The national Group Health Insurance guide covers how group plans work: eligibility, the master contract and certificates, federal COBRA, HIPAA and coordination of benefits. This guide covers the Washington rules on continuation, conversion, small groups and out-of-state association groups.

Small groups (RCW 48.43.005)

In Washington, a small employer averaged at least one and no more than 50 employees during the previous calendar year.

Continuation option (RCW 48.21.250)

• An insurer issuing group hospital or medical coverage must offer the policyholder an option to include a continuation provision.
• Under it, a person who loses eligibility may continue group benefits for an agreed period at an agreed rate.
• HCSCs and HMOs have parallel requirements.
• After continuation ends, the person may convert.

Conversion (RCW 48.21.260)

• A group medical policy must let a person whose eligibility ends obtain an individual conversion policy.
• Conversion may be refused to a person:
  • eligible for Medicare
  • covered under another group plan
  • terminated for misconduct. In that case, the insurer must still offer conversion to the spouse and dependents.

Out-of-state group coverage (WAC 284-30-610)

When a producer solicits a Washington resident for coverage under a group policy issued outside Washington, such as to an out-of-state association, the producer:

• brings a disclosure statement to the person's attention before the application is completed
• has it signed by the licensee and the individual
• gives the individual a copy

Common exam traps

• A Washington small group has 1 to 50 employees.
• Continuation must be offered to the policyholder as an option. After continuation, the person may convert.
• Conversion may be denied to an employee fired for misconduct, but not to the spouse and dependents.
• Medicare eligibility or other group coverage ends conversion rights.
• Out-of-state group coverage needs a signed disclosure before the application is completed.