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    OpenPayerPolicy UpdatesAdministrative/Operational PolicyWashington HCA Election Tolling Update | OpenPayer
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    CurrentWashington State Health Care AuthorityPolicy 56-2

    Election period tolling for applicants with mental or physical impairment or incapacitation

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    This policy governs how the SEBB Program evaluates requests to pause, delay, or suspend enrollment, annual open enrollment, or special open enrollment election periods when an applicant is mentally or physically impaired or incapacitated. It applies to applicants and legal representatives or other parties acting on their behalf.

    Policy Summary
    PayerWashington State Health Care Authority
    PolicyElection period tolling for applicants with mental or physical impairment or incapacitation
    Policy CodePolicy 56-2
    Change TypeNo material change
    Effective DateJanuary 1, 2027
    Next Review DateN/A
    Key ActionReview a physician note or supporting documents identifying the condition and the dates the impairment or incapacitation began and ended or remains ongoing.
    SourceLink
    POLICY UPDATE CHANGES

    No material clinical or coverage changes in this revision.

    120 daysWritten tolling request deadline
    120 daysLegal representation documentation deadline
    BalanceElection time restored after approval
    Retroactive

    OpenPayer is powered by Trek Health's payer performance platform. Trek continuously ingests, validates, and normalizes Transparency in Coverage data alongside payer policies and other commercial payer data to create a structured payer intelligence foundation. OpenPayer uses this foundation to deliver personalized search results, dynamically generated policy pages, and tailored policy monitoring based on each user's payers, specialties, billing codes, and areas of interest. The same intelligence powers broader payer performance workflows, including reimbursement benchmarking, contract evaluation, payer negotiations, and financial decision-making.

    Coverage after timely election
    AvailableDenied request appeal

    Election Period Tolling Criteria

    Eligibility for election period tolling

    Tolling may be approved when ALL of the following are met:

    ALL of the following

    • ONE of

      • The applicant or the applicant's legal representative requests tolling; a legal representative provides proof of legal representation.
      • Another party acts on behalf of the applicant as permitted by the policy.
    • The applicant's mental or physical impairment or incapacitation prevented the applicant from making the election.

    • ONE of

      • A physician note identifies the condition and the date the impairment or incapacitation began and, if it ended, the date it ended.
      • If a physician note is unavailable, supporting documents clearly identify the condition and whether and when the impairment or incapacitation began, ended, or remains ongoing.
    • The written request is received by the SEBB Program no later than 120 days after the end of the election period being tolled.<= 120 days

    Effect and resumption of approved tolling

    When tolling is approved, the election period is paused for the documented impairment or incapacitation interval and the applicant receives the remaining election time.

    ALL of the following

    • Tolling begins on the documented date the applicant's mental or physical impairment or incapacitation began.

    • The remaining election period begins when ONE of the following occurs

      • The applicant reestablishes coherence or capability.
      • Legal representation is established.
      • A party acting on behalf of the applicant begins acting.
    • If the applicant's incapacitation remains unresolved when the request is made, the applicant has legal representation with capacity to act on the applicant's behalf.

    Coverage after a timely election

    A timely election made during the remaining tolled period may result in retroactive coverage, subject to payment obligations.

    ALL of the following

    • The election is made within the balance of the tolled election period.
    • Coverage begins retroactive to the date of the qualifying event.
    • Any unpaid premiums and applicable premium surcharges are paid; all retroactive premiums are paid post-tax.

    Deadlines and Election Period Handling

    Tolling Request Submission Deadline
    Submission deadlineThe written tolling request must be received by the SEBB Program no later than 120 days after the end of the election period being tolled.
    Required submissionThe request must be made in writing.
    Supporting documentationA physician note or supporting documentation must be submitted with the request.
    Legal Representation Documentation Deadline
    Documentation deadlineProof of legal representation must be received by the SEBB Program no later than 120 days from the deadline the applicant is asking to be tolled.
    Required proofA legal representative must provide documentation establishing legal representation.

    Request Review and Processing Actions

    Documentation Required

    Accept Eligible Requests

    Accept a written request from the applicant or the applicant’s legal representative to toll the election period. A legal representative must provide proof of legal representation and, when the applicant’s incapacitation is ongoing, must have capacity to act on the applicant’s behalf. If the applicant dies during the election period, the legal representative or guardian may request tolling to make an election on the applicant’s behalf and must prove authority to do so.

    • Requests must be received by the SEBB Program no later than 120 days after the end of the election period or deadline being tolled.
    • Documentation of legal representation must be received by the SEBB Program no later than 120 days from the deadline the applicant is asking to be tolled.
    Note

    Determine Impairment or Incapacitation

    The HCA Clinical Quality and Care Transformation (CQCT) Division determines whether the applicant had a mental or physical impairment or incapacitation that prevented the applicant from making the election.

    • The determination may address an impairment or incapacitation that has ended or is ongoing.

    Key Terms

    Tolling or Tolled
    MeaningTolling or tolled means to pause, delay, or suspend the time period to make an election.
    Enrollment electionsThe election period may involve electing enrollment.
    Annual open enrollmentThe election period may involve annual open enrollment.
    Special open enrollmentThe election period may involve special open enrollment.
    Mental or Physical Impairment or Incapacitation
    Qualifying conditionA mental or physical condition that prevents or prevented the applicant from making the election.
    Evaluating division
    Policy Summary
    PayerWashington State Health Care Authority
    PolicyElection period tolling for applicants with mental or physical impairment or incapacitation
    Policy CodePolicy 56-2
    Change TypeNo material change
    Effective DateJanuary 1, 2027
    Next Review DateN/A
    Key ActionReview a physician note or supporting documents identifying the condition and the dates the impairment or incapacitation began and ended or remains ongoing.
    SourceLink
    On This Page
    Election Period Tolling CriteriaDeadlines and Election Period HandlingRequest Review and Processing ActionsKey Terms
    Submission recipientThe documentation must be received by the SEBB Program.
    Resumption of the Tolled Election Period
    Applicant recoveryThe remaining election period begins when the applicant reestablishes coherence or capability, as demonstrated by supporting documentation.
    Legal representation establishedThe remaining election period begins when legal representation is established, as demonstrated by supporting documentation.
    Party acting on the applicant’s behalfFor another party acting on behalf of the applicant, the remaining election period begins on the date that party began acting on the applicant’s behalf.
  1. If the incapacitation is ongoing, the applicant must have legal representation with capacity to act on the applicant’s behalf.
    2. Documentation Required

    Review Supporting Documentation

    Review the physician’s written note submitted with the tolling request. If a physician note is unavailable, the HCA CQCT Division may determine eligibility from supporting documents submitted on the applicant’s behalf.

    • The documentation must clearly identify the condition that rendered or renders the applicant mentally or physically impaired or incapacitated.
    • It must state the date the impairment or incapacitation began and, if resolved, the date it ended; otherwise, it must state that the condition is ongoing.
    • Requests must include either the physician note or alternate supporting documentation.
    Billing Rule

    Apply Approved Tolling

    When tolling is approved, pause the election period for the documented interval of mental or physical impairment or incapacitation. The applicant or legal representative may then make the election during the balance of the original election period.

    • The remaining period begins when the applicant reestablishes coherence or capability, or when legal representation is established, as shown by supporting documentation.
    • For a party acting on the applicant’s behalf, the balance begins when that party began acting; if an impaired legal representative is already on file, it begins when that representative regains capacity or a new representative is established.
    • After an election is made within the remaining period, coverage is retroactive to the qualifying event, subject to payment of unpaid premiums and applicable surcharges.
    Denial Risk

    Process Denial Appeals

    If a tolling request is denied, direct the applicant or another party acting on the applicant’s behalf to appeal the denial to the SEBB Appeals Unit using the process described in WAC 182-32-2030.

    • The appeal pathway applies to denials of election-period tolling requests.
    The HCA Clinical Quality and Care Transformation Division evaluates the applicant’s mental or physical impairment or incapacitation.
    DocumentationSupporting documentation must identify the condition and when the impairment or incapacitation began, ended, or remains ongoing.