CurrentWashington State Health Care AuthorityPolicy 56-1

Reinstatement for Subscribers with Mental or Physical Impairment or Incapacitation

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This policy governs written requests to reinstate continuation coverage or school board member coverage when nonpayment of premiums or applicable premium surcharges resulted from a subscriber’s mental or physical impairment or incapacitation.

Policy Summary

PayerWashington State Health Care Authority

PolicyReinstatement for Subscribers with Mental or Physical Impairment or Incapacitation

Policy CodePolicy 56-1

Change TypeAdministrative policy

Effective DateJanuary 1, 2027

Next Review DateNot specified

Key ActionSubmit a written reinstatement request to the SEBB Program within 120 days after the date on the HCA termination letter.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

120 daysRequest deadline

2Documentation elements

RetroactiveApproved coverage

100%Payment required

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CurrentWashington State Health Care AuthorityPolicy 56-1

Reinstatement for Subscribers with Mental or Physical Impairment or Incapacitation

Customize your policy alerts

Sign up for Washington State Health Care Authority Policy 56-1 alerts

Get alerted when Policy 56-1 changes without checking for updates manually.

Monitor payer policy activity

Receive email alerts as soon as relevant payer policies are published or updated.

Policy Summary

PayerWashington State Health Care Authority

PolicyReinstatement for Subscribers with Mental or Physical Impairment or Incapacitation

Policy CodePolicy 56-1

Change TypeAdministrative policy

Effective DateJanuary 1, 2027

Next Review DateNot specified

Key ActionSubmit a written reinstatement request to the SEBB Program within 120 days after the date on the HCA termination letter.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

120 daysRequest deadline

2Documentation elements

RetroactiveApproved coverage

100%Payment required

AvailableDenial appeal

Reinstatement Criteria and Outcomes

Reinstatement criteria and outcomes

Reinstatement is available only when the request meets the eligibility, impairment determination, documentation, timing, and payment requirements below.

Reinstatement eligibility

Coverage type
- The request concerns continuation coverage.
- The request concerns school board member coverage.
Nonpayment of premiums or applicable premium surcharges resulted from the subscriber’s mental or physical impairment or incapacitation.
The request is made by the subscriber or a permitted party acting or paying on the subscriber’s behalf.

Impairment documentation and determination

The HCA Clinical Quality and Care Transformation Division determines whether the impairment or incapacitation prevented the subscriber from making premium or applicable premium-surcharge payments.
Documentation source
- Submit a written note from the subscriber’s physician.
- If a physician note is unavailable, submit supporting documents on behalf of the subscriber.
Required documentation content
- The documentation identifies the condition that renders or rendered the subscriber mentally or physically impaired or incapacitated.
- The documentation states when the impairment or incapacitation began and when it ended, or states that it is ongoing.

Timely written request

The reinstatement request is made in writing and received by the SEBB Program no later than 120 days after the date on the HCA termination letter.within 120 days
The physician note or supporting documentation is submitted with the reinstatement request.

If reinstatement is approved

Coverage is reinstated retroactively to the date of termination for nonpayment of premiums or applicable premium surcharges.
Reinstatement is contingent on payment of all unpaid premiums and applicable premium surcharges.
The subscriber or another party acting on the subscriber’s behalf pays all unpaid premiums and applicable premium surcharges.

If reinstatement is denied

The subscriber’s coverage remains terminated.
The subscriber or another party acting on the subscriber’s behalf may appeal the denial to the SEBB Appeals Unit by following the process described in WAC 182-32-2030.

Required Actions and Appeal Rights

Prior Authorization

Submit a Timely Written Reinstatement Request

The subscriber or a party permitted to pay premiums on the subscriber’s behalf may request reinstatement of continuation coverage or school board member coverage. The written request must be received by the SEBB Program no later than 120 days after the date on the HCA termination letter.

Eligible requesters may include a spouse, state registered domestic partner, dependent, legal representative, hospital administration, or another authorized party.
Submit the request in writing within the 120-day receipt deadline.

Documentation Required

Document Impairment or Incapacitation

Submit a physician’s written note with the reinstatement request, or provide supporting documentation if a physician’s note is unavailable. The documentation must identify the condition that rendered or renders the subscriber mentally or physically impaired or incapacitated and state when the condition began, when it ended, or whether it is ongoing.

Key Terms

Party acting on behalf of the subscriber

Who may actThe subscriber or a permitted party acting on the subscriber’s behalf may request reinstatement or pay premiums.

Examples of permitted partiesSpouse, state registered domestic partner, dependent, legal representative, hospital administration, or another similar authorized party.

Mental or physical impairment or incapacitation

DefinitionA mental or physical condition that prevents or prevented the subscriber from making required premium or applicable premium-surcharge payments.

Required documentationDocumentation must identify the condition and state when it began, when it ended, or whether it is ongoing.

DeterminationThe HCA Clinical Quality and Care Transformation Division determines whether the impairment or incapacitation prevented payment.

Policy Summary

PayerWashington State Health Care Authority

PolicyReinstatement for Subscribers with Mental or Physical Impairment or Incapacitation

Policy CodePolicy 56-1

Change TypeAdministrative policy

Effective DateJanuary 1, 2027

Next Review DateNot specified

Key ActionSubmit a written reinstatement request to the SEBB Program within 120 days after the date on the HCA termination letter.

SourceLink

On This Page

The physician note or supporting documents must be submitted with the written reinstatement request.
Documentation must clearly identify both the qualifying condition and its onset, end date, or ongoing status.

Note

Obtain HCA Impairment Determination

The HCA Clinical Quality and Care Transformation (CQCT) Division determines whether the subscriber’s mental or physical impairment or incapacitation prevented the subscriber from making required premium and applicable premium surcharge payments. If no physician note is available, CQCT will make its determination from submitted supporting documents.

CQCT reviews the physician note or supporting documentation.
Supporting documents must clearly state the qualifying condition and its onset, end date, or ongoing status.

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Denial Risk

Appeal a Reinstatement Denial

If the reinstatement request is denied, the subscriber’s coverage remains terminated. The subscriber or another party acting on the subscriber’s behalf may appeal the denial to the SEBB Appeals Unit by following the process in WAC 182-32-2030.

A denial does not reinstate coverage.
Appeals are submitted to the SEBB Appeals Unit under WAC 182-32-2030.

Note

Apply Tolling Rule for Impaired Representatives

If a legal representative or guardian already on file with the HCA is also mentally or physically impaired or incapacitated, the tolled election period begins when that representative or guardian reestablishes coherence or capability, or when a new legal representative or guardian is established.

Apply the tolling rule when the impaired representative or guardian is already on file with the HCA.
The election period starts upon restored coherence or capability, or establishment of a new legal representative or guardian.

Tolled election period

DefinitionThe period during which the applicable reinstatement or election deadline is paused because the subscriber or a qualifying legal representative or guardian is mentally or physically impaired or incapacitated.

Impaired representative or guardianIf a legal representative or guardian already on file is impaired or incapacitated, the period begins when that person reestablishes coherence or capability, or when a new representative or guardian is established.