by a state agency about eligibility, premium surcharges, or enrollment in benefits.

(1) An eligibility, premium surcharges, or enrollment decision made by a state agency may be appealed by submitting a written request for administrative review to the state agency. The state agency must receive the request for administrative review no later than thirty days after the date of the denial notice. The contents of the request for administrative review are to be provided as described in WAC 182-16-2070.
(a) Upon receiving the request for administrative review, the state agency must perform a complete review of the denial by one or more staff who did not take part in the decision resulting in the denial.
(b) The state agency must render a written decision within thirty days of receiving the request for administrative review. The written decision must be sent to the employee or employee's dependent who submitted the request for administrative review and must include a description of appeal rights. The state agency must also send a copy of the state agency's written decision to the state agency's administrator (or designee) and to the public employees benefits board (PEBB) appeals unit. If a state agency fails to render a written decision within thirty days of receiving the written request for administrative review, the request for administrative review may be considered denied as of the thirty-first day and the original underlying state agency decision may be appealed to the PEBB appeals unit by following the process in this section.
(c) The state agency may reverse eligibility, premium surcharges, or enrollment decisions as permitted by WAC 182-08-187.
(2) Any current or former employee or employee's dependent who disagrees with the state agency's decision in response to a written request for administrative review, as described in subsection (1) of this section, may request a brief adjudicative proceeding to be conducted by the authority by submitting a written request to the PEBB appeals unit.
(a) The PEBB appeals unit must receive the request for a brief adjudicative proceeding no later than thirty days after the date of the state agency's written decision on the request for administrative review. The contents of the request for a brief adjudicative proceeding are to be provided as described in WAC 182-16-2070.
(i) The PEBB appeals unit must notify the appellant in writing when the request for a brief adjudicative proceeding has been received.
(ii) Once the PEBB appeals unit receives a request for a brief adjudicative proceeding, the PEBB appeals unit will send a request for documentation and information to the applicable state agency. The state agency will then have two business days to respond to the request and provide the requested documentation and information. The state agency will also send a copy of the documentation and information to the appellant.
(iii) The brief adjudicative proceeding will be conducted by a presiding officer designated by the director.
(b) If an employee fails to timely request a brief adjudicative proceeding to appeal the state agency's written decision within thirty days by following the process in (a) of this subsection, the state agency's prior written decision becomes the health care authority's final decision without further action.
[Statutory Authority: RCW 41.05.021, 41.05.160, and PEBB policy resolutions. WSR 19-17-073 (Admin #2019-01), § 182-16-2020, filed 8/20/19, effective 1/1/20. Statutory Authority: RCW 41.05.021 and 41.05.160. WSR 18-22-033 (Admin #2018-03), § 182-16-2020, filed 10/29/18, effective 1/1/19.]
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