Washington Administrative Code

(1) When the rules in this chapter or in other school employees benefits board (SEBB) program rules or statutes require a party to serve copies of documents on other parties, a party must send copies of the documents to all other parties or their representatives as described in t…

(1) A school employees benefits board (SEBB) organization or employer group must apply SEBB program rules adopted in the Washington Administrative Code (WAC) and follow instructions from the authority.(2) A presiding officer, reviewing officer or officers, or hearing officer must…

(1) The burden of proof is a party's responsibility to provide evidence regarding disputed facts and persuade the presiding officer, reviewing officer or officers, or hearing officer that a position is correct based on the standard of proof. Unless stated otherwise in rules or la…

(1) In computing any period of time prescribed by this chapter, the day of the event from which the time begins to run is not included. (For example, if an initial order is served on Friday and the party has twenty-one days to request a review, start counting the days with Saturd…

(1) A final order may be relied upon, used, or cited as precedent by a party only if the final order has been indexed in the authority's index of significant decisions in accordance with RCW 34.05.473 (1)(b).(2) An index of significant decisions is available to the public on the …

Pursuant to RCW 34.05.482, the authority may use brief adjudicative proceedings for issues identified in this chapter when doing so would not violate law, or when protection of the public interest does not require the authority to give notice and an opportunity to participate to …

The record in a brief adjudicative proceeding consists of any documents regarding the matter, considered or prepared by the presiding officer for the brief adjudicative proceeding or by the reviewing officer or officers for any review. The authority's record does not have to cons…

(1) Any current or former school employee of a school employees benefits board (SEBB) organization or their dependent aggrieved by a decision made by the SEBB organization with regard to SEBB eligibility, enrollment, or premium surcharges may appeal that decision to the SEBB orga…

(1) An eligibility, premium surcharges, or enrollment decision made by a school employees benefits board (SEBB) organization may be appealed by submitting a written request for administrative review to the SEBB organization. The SEBB organization must receive the request for admi…

(1) A decision made by the school employees benefits board (SEBB) program regarding eligibility, enrollment, premium payments, premium surcharges, or a SEBB wellness incentive may be appealed by submitting a request to the SEBB appeals unit for a brief adjudicative proceeding to …

(1) Any subscriber aggrieved by a decision made by the school employees benefits board (SEBB) wellness incentive program contracted vendor regarding the completion of the wellness incentive program requirements, or request for a reasonable alternative to a wellness incentive prog…

(1) Any school employee who disagrees with a decision that denies eligibility for, or enrollment in, a benefit offered under the salary reduction plan may appeal that decision by submitting a written request for administrative review to their school employees benefits board (SEBB…

(1) An entity or organization whose employer group application to participate in school employees benefits board (SEBB) insurance coverage is denied by the authority may appeal the decision by submitting a request for a brief adjudicative proceeding to the SEBB appeals unit.(2) T…

(1) A written request for administrative review of the school employees benefits board (SEBB) organization's or employer group's decision and a request for brief adjudicative proceeding should contain the following:(a) The name and mailing address of the party requesting an admin…

(1) The appellant may act as their own representative or may choose to be represented by another person, except that employees of the health care authority (HCA) or HCA's authorized agents may not represent an appellant, unless approved by a presiding officer or reviewing officer…

The presiding officer, reviewing officer or officers may grant, in their sole discretion, a request for a continuance on motion of the appellant, the authority, or on their own. The continuance may be up to 30 calendar days.[Statutory Authority: RCW 41.05.021 and 41.05.160. WSR 2…

Unless a continuance has been granted, the presiding officer will render a written initial order that addresses the issue or issues raised by the appellant in their appeal within 10 days after the presiding officer receives the contents of the request for a brief adjudicative pro…

(1) Both the appellant and the authority may request review of an initial order. An appellant who has received an initial order upholding a school employees benefits board (SEBB) organization decision, employer group decision, SEBB program decision, or a decision made by a SEBB p…

(1) The appellant may withdraw the request for a brief adjudicative proceeding or review of an initial order for any reason, and at any time, by contacting the school employees benefits board (SEBB) appeals unit. The SEBB appeals unit will present the withdrawal request to the pr…

(1) A final order issued by the reviewing officer or officers will be in writing and include a brief statement of the reasons for the decision. (2) The final order must be served within 20 days of the date of the initial order or of the date the request for review of the initial …

(1) A request for reconsideration asks the reviewing officer or officers to reconsider the final order because the party believes the reviewing officer or officers made a mistake of law, mistake of fact, or clerical error.(2) A request for reconsideration must state in writing wh…

(1) Judicial review is the process of appealing a final order to a court.(2) The appellant may appeal a final order by filing a written petition for judicial review that meets the requirements of RCW 34.05.510 through 34.05.598. Neither the school employees benefits board (SEBB) …

Delivery pursuant to RCW 34.05.542(4) shall be deemed to have been made when a copy of the petition for judicial review has been received by the school employees benefits board (SEBB) appeals unit at Cherry Street Plaza, 626 8th Avenue S.E., Olympia, WA 98501 or received by mail …

The designation of a presiding officer must be consistent with the requirements of RCW 34.05.485 and the presiding officer must not have personally participated in the decision made by the school employees benefits board (SEBB) organization, employer group, or SEBB program.(1) Th…

(1) The designation of a reviewing officer or officers must be consistent with the requirements of RCW 34.05.491 and the reviewing officer or officers must not have personally participated in the decision made by the school employees benefits board (SEBB) organization, employer g…

(1) The presiding officer or the reviewing officer or officers, in their sole discretion, may convert a brief adjudicative proceeding to a formal administrative hearing at any time before the final order is issued on motion by:(a) The appellant;(b) The representative of the appel…

(1) When a brief adjudicative proceeding is converted to a formal administrative hearing consistent with WAC 182-32-2160, the director designates a hearing officer to conduct the formal administrative hearing.(2) Formal administrative hearings are conducted consistent with the Ad…

The record in a formal administrative hearing consists of the official documentation of the hearing process. The record includes, but is not limited to, recordings or transcripts, admitted exhibits, decisions, briefs, notices, orders, and other filed documents.[Statutory Authorit…

(1) All parties must provide the hearing officer and all other parties with their name, address, and telephone number.(2) The appellant may act as their own representative or have another person represent them, except that employees of the health care authority (HCA) or HCA's aut…

(1) Assignment: A hearing officer will be assigned at least five business days before a hearing. A party may ask which hearing officer is assigned to a hearing by contacting the hearing officer's office listed on the notice of hearing. If requested by a party, the hearing officer…

(1) A hearing officer must hear and decide the issues based on the evidence and oral or written arguments presented during a formal administrative hearing and admitted into the record.(2) A hearing officer has no inherent or common law powers, and is limited to those powers grant…

(1) The hearing officer or their designee must serve a notice of a formal administrative hearing to all parties and their representatives at least twenty-one calendar days before the hearing date. The parties may agree to, but the hearing officer cannot impose, a shorter notice p…

(1) A hearing officer must be present at all hearings. Hearings may be held either in person or telephonically.(a) A telephonic hearing is where all parties and the hearing officer are present by telephone.(b) An in-person hearing is where the appellant appears face-to-face with …

(1) Any party may request the hearing officer to reschedule a formal administrative hearing if a rule requires notice of a hearing and the amount of notice required was not provided.(a) The hearing officer must reschedule the formal administrative hearing under circumstances iden…

(1) A prehearing conference is a formal proceeding conducted on the record by a hearing officer to prepare for a formal administrative hearing.(a) The hearing officer must record a prehearing conference using audio recording equipment.(b) The hearing officer may conduct a prehear…

(1) A dispositive motion could dispose of one or all the issues in a formal administrative hearing, such as a motion to dismiss or motion for summary judgment.(2) To request a dispositive motion hearing a party must file a written dispositive motion with the hearing officer and s…

(1) Hearing officers, the health care authority (HCA) hearing representative, and attorneys for the parties may prepare subpoenas as described in Washington state civil rule 45, unless otherwise prohibited by law. Any party may request the hearing officer prepare a subpoena on th…

(1) An order of dismissal is an order from the hearing officer ending the matter. The order is entered because the party who made the appeal withdrew from the proceeding, the appellant is no longer aggrieved, the hearing officer granted a dispositive motion dismissing the matter,…

(1) The appellant may withdraw a formal administrative hearing for any reason, and at any time, by contacting the health care authority (HCA) hearing representative who will coordinate the withdrawal with the hearing officer.(2) The request for withdrawal must generally be made i…

(1) Initial order: When the office of administrative hearings is holding a formal administrative hearing on behalf of the authority, the hearing officer must render a written initial order that addresses the issue or issues raised by the appellant in their appeal. The hearing off…

(1) Both the appellant and the authority may request review of an initial order. An appellant who has received an initial order upholding a school employees benefits board (SEBB) organization or employer group decision, a SEBB program decision, or a decision made by a SEBB progra…

(1) A request for reconsideration asks the hearing officer to reconsider the final order because the party believes the hearing officer made a mistake of law, mistake of fact, or clerical error.(2) A request for reconsideration must state in writing why the party wants the final …

(1) Unless the request for reconsideration is denied as untimely filed under WAC 182-32-3180, the same hearing officer who entered the final order, if reasonably available, will also decide the request as well as any responses received.(2) The decision on the request for reconsid…

(1) Judicial review is the process of appealing a final order to a court.(2) The appellant may appeal a final order by filing a written petition for judicial review that meets the requirements of RCW 34.05.510 through 34.05.598. The school employees benefits board (SEBB) program …

Delivery pursuant to RCW 34.05.542(4) shall be deemed to have been made when a copy of the petition for judicial review has been received by the school employees benefits board (SEBB) appeals unit at Cherry Street Plaza, 626 8th Avenue S.E., Olympia, WA 98501 or received by mail …

(Effective January 1, 2027)The rules in this chapter are effective January 1, 2027, and implement the requirements and limitations in RCW 41.05.028.[Statutory Authority: RCW 41.05.021, 41.05.160, and 41.05.028. WSR 25-24-066, s 182-40-0100, filed 12/1/25, effective 1/1/27.]

(Effective January 1, 2027)The following definitions and those found in chapter 41.05 RCW apply to this chapter. If a definition in this chapter conflicts with a definition in chapter 41.05 RCW, the definition in chapter 41.05 RCW prevails:"Authority" - See RCW 41.05.011."Allowed…

(Effective January 1, 2027)(1) In-network hospitals. The maximum reimbursement paid to an in-network hospital for inpatient and outpatient hospital services, including contractor payments and any applicable member cost-sharing, must be the lesser of:(a) The billed charges;(b) The…

(Effective January 1, 2027)(1) Reimbursement for in-network primary care and in-network nonfacility-based behavioral health services may not be less than 150 percent of the total amount medicare would have reimbursed for the same or similar service, inclusive of contractor paymen…

(Effective January 1, 2027)A contractor may reimburse a provider or hospital using a payment methodology other than fee-for-service as long as:(1) The payments incentivize higher quality or improved outcomes including, but not limited to:(a) Value-based payments;(b) Capitation pa…