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Oregon Bulletin

January 1, 2011

 

Department of Administrative Services,
Public Employees’ Benefit Board
Chapter 101

Rule Caption: Adopts/suspends within Division 15, Eligibility, Dependent.

Adm. Order No.: PEBB 6-2010(Temp)

Filed with Sec. of State: 11-29-2010

Certified to be Effective: 11-29-10 thru 12-31-10

Notice Publication Date:

Rules Adopted: 101-015-0014

Rules Suspended: 101-015-0012(T), 101-015-0013(T)

Subject: Suspends current Temporary OAR 101-015-0013 and continues suspense of current Temporary OAR 101-015-0012(T). Current Temporary OAR 101-015-0013 expired effective Nov. 28, 2010, while Temporary OAR 101-015-0012(T) was suspended effective Sept. 23, 2010 (when it was replaced with Temporary OAR 101-015-0013). This Temporary OAR 101-015-0014 bridges the remainder of the health plan year and terminates effective Dec. 31, 2010, at which time it is replaced with Permanent OAR 101-015-0011, as filed amended Oct. 12, 2010, and in process for an effective date of Jan 1, 2011.

Rules Coordinator: Cherie M. Taylor—(503) 378-5473, ext. 325

101-015-0012

Dependent Child

(1) Beginning June 1, 2010 and extending through December 31, 2010,

(a) Dependent children that are enrolled and receiving PEBB health plan coverage that would otherwise lose coverage under OAR 101-015-0011 during this period will continue to receive coverage, provided the child meets the following requirements:

(A) The child is an eligible employee’s, spouse’s, or domestic partner’s son, daughter, stepson, stepdaughter, adopted child or child placed for adoption, foster child or other legallyplaced child, and;

(B) The child will not have attained age 27 by December 31, 2010, except as provided in section (4) of this rule.

(b) Newly eligible employees or eligible employees with a qualified mid-year plan change event may enroll only those children who meet the dependent eligibility conditions of OAR 101-015-0011 during this period.

(2) Beginning January 1, 2011 a dependent child must meet the following eligibility conditions to receive PEBB health plan coverage:

(a) The child is:

(A) An eligible employee’s, spouse’s, or domestic partner’s son, daughter, stepson, stepdaughter, adopted child or child placed for adoption, foster child or other legally placed child, or;

(B) The biological child of an eligible dependent child and meets one of the following criteria:

(i) The child’s parent will not be older than age 26 on the last day of the plan year, is unmarried and without a domestic partner, both the parent and the child live in the household of the eligible employee, and both receive over half of their financial support from the employee; or;

(ii) The child lives with the eligible employee and the employee is legally responsible for the welfare of the grandchild. The employee must be able to provide legal documentation of guardianship, conservatorship, or other custody documents.

(b) The child will not have attained age 27 as of December 31 of the plan year. The exception is a child who meets all the requirements of section (4) of this rule.

(3) An employee must complete and submit the appropriate PEBB affidavit and any required legal documents in order to provide coverage to the following children: a foster child, a child placed for adoption, a ward of the court, a child under legal guardianship or other court order, or an eligible grandchild. The employee must complete and return to the agency the notarized affidavit and any required evidence of legal responsibility within five business days of the child’s electronic enrollment date or the date the agency receives the enrollment forms. PEBB or the agency will terminate the child’s coverage retroactive to the effective date if the affidavit or required documents are not received within the specified time.

(4) There is no age limit for a dependent child who is incapable of self-sustaining employment because of a developmental disability, mental illness, or physical disability. When the dependent child is 26 years of age or older all the following requirements must be met:

(a) The disability must have existed before attaining age 26.

(b) The employee must provide evidence to the agency or PEBB that the child had continuous health plan coverage, group or individual, prior to attaining age 26, which continued until the PEBB health plan effective date.

(c) The child’s attending physician must submit documentation of the disability to the eligible employee’s PEBB health plan insurance plan for review and approval. If the child receives health plan approval, the health plan may review the child’s health status at any time to determine continued PEBB coverage eligibility.

(d) If the child terminates from PEBB health plan coverage after the age of 26, the child is ineligible for future enrollment as a dependent child under PEBB coverage.

(5) PEBB terminates all health plan coverage at midnight on December 31 for dependent children who have reached age 26 during the calendar year. PEBB will not terminate coverage for children age 26 or older when approved by the health plan as incapable of self-sustaining employment because of a developmental disability, mental illness, or physical disability pursuant to section (4) of this rule.

Stat. Auth.: ORS 243

Stats. Implemented: ORS 183, 192, 243, 292, 302, 659 & 743

Hist.: PEBB 1-2010(Temp), f. & cert. ef. 6-1-10 thru 11-28-10; PEBB 2-2010(Temp), f. & cert. ef. 6-3-10 thru 11-28-10; Suspended by PEBB 4-2010(Temp), f. 9-23-10, cert. ef. 10-1-10 thru 11-28-10; Suspended by PEBB 6-2010(T), f. & cert. ef. 11-29-10 thru 12-31-10

101-015-0013

Dependent Child

(1) Beginning January 1, 2011, a dependent child must meet the following eligibility conditions to receive PEBB health plan coverage:

(a) The child is:

(A) An eligible employee’s, spouse’s, or domestic partner’s son, daughter, stepson, stepdaughter, adopted child or child placed for adoption, foster child or other legally placed child, or;

(B) The biological child of an eligible dependent child of an eligible employee, spouse, or domestic partner (a grandchild) and meets one of the following criteria:

(i) The child’s parent will not be older than age 26 on the last day of the plan year, is unmarried and without a domestic partner, both the child’s parent and the child live in the household of the eligible employee, and both receive over half of their financial support from the employee; or

(ii) The child lives with the eligible employee and the employee is legally responsible for the welfare of the grandchild. The employee must provide legal documentation of guardianship, conservatorship, or other custody documents upon enrollment.

(b) The child will not have attained age 27 as of December 31 of the plan year. The exception is a child who meets all the requirements of section (4) of this rule.

(2) During Open Enrollment the employee may electronically enroll a foster child, child placed for adoption, a ward of the court, a child under legal guardianship or other court order if the notarized affidavit and required legal documentation are submitted within five business days following close date of the period. The exception is for an employee who is a newly eligible employee after the closure of the open enrollment period but before the start of the new plan year. The employee must complete paper open enrollment forms and submit the required legal documentation, as listed in (3) of this rule, to the agency before the start of the new plan year. If the employee does not submit the documentation as required, the child’s enrollment will not activate.

(3) Beginning November 1, 2010, newly eligible employees or employee’s with a midyear change request to enroll a foster child, a child placed for adoption, a ward of the court, a child under legal guardianship or other court order, or an eligible grandchild must be received by the agency on the appropriate forms with the required documentation within the allowable enrollments allowable time, before enrollment will occur. The agency will not process the employee’s enrollments until the employee submits all of the following:

(a) Completed and signed enrollment form;

(b) Completed and notarized affidavit; and

(c) Legal documentation.

(4) There is no age limit for a dependent child who is incapable of self-sustaining employment because of a developmental disability, mental illness, or physical disability, when the child is enrolled in PEBB coverage and continues to meet the criteria. The eligible employee’s health plan may review a disabled dependent child’s health status at any time to determine continued disability and PEBB coverage.

(a) All the following requirements must be met when a newly eligible employee requests, or an employee submits a midyear change request, to add a disabled dependent child to coverage who is 26 years of age or older:

(A) The child’s attending physician must submit to the employee’s health plan documentation of the disability and verify the disability existed before the child attained age 26.

(B) In addition to the enrollment forms, the employee must provide evidence to PEBB that the child has had continuous health plan coverage, group or individual, prior to attaining age 26 and the coverage remains in effect. The other coverage must continue until the employee’s medical plan approves the child’s health status as disabled and the PEBB plan is effective.

(b) If a disabled dependent child’s coverage terminates for any reason after the age of 26, the child is ineligible for future enrollment as a dependent child under PEBB coverage.

(5) PEBB terminates all plan coverage for dependent children who reach age 26 during a calendar year at midnight December 31. PEBB will not terminate coverage for children age 26 or older when approved by the health plan as incapable of self-sustaining employment because of a developmental disability, mental illness, or physical disability pursuant to section (4) of this rule.

Stat. Auth.: ORS 243

Stats. Implemented: ORS 183, 192, 243, 292, 302, 659 & 743

Hist.: PEBB 4-2010(Temp), f. 9-23-10, cert. ef. 10-1-10 thru 11-28-10; Suspended by PEBB 6-2010(T), f. & cert. ef. 11-29-10 thru 12-31-10

101-015-0014

Dependent Child

(1) Beginning June 1, 2010 and extending through December 31, 2010,

(a) Dependent children that are enrolled and receiving PEBB health plan coverage that would otherwise lose coverage under OAR 101-015-0011 during this period will continue to receive coverage, provided the child meets the following requirements:

(A) The child is an eligible employee’s, spouse’s, or domestic partner’s son, daughter, stepson, stepdaughter, adopted child or child placed for adoption, foster child or other legally placed child, and;

(B) The child will not have attained age 27 by December 31, 2010, except as provided in section (5) of this rule.

(b) Newly eligible employees or eligible employees with a qualified mid-year plan change event may enroll only those children who meet the dependent eligibility conditions of OAR 101-015-0011 during this period.

(2) Beginning January 1, 2011, a dependent child must meet the following eligibility conditions to receive PEBB health plan coverage:

(a) The child is:

(A) An eligible employee’s, spouse’s, or domestic partner’s son, daughter, stepson, stepdaughter, adopted child or child placed for adoption, foster child or other legally-placed child, or;

(B) The biological child of an eligible dependent child of an eligible employee, spouse, or domestic partner (a grandchild) and meets one of the following criteria:

(i) The child’s parent will not be older than age 26 on the last day of the plan year, is unmarried and without a domestic partner, both the child’s parent and the child live in the household of the eligible employee, and both receive over half of their financial support from the employee; or

(ii) The child lives with the eligible employee and the employee is legally responsible for the welfare of the grandchild. The employee must provide legal documentation of guardianship, conservatorship, or other custody documents upon enrollment.

(b) The child will not have attained age 27 as of December 31 of the plan year. The exception is a child who meets all the requirements of section (5) of this rule.

(3) During Open Enrollment the employee may electronically enroll a foster child, a child placed for adoption, a ward of the court, a child under legal guardianship or other court order if the notarized affidavit and required legal documentation are submitted within five business days following close date of the open enrollment period. The exception is for an employee who is a newly eligible employee after the closure of the open enrollment period but before the start of the new plan year. The employee must complete paper open enrollment forms and submit the required legal documentation, as listed in (4) of this rule, to the agency before the start of the new plan year. If the employee does not submit the documentation as required, the child’s enrollment will not activate.

(4) Beginning November 1, 2010, newly eligible employees or employees with a midyear change request to enroll a foster child, a child placed for adoption, a ward of the court, a child under legal guardianship or other court order, or an eligible grandchild must submit to the agency the appropriate forms with the required documentation within the allowable time, before enrollment will occur. The agency will not process the employee’s enrollments until the employee submits all of the following:

(a) Completed and signed enrollment form;

(b) Completed and notarized affidavit, and;

(c) Legal documentation.

(5) There is no age limit for a dependent child who is incapable of self-sustaining employment because of a developmental disability, mental illness, or physical disability when the child is enrolled in PEBB coverage and continues to meet the eligibility criteria. PEBB must receive all enrollment forms or requests for enrollment of a disabled child. The child’s attending physician must submit documentation of the disability and verify the disability to the employee’s health plan for review and potential approval as disabled to PEBB.

(a) All of the following requirements must be met when a newly eligible employee requests, or an employee submits a midyear change request to add a disabled dependent child to coverage who is 26 years of age or older:

(A) A disabled child over the age of 26 must be a qualifying tax dependent of the employee, spouse, or domestic partner.

(B) The child’s attending physician must submit documentation of the disability, and verify the disability existed before the child attained age 26, to the employee’s health plan for review and approval.

(C) The employee must provide evidence to PEBB that the child has had continuous health plan coverage, group or individual, prior to attaining age 26 and that the coverage remains in effect. The child’s other coverage must continue until the employee’s medical plan approves the child’s health status as disabled and the PEBB plan is in effect.

(b) An eligible employee’s health plan can review and request physician documentation of a disabled dependent child’s health status at any time to determine continued disability and PEBB coverage.

(c) If a disabled dependent child’s coverage terminates for any reason after the age of 26, the child is ineligible for future enrollment as a dependent child under PEBB coverage.

(6) PEBB terminates all plan coverage for dependent children who reach age 26 during a calendar year at midnight December 31. PEBB will not terminate coverage for children age 26 or older when approved by the health plan as incapable of self-sustaining employment because of a developmental disability, mental illness, or physical disability pursuant to section (5) of this rule.

Stat. Auth.: ORS 243

Stats. Implemented: ORS 183, 192, 243, 292, 302, 659 & 743

Hist: PEBB 6-2010(Temp) f. & cert. ef. 11-29-10 thru 12-31-10

 

Rule Caption: Adopted/amended rules for compliance with recent federal healthcare form.

Adm. Order No.: PEBB 7-2010

Filed with Sec. of State: 12-10-2010

Certified to be Effective: 1-1-11

Notice Publication Date: 11-1-2010

Rules Adopted: 101-015-0026

Rules Amended: 101-010-0005, 101-015-0005, 101-015-0011, 101-020-0002, 101-020-0005, 101-020-0015, 101-020-0018, 101-020-0025, 101-020-0032, 101-020-0037, 101-020-0045, 101-020-0050, 101-030-0010, 101-030-0015, 101-030-0022

Rules Repealed: 101-015-0014(T), 101-015-0026(T)

Rules Ren. & Amend: 101-020-0070 to 101-030-0070

Subject: Adoption/amendments herein result from recent federal healthcare reform, promulgating compliance in PEBB’s OARs regarding eligibilities, dependent child(ren), domestic partnerships, and opting out, rescissions and continuations of coverage.

Rules Coordinator: Cherie M. Taylor—(503) 378-5473, ext. 325

101-010-0005

Definitions

Unless the context indicates otherwise, as used in OAR Chapter 101, Divisions 1 through 60, the following definitions will apply:

(1) “Actively at work” for medical and dental insurance coverage means an active eligible employee at work, in paid status and scheduled for work during the month. Optional plan policies or plan certificates contain “actively at work” criteria specific to the individual plan.

(2) “Active Participation” in reference to a Flexible Spending Account (FSA) means an eligible employee currently enrolled in the plan and who each month deposits the required dollar contribution in the account.

(3) “Affidavit of Dependency” means a notarized document that attests a dependent child meets the criteria for a dependent child under OAR 101-015-0011.

(4) “Affidavit of Domestic Partnership” means a notarized document that attests the eligible employee and one other individual meet the criteria in OAR 101-015-0025(2).

(5) “Agency” means a PEBB participating organization such as an individual state of Oregon public agency, semi-independent agency, and individual OUS university.

(6) “Benefit amount” means the amount of money paid by a PEBB participating organization for the purchase of core benefit plans on behalf of active eligible employees PEBB does not determine the benefit amount.

(7) “CBIW” means Continuation of Benefits for Injured Workers.

(8) “Certificate of Registered Domestic Partnership” means the certificate issued by an Oregon county clerk to two individuals of the same sex after they file a Declaration of Domestic Partnership with the county clerk.

(9) “COBRA” means the federal Consolidated Omnibus Reconciliation Act of 1985.

(10) “Core Benefits” means the specific benefit plans that a PEBB employer pays a benefit amount for plan coverage of active eligible employees (e.g., medical, dental and employee basic term life coverage).

(11) “Dependent Care Flexible Spending Account” or “Dependent Care FSA” means the dependent care assistance program that PEBB has adopted in accordance with section 129 of the Internal Revenue Code.

(12) “Dependent child” means a child that satisfies the conditions of OAR 101-015-0011, as applicable.

(13) “Domestic partner” means an eligible employee’s partner in a registered domestic partnership under Chapter 99 Oregon Laws 2007 or unmarried partner of the same or opposite sex that meets the requirements as outlined in OAR 101-015-0025(2).

(14) “Eligible employee” means an individual eligible to enroll in PEBB plan benefits and includes:

(a) “Active eligible employee” means an employee of a PEBB participating organization, including state officials, in exempt, unclassified, classified and management service positions who are expected to work at least 90 days; and who work at least half-time or are in a position classified as job share. These employees are eligible for PEBB core benefits and some optional plans depending on their job classification.

(b) “Retired eligible employee” means a previously active eligible employee, who meets retiree eligibility as defined in OAR 101-050-0005. A retired eligible employee is eligible to self-pay for only the benefit plans established in Division 50 of this chapter.

(c) “Other eligible employee” means an individual of a specific self-pay group as established by ORS 243.140 and 243.200. These groups are eligible only for medical or dental benefits as approved by PEBB.

(15) “Family member” means a spouse or dependent child.

(16) “FMLA” means the federal Family Medical Leave Act.

(17) “FTE” means full time equivalent job position.

(18) “Grandchild Affidavit” means a notarized document that attests a grandchild of an eligible employee, spouse, or domestic partner meets the eligibility criteria for PEBB grandchild coverage as defined in OAR 101-015-0011(1)(B).

(19) “Half-time” means an eligible employee who works less than full time but at least:

(a) Eighty paid regular hours per month; or

(b) 0.5 FTE for unclassified OUS employees; or

(c) Eighty paid regular hours per month and is in a position with written documentation of .5 FTE for Oregon Judicial Department employees; or

(d) As defined by collective bargaining.

(20) “Health Flexible Spending Account” or “Health FSA” means the health flexible spending arrangement that PEBB has adopted in accordance with the Internal Revenue Code.

(21) “Imputed value” means a dollar amount established yearly for an insurance premium at fair market value. The IRS or the Oregon Department of Revenue may view the imputed value as taxable income. The imputed value dollar amount is added to the eligible employee’s taxable wages.

(22) “Ineligible individual” means an individual who does not meet the definition of an eligible employee, spouse, domestic partner, or dependent child as defined in PEBB administrative rules.

(23) “Job share” means two eligible employees sharing one full time equivalent position. Each eligible employee’s percentage of the total position determines the benefit amount the employee receives. The monthly benefit percentage amount remains the same regardless of individual hours worked per month. Job share employees may not donate their portion of the benefit amount to the job share co-worker.

Example 1: John and Jill share one full time equivalent position. When they were hired into the position in July, John’s percentage of the total position was 40 percent; Jill’s percentage was 60 percent. John worked 70 percent of the available hours in September. John’s benefit amount percentage for September remains at 40 percent. Jill’s benefit amount percentage remains at 60 percent.

(24) “Mid year plan change event” means an event that provides an eligible employee an exception to the general plan year irrevocability rule that applies to PEBB plan elections. Permissible mid year events fall into three broad groups: (1) change in status (QSC), (2) cost or coverage changes, or (3) other laws or court orders.

(25) “OFLA” means the Oregon Family Leave Act.

(26) “OSPS” means the Oregon State Payroll System.

(27) “OUS” means the Oregon University System.

(28) “Open enrollment period” means an annual period chosen by PEBB when both active and other eligible employees and COBRA participants can make benefit plan changes or elections for the next plan year.

(29) “Optional plans” means, but is not limited to:

(a) Dependent life insurance;

(b) Employee, spouse, or domestic partner optional life insurance;

(c) Accidental Death & Dismemberment (AD&D) insurance;

(d) Short Term Disability insurance;

(e) Long Term Disability insurance;

(f) Flexible Spending Accounts (Health and Dependent Care); and

(g) Long Term Care insurance.

(30) “Paid regular status” means in current payroll status, and receiving payment for work time. Paid regular status includes the use of vacation, sick, holiday, or personal leave accruals, compensatory time, or other employer approved paid status such as furlough.

(31) “Pebb.benefits” means the electronic benefit management system sponsored by PEBB. The system allows electronic enrollment and termination of the eligible individual’s benefit plans, personal information updates, and the transmittal of data to plans, payroll centers, and third party administrators.

(32) “PEBB participating organization” means a state agency, board, commission, university, or other entity that receives approval to participate in PEBB benefit plans.

(33) “Plan change period” means a period chosen by PEBB when retirees can make limited benefit plan changes.

(34) “Plan year” means a period of twelve consecutive months.

(35) “Qualified status change” (QSC) means a change in family or work status that allows or requires limited mid-year changes to benefit plans consistent with the individual event.

(36) “Rescission” means a cancellation or discontinuance of coverage that has a retroactive effect. A cancellation or discontinuation of coverage that is prospective only, or one that is effective retroactively but is attributable to nonpayment of premiums or contributions, is not a rescission.

(37) “Reinstate” means to reactivate previous benefits and enrollments, if available, to an eligible employee returning to eligible status within a specific time frame. Reinstated enrollment does not include FSA or Long Term Care.

(38) “Spouse” means a person of the opposite sex who is a husband or wife. A relationship recognized as a marriage in another state between two opposite sex partners will be recognized in Oregon even though such a relationship would not be a marriage if the same facts had been relied upon to create a marriage in Oregon. The definition of spouse does not include a former spouse and a former spouse does not qualify as a dependent.

Stat. Auth.: ORS 243.061 - 243.302

Stats. Implemented: ORS 243.061–302, 659A.060–069, 743.600–602, 743.707

Hist.: PEBB 1-1999, f. 12-8-99, cert. ef. 1-1-00; PEBB 1-2000, f. 11-15-00, cert. ef. 1-1-01; PEBB 1-2001, f. & cert. ef. 9-6-01; PEBB 1-2002, f. 7-30-02, cert. ef. 8-1-02; PEBB 1-2003, f. & cert. ef. 12-4-03; PEBB 1-2004, f. & cert. ef. 7-2-04; PEBB 3-2004, f. & cert. ef. 10-7-04; PEBB 3-2005, f. 8-31-05, cert. ef. 9-1-05; PEBB 2-2006(Temp), f. & cert. ef. 12-14-06 thru 6-12-07; PEBB 1-2007(Temp), f. & cert. ef. 6-11-07 thru 12-8-07; PEBB 2-2007, f. 9-28-07, cert. ef. 10-1-07; PEBB 1-2008(Temp), f. & cert. ef. 2-4-08 thru 8-1-08; PEBB 2-2008, f. & cert. ef. 8-1-08; PEBB 3-2009, f. 9-29-09 cert. ef. 10-1-09; HLA 4-2010, f. & cert. ef. 5-18-10; PEBB 1-2010(Temp), f. & cert. ef. 6-1-10 thru 11-28-10; PEBB 7-2010, f. 12-10-10, cert. ef. 1-1-11

101-015-0005

Eligible Individuals

(1) The following individuals are eligible to participate in PEBB-sponsored benefit plans:

(a) An eligible employee as defined in OAR 101-010-0005(14).

(b) A seasonal or intermittent employee described as follows:

(A) An individual hired for the first time is eligible for PEBB-sponsored benefit plans if expected to work at least a 90-day continual period and work at least half-time or in a position classified as job share. The eligible employee must enroll within 30 days of his or her hire date or eligibility.

(B) An individual hired for the first time, working at least half-time or in a position classified as job share and not expected to work a 90-day or more continual period is eligible for PEBB-sponsored benefit plans if they work more than a 90-day continual period. When the eligible employee submits enrollment forms, the benefits are retroactive to the first of the month following 30 days from the individual’s hire date.

(C) A previously ineligible employee returning to work is eligible for benefit plans once they accumulate a total of 60 calendar days of employment within the current or immediately previous plan year. The 60 calendar days of employment need not be consecutive.

(c) A current spouse, domestic partner, or an eligible dependent child listed by the eligible employee on the required enrollment form or the electronic equivalent. An ex-spouse or ex-domestic partner is not eligible for active, or retired, employee PEBB plan coverage.

(d) An appointed and elected official. Eligibility for benefit plans begins on the first day of the month following the date the official takes the oath of office.

(2) The eligible employee is responsible to maintain a valid PEBB enrollment for all eligible individuals receiving coverage. See OAR 101-020-0025.

Stat. Auth.: ORS 243.061 - 243.302

Stats. Implemented: ORS 243.061-302, 659A.060-066, 743.600-602 & 743.707

Hist.: PEBB 1-1999, f. 12-8-99, cert. ef. 1-1-00; PEBB 1-2000, f. 11-15-00, cert. ef. 1-1-01; PEBB 1-2001, f. & cert. ef. 9-6-01; PEBB 1-2004, f. & cert. ef. 7-2-04; PEBB 1-2004, f. & cert. ef. 7-2-04; PEBB 3-2004, f. & cert. ef. 10-7-04; PEBB 3-2005, f. 8-31-05, cert. ef. 9-1-05; PEBB 2-2007, f. 9-28-07, cert. ef. 10-1-07; PEBB 2-2008, f. & cert. ef. 8-1-08; PEBB 7-2010, f. 12-10-10, cert. ef. 1-1-11

101-015-0011

Dependent Child

(1) A dependent child must meet the following eligibility conditions to receive PEBB health plan coverage:

(a) The child is:

(A) An eligible employee’s, spouse’s, or domestic partner’s son, daughter, stepson, stepdaughter, adopted child or child placed for adoption, foster child or other legally placed child; or

(B) The biological child of an eligible dependent child of an eligible employee, spouse, or domestic partner (a grandchild) and meets one of the following criteria:

(i) The child’s parent will not be older than age 26 on the last day of the plan year, is unmarried and without a domestic partner, both the child’s parent and the child live in the household of the eligible employee, and both receive over half of their financial support from the employee; or

(ii) The child lives with the eligible employee and the employee is legally responsible for the welfare of the grandchild. The employee must provide legal documentation of guardianship, conservatorship, or other custody documents upon enrollment. An employee who (1) gains legal responsibility and continues to have responsibility for a grandchild before the child reaches age 18, and (2) has provided continuous PEBB coverage since gaining legal responsibility for the child, can continue to provide PEBB coverage to the grandchild the same as if the child were a biological son or daughter beyond the age of 18. An eligible employee may not add a grandchild age 19 or older to their PEBB coverage unless they can provide legal documentation for responsibility of the child beyond the age of 18.

(b) The child will not have attained age 27 as of December 31 of the plan year. The exception is a child who meets all the requirements of section (4) of this rule.

(2) During Open Enrollment, the employee may electronically enroll a foster child, child placed for adoption, a ward of the court, a child under legal guardianship or other court order, or grandchild if the appropriate notarized affidavit and required legal documentation are submitted within five business days following close date of the period. The exception is for an employee who is a newly eligible employee after the closure of the open enrollment period but before the start of the new plan year. The employee must complete paper open enrollment forms and submit the required legal documentation, as listed in (3) of this rule, to the agency before the start of the new plan year. If the employee does not submit the documentation as required, the child’s enrollment will not activate. PEBB coverage for a child by affidavit will not extend beyond the last day of the month of the end date of responsibility stipulated in the legal document.

Example: Jack’s foster child Joe is receiving PEBB coverage. Jack’s legal documentation used at the time of Joe’s enrollment stated that Jack will no longer be responsible for Joe when Joe turns 18. Joe’s birth date is November 11, if there is no change to the legal responsibility or the documented responsibility end date, Joe’s PEBB coverage will terminate November 30 the year he turns 18.

(3) Newly eligible employees or employee’s with a midyear change requesting to enroll a foster child, a child placed for adoption, a ward of the court, a child under legal guardianship or other court order, or an eligible grandchild must submit the appropriate forms and any legal documentation to the agency within the allowable enrollment time. The agency will not process the employee’s enrollments until the employee submits all of the following:

(a) Completed and signed appropriate forms;

(b) Completed and notarized affidavit; and

(c) Legal documentation as required.

(4) There is no age limit for a dependent child who is incapable of self-sustaining employment because of a developmental disability, mental illness, or physical disability, when all the criteria in this section are met.

(a) The employee must submit to PEBB any appeal and enrollment forms to enroll a disabled child age 26 or older, or to indicate the child disabled in the PEBB benefit record when the child is already receiving coverage.

(b) The child’s attending physician must submit documentation of the child’s disability to the employee’s health plan. The health plan provides a medical review of the physician’s medical documentation and provides PEBB a disability determination based on the review.

(c) When the employee requests to enroll a disabled child over the age of 26:

(A) The child must be the employee’s qualifying tax dependent.

(B) The physician must verify to the health plan that the disability existed before the child attained age 26.

(C) The child must be unable to engage in substantial gainful activity because of a medically determinable physical or mental impairment which can be expected to result in death or which has lasted or can be expected to last for a continuous period of not less than 12 months.

(D) The employee must provide evidence to PEBB that the child has had continuous health plan coverage, group or individual, prior to attaining age 26 and the coverage remains in effect. The other coverage must continue until the employee’s medical plan approves the child’s health status as disabled and the PEBB plan is effective. If the child has not had continuous coverage, the child is not eligible for PEBB coverage.

(d) When a disabled child is receiving coverage beyond the age of 26, the employee’s health plan can review the child’s health status at any time and determine if the child continues to meet the criteria for a disabled child.

(e) If a disabled dependent child’s PEBB coverage terminates for any reason after the age of 26, the child is ineligible for future enrollment as a dependent child under PEBB coverage. The exception is termination of the child’s coverage due to the employee’s termination of employment when the employee is rehired later into a PEBB benefit eligible position. In this situation, to enroll the child again as disabled all PEBB criteria for disabled child within (4) of this rule must be met.

(5) PEBB terminates all plan coverage for dependent children who reach age 26 during a calendar year at midnight December 31. PEBB will not terminate coverage for children age 26 or older when approved by the health plan as incapable of self-sustaining employment because of a developmental disability, mental illness, or physical disability pursuant to section (4) of this rule.

Stat. Auth.: ORS 243.125

Stats. Implemented: ORS 183, 192 & 243

Hist.: PEBB 3-2009, f. 9-29-09 cert. ef. 10-1-09; PEBB 1-2010(Temp), f. & cert. ef. 6-1-10 thru 11-28-10; PEBB 7-2010, f. 12-10-10, cert. ef. 1-1-11

101-015-0026

Domestic Partnership

(1) Certificate of Registered Domestic Partnership. When a Registered Domestic Partnership exists and the eligible employee wants to enroll the domestic partner or the domestic partner’s eligible children in benefit plans, the employee may electronically enroll or submit enrollment update forms to the agency at the appropriate time as defined by PEBB enrollment rules.

(2) PEBB Affidavit of Domestic Partnership. An eligible employee and an individual of the opposite sex, or of the same sex without a Certificate of Registered Domestic Partnership, who want enrollment in PEBB plans as Domestic Partners must meet all of the following criteria:

(a) Are both at least 18 years of age;

(b) Are responsible for each other’s welfare and are each other’s sole domestic partners;

(c) Are not married to anyone;

(d) Share a close personal relationship and are not related by blood closer than would bar marriage in the State of Oregon;

(e) Currently share the same regular permanent residence;

(f) Are jointly financially responsible for basic living expenses defined as the cost of food, shelter, and any other expenses of maintaining a household. Financial information must be provided if requested, and;

(g) Eligible employees must submit enrollment forms and a notarized affidavit to enroll domestic partners and children. To enroll eligible dependent children of a domestic partnership by affidavit in benefit plans, whether or not the enrollment includes the domestic partner, the employee must submit an Affidavit of Domestic Partnership.

(A) For open enrollment, the agency must receive the notarized affidavit within five business days following close date of the open enrollment period. The exception is for an employee who is a newly eligible employee after the closure of the open enrollment period but before the start of the new plan year. The employee must complete paper open enrollment forms and submit the notarized affidavit to their agency before the start of the new plan year. The agency or PEBB will not process an employee’s domestic partner or partner’s children until the enrollment documentation submission is complete.

(B) Newly eligible employees or employees with qualified mid-year changes may only enroll a domestic partner or partner’s children by submitting the correct enrollment forms and notarized affidavit within the allowable time for the enrollment type. Agencies will not process a domestic partner or a partner’s children’s enrollment until the enrollment documentation submission is complete.

(3) An imputed value for the fair market value of the domestic partner and domestic partner’s dependent children’s insurance premium will be added to the eligible employee’s taxable wages.

(4) An eligible employee ending a domestic partnership established under the PEBB Affidavit of Domestic Partnership must complete and submit a Termination of Domestic Partnership form and enrollment update forms to the agency within 30 days of the event. If the domestic partnership was established under the Certificate of Registered Domestic Partnership, only enrollment update forms must be submitted to the agency within 30 days of the event. Insurance coverage for the domestic partner and domestic partner’s dependent children ends the last day of the month that eligibility is lost.

Stat. Auth.: ORS 243.061-302

Stats. Implemented: ORS 243.061-302, Ch. 99, OL 2007

Hist.: PEBB 5-2010(Temp), f. 9-23-10, cert. ef. 10-1-10 thru 3-29-11; PEBB 7-2010, f. 12-10-10, cert. ef. 1-1-11

101-020-0002

Eligible Employee Plan Effective and Termination Dates

(1) Irrevocability Rule. Except as otherwise provided in OAR Chapter 101, all eligible employee benefit plan elections or mid-year plan changes are irrevocable for the plan year and must have a prospective effective date.

(2) The active plan coverage effective date for newly eligible employees or for employees who have qualified mid year change events is the first of the month following the later of the agency’s receipt of all appropriate forms as required by the employee’s enrollment elections or electronic equivalent, or the actual event date.

(a) The employee must be actively at work as specified in OAR 101-010-0005(1) for medical and dental coverage to become effective and as specified by optional plans in optional plan policies or certificates.

(b) When an optional plan requires a medical underwriting prior to coverage approval, coverage will be effective the first of the month following plan approval.

(3) Open enrollment elections are effective on the first day of the new plan year. When an optional plan requires a medical underwriting prior to coverage approval, coverage will be effective the first of the month following plan approval in the new plan year.

(4) Coverage effective date for special enrollment rights. An eligible employee, family member, domestic partner, or domestic partner’s dependent child losing other group medical coverage may enroll in PEBB plans within 30 days of the date of the loss of other group coverage. PEBB coverage will be effective from the date of the loss of the other group coverage.

Example 1: Joe loses coverage under his spouse’s plan Oct. 15. Joe submits enrollment update forms Oct. 16. Joe’s coverage effective date is October 1.

Example 2: Joe loses coverage under his spouse’s plan October 31. Joe submits enrollment update forms November 16. Joe’s coverage effective date is November 1.

(5) Active eligible employee core benefit termination dates:

(a) If an active eligible employee accumulates less than 80 paid regular hours in a month and is not within an employer’s approved leave with core benefit continuation, or terminates employment, benefit coverage in effect that month will end the last day of the month.

(b) If an active eligible employee accumulates 80 or more paid regular hours in a month, and is in a leave without pay status that is not within an employer’s approved leave with core benefit continuation, or terminates employment, the core benefit coverage in effect that month ends the last day of the following month.

(6) Self-pay individuals and retired employees’ benefits terminate the last day of the last period for which the required premium contribution is paid.

(7) Optional plan coverages end according to the individual optional plan’s policy or certificate directives. Refer to OAR 101-020-0060 and 101-020-0065 for FSA termination dates.

Stat. Auth.: ORS 243.061-302

Stats. Implemented: ORS 243.061-302, 659A.060-069, 743.600-602 & 743.707

Hist.: PEBB 2-2007, f. 9-28-07, cert. ef. 10-1-07; PEBB 2-2008, f. & cert. ef. 8-1-08; PEBB 7-2010, f. 12-10-10, cert. ef. 1-1-11

101-020-0005

Newly Hired and Newly Eligible Employee

(1) A newly hired or newly eligible employee has 30 days from the date of hire or date of eligibility to enroll in PEBB core and optional benefit plans. Benefit plan elections are irrevocable for the plan year except as specified in OAR 101-020-0050. A newly eligible employee:

(a) May enroll in benefit plans for the following month regardless of the number of hours worked in the month of eligibility; however, the employee must meet the requirement of a minimum of 80 hours in paid regular status in the following months to continue to receive coverage.

(b) Must be actively at work, as specified in OAR 101-010-0005(1), on the effective date of the insurance coverage.

Example: Sarah was hired and she enrolled in benefit plans on June 25. Sarah was in paid regular status on July 1; her coverage is effective July 1. Sarah will need to be in paid regular status for 80 hours in July in order to receive August coverage.

(c) Who enrolls in benefit plans and terminates employment before the effective date of insurance coverage will not receive active employee benefits or COBRA.

Example 1: Sarah was hired and enrolled in benefit plans on June 25. Sarah was in paid regular status on July 1; on July 2, she terminated employment. Sarah’s coverage was effective July 1 and will remain in place through July 31. Sarah will not receive PEBB coverage in August, but will receive a COBRA notice.

Example 2: Ron was hired and enrolled in benefit plans on June 25. He terminated employment on June 30. Ron is not eligible for insurance coverage because he was not in paid regular status on July 1. He will not receive a COBRA notice because he did not receive active coverage.

(2) An employee that becomes eligible for benefits during or after the open enrollment period but before the start of the new plan year must receive the opportunity to complete open enrollment elections before the start of the plan year.

Stat. Auth.: ORS 243.061 - 302

Stats. Implemented: ORS 243.061 - 302

Hist.: PEBB 1-1999, f. 12-8-99, cert. ef. 1-1-00; PEBB 1-2000, f. 11-15-00, cert. ef. 1-1-01; PEBB 1-2001, f. & cert. ef. 9-6-01; PEBB 1-2002, f. 7-30-02, cert. ef. 8-1-02; PEBB 1-2004, f. & cert. ef. 7-2-04; PEBB 3-2004, f. & cert. ef. 10-7-04; PEBB 3-2005, f. 8-31-05, cert. ef. 9-1-05; PEBB 2-2007, f. 9-28-07, cert. ef. 10-1-07; PEBB 3-2009, f. 9-29-09 cert. ef. 10-1-09; PEBB 7-2010, f. 12-10-10, cert. ef. 1-1-11

101-020-0015

Opting Out of Medical Insurance Coverage

(1) An eligible employee opting out of medical coverage may receive cash, as determined by PEBB, in lieu of medical insurance coverage. To opt out an eligible employee must have medical insurance provided by another employer-sponsored group medical plan. Benefit eligible employees may opt out of PEBB-sponsored:

(a) Medical insurance only, or;

(b) Beginning in plan year 2011, both medical and dental insurance.An employee may not opt out of dental coverage only.

(2) PEBB requires eligible employees electing to only opt out of a medical plan to enroll in other core benefits, such as dental and employee basic life coverage.

(3) The eligible employee opting out of PEBB coverage must provide documentation to their agency of current other employer group-sponsored medical, or medical and dental, coverage. Examples of documentation include, but are not limited to, plan identification cards or an employer letter of coverage. Eligible employees that are receiving health coverage under another PEBB eligible employee may request their agency to verify the other PEBB coverage electronically or contact PEBB for verification.

(4) Employees must submit documentation of other employer-sponsored coverage to their agency for an opt out enrollment to become effective. The agency or PEBB will void an employee’s open enrollment opt out election if the required documentation is not received within the required time. When an opt out election becomes void, PEBB enrolls the employee only in a medical plan and a dental plan that provides service statewide. All other employee optional plan elections will.

(a) Employees enrolling in opt out during open enrollment must submit proof of other coverage within five business days following the close date of the open enrollment period. The exception is an employee who is a newly eligible employee after the closure of the open enrollment period but before the start of the new plan year. The employee must complete paper open enrollment forms and submit proof of other group sponsored coverage to their agency before the start of the new plan year.

Example: John electronically enrolls in medical and dental opt out during Oct. open enrollment. On Nov. 2, (within five business days of the close of the open enrollment period) John provides his agency with a copy of both his medical and dental ID cards from his wife’s employer sponsored coverage. John’s opt out election will start effective Jan. 1, the start of his new plan year.

(b) Newly eligible employees or employees with qualified mid-year plan changes may only enroll in opt out by submitting the correct enrollment forms and proof of other employer sponsored coverage to the agency within the allowable time for the enrollment type. Agencies will not enroll eligible employees in an opt out choice or any other PEBB plan until the enrollment forms and documentation submission are complete.

Example: Mary is a newly eligible employee on March 15. Mary cannot electronically enroll because she wants to opt out of medical only coverage. On March 25, she submits her paper enrollment form electing to opt out of medical to her agency; however, she does not include documentation of other employer group medical coverage. Mary’s agency cannot enroll her in any of her elections until she submits all required documentation. If Mary resubmits her enrollment and documentation before April 1, Mary’s elections will be effective on April 1. If Mary does not resubmit her enrollment and documentation until April, the elections will be effective May 1.

(5) An eligible employee enrolled in Medicare, Medicaid, Veterans’ Administration Health Benefit Programs, TRICARE or Student Health Insurance may not opt out in lieu of enrollment in a PEBB medical insurance plan. Beginning in plan year 2011, eligible employees may opt out of PEBB medical coverage if their employer sponsored group medical plan is TRICARE.

(6) A PEBB plan retiree receiving a state premium subsidy (e.g., early retirement premium subsidy) that returns to active employee status as benefit eligible but chooses to continue coverage under a PEBB retiree or COBRA plan is not eligible to opt out and receive cash in lieu of active employee medical benefits

Stat. Auth.: ORS 243.061 - 302

Stats. Implemented: ORS 243.061 - 302

Hist.: PEBB 1-1999, f. 12-8-99, cert. ef. 1-1-00; PEBB 1-2000, f. 11-15-00, cert. ef. 1-1-01; PEBB 1-2002, f. 7-30-02, cert. ef. 8-1-02; PEBB 1-2003, f. & cert. ef 12-4-03; PEBB 1-2004, f. & cert. ef. 7-2-04; PEBB 3-2004, f. & cert. ef. 10-7-04; PEBB 2-2007, f. 9-28-07, cert. ef. 10-1-07; PEBB 3-2009, f. 9-29-09 cert. ef. 10-1-09; PEBB 3-2010, f. 9-23-10, cert. ef. 10-1-10; PEBB 7-2010, f. 12-10-10, cert. ef. 1-1-11

101-020-0018

Declining Benefits

(1) An active eligible employee who declines PEBB core benefits waives the employee’s right to the benefit amount and enrollment in any PEBB- sponsored plans.

(2) An eligible employee may decline benefits at the time of hire or meeting eligibility, consistent with a qualifying midyear plan change event, or during the open enrollment period.

(3) An eligible employee who previously declined benefits may enroll in benefit plans consistent with a qualifying midyear plan change event or during the open enrollment period.

Stat. Auth.: ORS 243.061 - 243.302

Stats. Implemented: ORS 243.061 - 302

Hist.: PEBB 1-2002, f. 7-30-02, cert. ef. 8-1-02; PEBB 1-2003, f. & cert. ef 12-4-03; PEBB 1-2004, f. & cert. ef. 7-2-04; PEBB 3-2004, f. & cert. ef. 10-7-04; PEBB 2-2007, f. 9-28-07, cert. ef. 10-1-07; PEBB 7-2010, f. 12-10-10, cert. ef. 1-1-11

101-020-0025

Terminating Coverage due to a Midyear Plan Change Event, Rescissions, Agency Premium Refunds

(1) An employee can experience a qualified midyear change event that will permit or require the employee to request a termination of coverage for other individuals on their healthcare coverage. The employee’s request for any coverage termination for an individual must be submitted within 30 days of the qualifying midyear change event, and submitted to the employee’s agency on the appropriate forms.

(a) When an employee experiences a qualifying midyear change that permits the employee to remove an individual from coverage, but does not require the employee to terminate the coverage due to a loss of eligibility agencies must terminate the coverage prospectively. Coverage ends prospectively, the last day of the month following receipt of the appropriate forms. Submission of the forms beyond 30 days will result in a denial of the termination. The employee must wait until open enrollment and move the individual at that time.

Example: Bill currently provides PEBB coverage for his 22-year-old son, Mark. On May 5th Mark starts a new job that provides him with health care coverage. Bill can continue Mark’s PEBB coverage, or based on the qualified midyear event of “Gain of Coverage Eligibility under Another Employer’s Plans” Bill can terminate the coverage. Bill decides to terminate coverage for Mark and submits a midyear change form to his agency on June 1. (Within 30 days of the event date) The agency will terminate Mark’s coverage effective June 30.

(b) An employee must request termination of coverage for an individual receiving PEBB coverage under their enrollments that becomes ineligible for the coverage. Examples of individuals who no longer meet eligibility and require termination from coverage include, but are not limited to, an ex- spouse, ex- domestic partner, a child by affidavit no longer eligible due to age limitation within the legal responsibility document, and a disabled child who no longer meets criteria. Agencies will terminate an ineligible individual’s coverage prospectively, coverage ends the last day of the month following receipt of the appropriate forms from the employee. The exception to prospective termination is termination of coverage for an ex spouse, ex domestic partner, and their children who are not biological children or adopted children of the employee, in which case PEBB coverage must terminate retroactively to the last day of the month that the eligibility is lost. PEBB must process and complete all retroactive terminations.

Example 1: Ann’s divorce is final on June 6. On June 22, she submits the correct change form to her agency to remove her ex spouse from coverage. The agency can process Ann’s former spouse’s termination from PEBB coverage effective June 30.

Example 2: Mary’s divorce is final on June 15. On July 1, Mary submits the correct change forms to her agency to remove her ex spouse from coverage. The notification to the agency is in the month following the date of divorce however it is within the allowable 30 days of the event date. The ex-spouse coverage must terminate retroactively. The agency will send Mary’s forms to PEBB to process, coverage will terminate June 30.

(c) An ineligible individual will receive a COBRA availability notice when the coverage terminates within 60 days from eligibility loss.

(2) PEBB must receive all employee requests for termination of coverage of ineligible individuals beyond the allowable 30 days. PEBB will follow 1(b) of this rule in determining the correct termination date for the ineligible individual.

(a) When the coverage termination for the ineligible individual is prospective, the employee must pay an imputed value tax for each month of coverage that the ineligible individual received coverage. PEBB will communicate to the agency the imputed value to add to the employee’s taxable wages.

(b) When coverage must terminate retroactively:

(A) The agency will receive the following months of premium refunds for the most recent months of coverage received by the ineligible individual, (i) from PEBB up to six months for self-funded plans, (ii) from fully funded plans, up to one year.

(B) An eligible employee may be responsible to repay claims paid by benefit plans for an ineligible individual during any period of ineligibility for which premiums are refunded.

(3) An employee’s failure to report a family member’s or domestic partner’s loss of eligibility during the 12-month period before the start of each annual open enrollment period can result in civil or criminal charges against the employee for fraud or the intent to misrepresent the material facts of enrollment. To the extent allowed by law, PEBB may rescind coverage back to the last day of the month of the plan year when eligibility was lost. Rescission of coverage can occur to an employee, or an individual for whom the employee provides coverage. The following actions will occur during a rescission of coverage action taken by PEBB:

(a) PEBB will provide at least 30 calendar days’ advance notice of the rescission date to the ineligible individual. Coverage will rescind to last day of the month and plan year in which the individual lost eligibility.

(b) PEBB will include a notice of appeal rights with the rescission notice to the individual losing coverage.

(c) The agency may request premium refunds as described in (2)(b)(A) of this rule.

(d) An agency may determine that an employee must repay to the agency the premiums paid for coverage during the ineligible period.

(e) As contractually agreed to, a plan may determine that an employee must repay insurance claims paid by a plan for the ineligible individual during the ineligible period.

(f) An employee’s agency can take disciplinary action against the employee for the employee’s failure to remove an ineligible individual from coverage.

(g) The employee may have imputed value added to their taxable income for premiums not refunded by the plans or repaid by the employee to the agency.

Example: Ann’s divorce is final on June 6, 2010. Ann submits her update form to her agency a year later on June 1, 2011, after she certified during the October 2010 open enrollment period that all individuals receiving coverage in the new plan year were eligible for coverage. The agency sends Ann’s update forms to PEBB. PEBB sends a notice to Ann’s ex-spouse at the last known address informing the individual that on July 1, 2011 PEBB will rescind the individual’s coverage to June 30, 2010 (the month that eligibility was lost). PEBB includes a notice of appeal rights. The ex-spouse will receive a COBRA unavailability notice due to the employee’s late notice of loss of eligibility. Ann’s agency can receive premium refunds for the most recent months of allowable premium according to this rule. When premiums are refunded to the agency, Ann will be responsible for any claims paid by the plans for the ex-spouse during the refund period. For months of non-refunded premium paid by the agency and according to her agency’s policy, Ann may be responsible to repay the premium cost for her ex-spouse or responsible to pay an imposed imputed value tax for the months of coverage not refunded.

(4) When PEBB discovers an ineligible individual receiving coverage, PEBB can terminate coverage according to this rule whether requested by the employee or not.

(5) A benefit plan may remove from coverage or deny the claims of an eligible employee, a family member, domestic partner, or domestic partner’s dependent child because of fraud, intentional misrepresentation of a material fact as prohibited by the terms of the plan, eligibility violations, or policy term violations. When a plan removes an employee from coverage for violations:

(a) The employee may choose, as a midyear plan change, an alternative PEBB plan to replace the terminated plan. If no alternative PEBB plan is available in the employee’s service area, there is no coverage.

(b) The plan may retain all premiums paid and has the right to recover from the employee, the benefits paid because of such wrongful activity that are in excess of the premiums.

(c) The plan may deny future enrollments of the individual.

Stat. Auth.: ORS 243.061 - 302

Stats. Implemented: ORS 243.061-302, 659A.060-069, 743.600-602 & 743.707

Hist.: PEBB 1-1999, f. 12-8-99, cert. ef. 1-1-00; PEBB 1-2002, f. 7-30-02, cert. ef. 8-1-02; PEBB 1-2002, f. 7-30-02, cert. ef. 8-1-02; PEBB 1-2004, f. & cert. ef. 7-2-04; PEBB 3-2004, f. & cert. ef. 10-7-04; PEBB 2-2007, f. 9-28-07, cert. ef. 10-1-07; PEBB 2-2008, f. & cert. ef. 8-1-08; PEBB 3-2009, f. 9-29-09 cert. ef. 10-1-09; PEBB 7-2010, f. 12-10-10, cert. ef. 1-1-11

101-020-0032

Open Enrollment

(1) Active and other eligible employees may make benefit plan changes, new plan elections, enroll eligible individuals, or terminate only certain individuals during the annual open enrollment period. All plan elections or enrollments are subject to paragraph (6) of this rule. Eligible employees must submit plan elections, enrollments, or enrollment terminations as instructed during the designated period.

(2) Open enrollment coverage begins the first day of the new plan year. When coverage must receive plan-underwriting approval, the effective date of the coverage will be the first day of the month after approval in the new plan year.

(3) During the open enrollment period, the eligible employee is accountable for enrolling and providing coverage to only those individuals who will meet PEBB eligibility criteria for coverage the first day in the new plan year. The eligible employee is accountable during open enrollment for ensuring that only those individuals who meet PEBB eligibility are enrolled in the new plan year.

(a) Employees can terminate an individual currently receiving coverage, electronically or by using a form, if they know the individual will be ineligible for coverage the first day of the plan year or the employee no longer wants to provide coverage to the individual even though the individual will continue to meet eligibility. When terminated by an employee as part of the open enrollment period the individual’s coverage ends the last day of the last month of the current plan year. PEBB can audit an employee’s benefit record and investigate the reason why an individual will no longer receive coverage in the new plan year. When necessary PEBB can correct the coverage termination date of a terminated individual and take the appropriate termination of coverage action as provided by OAR 101-020-0025.

(b) Employees are not to use the open enrollment period to remove individuals who have lost eligibility or will lose eligibility. Employees must remove individuals who lose eligibility from their coverage and benefit record by submitting the correct midyear change forms to the agency or to PEBB. See OAR 101-020-0025.

(4) The agency must provide an eligible employee who becomes newly eligible or hired after the open enrollment period but before the start of the new plan year an opportunity for open enrollment elections.

(5) The agency must provide eligible employees away from work due to FMLA, CBIW, active military duty, or other approved employer leave status where the employer continues the employee’s core benefits, an opportunity for open enrollment elections before the start of the new plan year.

(6) Benefit plan elections are irrevocable for the new plan year except as specified in OAR 101-020-0050 or 101-020-0037.

Stat. Auth.: ORS 243.061 - 302

Stats. Implemented: ORS 243.061 - 302

Hist.: PEBB 2-2007, f. 9-28-07, cert. ef. 10-1-07; PEBB 7-2010, f. 12-10-10, cert. ef. 1-1-11

101-020-0037

Correcting Enrollment and Processing Errors

(1) Employee enrollment errors occur when an eligible employee provides incorrect information or fails to make correct selections when making benefit plan elections. An employee’s failure to take an enrollment action is not considered an employee enrollment error. For the purpose of this rule, an enrollment action means that the employee during the allowable enrollment times must take an action to enroll, add to, save, or change benefit plan enrollment elections, or enroll, add to, save, or change coverage of individuals. The eligible employee is responsible for identifying enrollment errors.

(a) PEBB authorizes the agency to correct employee enrollment errors when reported by the employee within 30 days of the original eligibility date or midyear plan change date. Corrections are retroactive to the first of the month following the date the agency received the original paper form or electronic equivalent. The exception is a correction to core benefit enrollments once the enrollment is effective, the enrollments may terminate prospectively only.

(A) PEBB must review all employee requests to correct enrollment errors received after 30 days of the original eligibility date or the midyear plan change date. If the correction is approved, the effective date is the first of the month following the receipt of the employee’s correction request.

(B) Enrollment error correction requests considered beyond 60 days of the eligibility date or the midyear plan change date must demonstrate facts and circumstances that clearly establish an employee error occurred.

Example: As a new employee, Anne enrolled in the Dependent Care Flexible Spending Account. Anne does not have any eligible dependents. Six months later Anne realizes the error after her first Health FSA claim is rejected. Anne may request an enrollment correction from PEBB.

(b) PEBB authorizes the agency to correct an employee’s open enrollment error. The agency may receive employee correction request after the open enrollment end date but no later than 30 days from receipt of the first paycheck of the new plan year. PEBB must review all employee correction requests received beyond 30 days from receipt of the first paycheck of the new plan year. Open Enrollment employee error corrections are effective the first day of the new plan year. The exception is a correction to core benefit enrollments once the enrollment is effective, the enrollments may terminate prospectively only.

(2) Administrative processing errors occur when benefit plan elections are processed incorrectly in the payroll and benefit system by the agency, PEBB, or third party administrative staff, or when a newly eligible employee does not receive correct enrollment information or materials within 30 days of the eligibility date.

(a) PEBB authorizes the agency to correct processing errors identified within 30 days of the eligibility date or the midyear plan change date. Corrections are retroactive to the first of the month following the date the agency received the paper form or electronic equivalent. The exception is a correction to core benefit enrollments once the enrollment is effective, the enrollments may terminate prospectively only. The agency must reconcile all premium discrepancies as described by contract with the insurer.

(b) PEBB must review all processing error correction requests identified after 30 days of the eligibility date or the midyear plan change date. If approved, corrections are retroactive to the first of the month following the date the paper form or electronic equivalent was first received by the agency. The exception is a correction to core benefit enrollments once the enrollment is effective, the enrollments may terminate prospectively only. The agency must reconcile all premium discrepancies as described by contract with the insurer.

(c) PEBB authorizes the agency to correct open enrollment processing errors. The agency must receive requests for correction after the open enrollment end date but no later than 30 days from receipt of the first paycheck of the new plan year. PEBB must review all open enrollment correction requests received beyond the 30 days from receipt of the first paycheck of the new plan year. All processing error corrections are effective the first day of the new plan year. The exception is a correction to core benefit enrollments once the enrollment is effective, the enrollments may terminate prospectively only.

(d) When a newly eligible employee fails to receive enrollment information within 30 days of the eligibility date or receives incorrect information, benefit plan elections will be effective retroactive to the first of the month following the eligibility date.

Stat. Auth.: ORS 243.061 - 302

Stats. Implemented: ORS 243.061 - 302

Hist.: PEBB 1-2003, f. & cert. ef. 12-4-03; PEBB 1-2004, f. & cert. ef. 7-2-04; PEBB 3-2004, f. & cert. ef. 10-7-04; PEBB 1-2005, f. & cert. ef. 4-14-05; PEBB 3-2005, f. 8-31-05, cert. ef. 9-1-05; PEBB 1-2006, f. & cert. ef. 11-28-06; Renumbered from 101-040-0080, PEBB 2-2007, f. 9-28-07, cert. ef. 10-1-07; PEBB 2-2008, f. & cert. ef. 8-1-08; PEBB 3-2009, f. 9-29-09 cert. ef. 10-1-09; PEBB 7-2010, f. 12-10-10, cert. ef. 1-1-11

101-020-0045

Returning to Work

(1) Refer to the following rules for an employee returning to active or paid regular status from the following leave status:

(a) Continuation of Benefits for Injured Workers (CBIW). See OAR 101-030-0010.

(b) Federal Family Medical Leave Act (FMLA). See OAR 101-030-0015.

(c) Oregon Family Leave Act (OFLA). See OAR 101-030-0020.

(d) Active Military Duty Leave (USERRA). See OAR 101-030-0022.

(2) An eligible employee returning from a (i) leave without pay not in (1) of this rule, or a (ii) reduction in hours below benefit eligibility criteria must work at least half-time in the month of return to be eligible for core benefits and optional plan coverages the following month. The exception is eligible employees in job share positions.

(3) An eligible employee returning to paid regular status within 30 days without a break in core benefit plan coverage will have all the employee’s previous coverage reinstated and cannot make benefit plan changes.

Example: Gary begins leave without pay on May 20 and is not planning to return until the fall. Gary worked more than 80 hours in May, and the agency correctly schedules his coverage end date as June 30. However, Gary returns to work on May 25 (within 30 days and with no break in core plan coverages). The agency will reinstate Gary’s coverage with an effective date of July 1. Gary cannot make any election changes to his enrollments. Gary will need to work at least 80 hours in June for coverage continuation in July.

(4) An eligible employee returning to paid regular status within 12 months of the core benefit coverage termination date following a layoff or termination of employment is not required to work at least half-time in the month they return to be eligible for benefits the following month. The agency will reinstate the previous plan enrollments, if available, effective the first of the month following the employee’s return to work. This excludes Health and Dependent Care Flexible Spending Accounts and Long Term Care. The employee may make midyear plan changes within 30 days of the date they return to work.

(5) An eligible employee returning to active or paid regular status after 12 months from the core benefit coverage termination date must enroll as a newly eligible employee.

Stat. Auth.: ORS 243.061 - 302

Stats. Implemented: ORS 243.061-302 & 659A.060-069

Hist.: PEBB 1-1999, f. 12-8-99, cert. ef. 1-1-00; PEBB 1-2000, f. 11-15-00, cert. ef. 1-1-01; PEBB 1-2001, f. & cert. ef. 9-6-01; PEBB 1-2002, f. 7-30-02, cert. ef. 8-1-02; PEBB 1-2004, f. & cert. ef. 7-2-04; PEBB 1-2004, f. & cert. ef. 7-2-04; PEBB 3-2004, f. & cert. ef. 10-7-04; PEBB 3-2005, f. 8-31-05, cert. ef. 9-1-05; PEBB 2-2007, f. 9-28-07, cert. ef. 10-1-07; PEBB 2-2008, f. & cert. ef. 8-1-08; PEBB 3-2009, f. 9-29-09 cert. ef. 10-1-09; PEBB 7-2010, f. 12-10-10, cert. ef. 1-1-11

101-020-0050

Midyear Benefit Plan Changes

(1) Eligible employee plan elections are irrevocable for the plan year. There are limited exceptions to the irrevocability rule if certain conditions or events are met. These events fall into three broad groups:

(a) Qualified Status Changes (QSC), which include:

(A) Changes in the eligible employee’s legal marital status, such as marriage or divorce;

(B) Changes in the eligible employee’s number of dependents, such as birth or adoption of a child;

(C) Changes in the employment status of the eligible employee or family member, such as the start or end of employment, or a change from part-time to full time;

(D) Changes in the eligibility of a dependent, such as attaining a certain age;

(E) Changes in the residence of the eligible employee or family member, or;

(F) Changes in the eligible employee’s domestic partnership.

(b) Cost or coverage changes. For example:

(A) An increase in out-of-pocket premium cost imposed by the employer;

(B) A reduction or a loss in the spouse’s or domestic partner’s group plan benefits, or;

(C) A reduction or a loss of plan coverage.

(c) Other laws or court orders. For example: National Medical Support Notice, Medicare, or HIPAA related special enrollments.

(2) The eligible employee may request only those midyear plan change elections that are consistent with the event.

Example: In the middle of the plan year, John moves from his current medical plan’s service area and can no longer access the plan’s closed panel of providers. However, all of John’s other coverages (dental, life, etc.) remain active for his new address. John may request to change his medical plan, because it is consistent with the event--due to a move from his current medical plan’s service area. John may not request to change or add any other elections at this time because that would not be consistent with the allowable midyear event occurrence.

(3) Eligible employees experiencing a qualified midyear event, and who request a change of enrollment elections must complete and submit to their agency the correct update forms and all required documentation within 30 days of the event. Agencies receiving employee midyear change requests can make only those changes that are consistent with the event. All election changes are effective the later of the first of the month after receiving all required update forms and documents or the event date. Agencies will not process enrollment request changes when enrollment and change request information is incomplete or missing required documentation.

(4) The tag-a-long rule applies when the eligible employee experiences a QSC addition of a new family member, domestic partner, or domestic partner’s child. The rule allows the employee to add another eligible family member, domestic partner, or domestic partner’s child who was previously eligible for PEBB plan coverage but never added to coverage, to be added to coverage at the same time as the new QSC individual.

Stat. Auth.: ORS 243.061-302

Stats. Implemented: ORS 243.061-302, 659A.060-069, 743.600-602 & 743.707

Hist.: PEBB 2-2007, f. 9-28-07, cert. ef. 10-1-07; PEBB 7-2010, f. 12-10-10, cert. ef. 1-1-11

101-030-0010

Continuation of Group Health Benefit Coverage for Injured Workers (CBIW)

(1) The state is required by ORS 659A.060-069 to continue to pay the benefit amount for PEBB health benefit coverage in effect at the time an eligible employee has a work-related injury or illness. The benefit amount may continue for up to 12 consecutive months or until one of the events listed in ORS 659A.063 occurs, whichever occurs first. Health benefit coverage for this purpose includes the medical, dental, vision, and prescription drug coverage of the employee, family members, and domestic partner.

(2) An eligible employee may continue coverage for life, short term and long -term disability, and accidental death and dismemberment insurance plans for up to 12 months if they self-pay the premiums to the agency.

(3) When an employee returns to work within 12 months, they will have their previous enrollment for medical, dental, life, and disability insurance reinstated the first of the month following their return to work. The employee may make midyear plan changes within 30 days of the date they return to work.

(4) An employee returning to work will not be reinstated in any pretax Flexible Spending Accounts. They may reenroll within 30 days of the date they return to work.

(5) An employee returning to work immediately following CBIW is not required to work at least half-time in the month they return to be eligible for benefits the following month.

(6) A COBRA qualifying event occurs at the end of the CBIW continuation period if the employee has not returned to work.

Stat. Auth.: ORS 243.061-302 & 659A.060-069

Stats. Implemented: ORS 243.061-302 & 659A.060-069

Hist.: PEBB 1-1999, f. 12-8-99, cert. ef. 1-1-00; PEBB 1-2004, f. & cert. ef. 7-2-04, PEBB 3-2004, f. & cert. ef. 10-7-04; PEBB 2-2007, f. 9-28-07, cert. ef. 10-1-07; PEBB 7-2010, f. 12-10-10, cert. ef. 1-1-11

101-030-0015

Continuation of Core Benefit Coverage for Employees Covered under the Federal Family Medical Leave Act (FMLA)

(1) The state will continue to pay the benefit amount for core benefits in effect at the time the eligible employee begins an approved FMLA leave.

(2) An eligible employee may continue the following optional plans during the approved FMLA leave by self-paying premiums or contributions to the agency:

(a) Optional Life Insurances,

(b) Short Term and Long Term Disability,

(c) Accidental Death and Dismemberment Insurance, and,

(d) Healthcare Flexible Spending Account (FSA) — The total contribution amount for the complete expected leave duration must be prepaid prior to the start of the leave.

(3) An eligible employee on FMLA leave during open enrollment may make open enrollment benefit elections.

(4) An eligible employee returning to work or paid regular status the first day following the end of approved FMLA leave will have previous enrollments reinstated retroactive to the first day of the month the employee returns. The returning employee is not required to work at least half-time in the month they return to be eligible for benefits the following month.

(a) The employee must self-pay premiums for optional insurance plan reinstatements for the month in which they return.

(b) An employee returning to work will not be reinstated in Long Term Care and FSA unless they continued contributions to a Healthcare FSA while on approved FMLA leave. In this case, the employee will be reinstated in the Healthcare FSA.

(c) The employee may make midyear plan changes within 30 days of the date they return to work.

(5) An employee who does not return to work or to paid regular status the first work day immediately following the end of approved FMLA leave is considered the same as if returning from leave without pay. See OAR 101-020-0045(2).

(6) A COBRA qualifying event occurs when the employee does not return to work and is not in paid regular status the first day after the qualified FMLA leave ends or the employee terminates employment.

Stat. Auth.: ORS 243.061 - 302

Stats. Implemented: ORS 243.061 - 302

Hist.: PEBB 1-1999, f. 12-8-99, cert. ef. 1-1-00; PEBB 1-2004, f. & cert. ef. 7-2-04; PEBB 3-2004, f. & cert. ef. 10-7-04; PEBB 2-2007, f. 9-28-07, cert. ef. 10-1-07; PEBB 2-2008, f. & cert. ef. 8-1-08; PEBB 7-2010, f. 12-10-10, cert. ef. 1-1-11

101-030-0022

Continuation of Benefit Coverage for Employees on Active Military Leave

(1) The state will continue to pay the benefit amount for core benefit coverage in effect at the time an eligible employee begins active military duty. This benefit coverage will continue for the duration of the active military leave, up to 24 consecutive months. The agency may end this coverage before or during the 24 months of active duty only if the member submits a signed written request to end the coverage.

(2) An eligible employee may continue the following optional plans during active military duty up to 12 months by self-paying premiums or contributions to the agency:

(a) Optional Life Insurances,

(b) Accidental Death and Dismemberment Insurance, and,

(c) Health Flexible Spending Account (FSA).

(3) An eligible employee on active military leave during open enrollment may make open enrollment benefit elections. The employee may allow another individual to make plan elections in the employee’s absence by providing documentation of a power of attorney to the agency. Enrollment in a Health FSA must occur during open enrollment in order to participate in the new plan year.

(4) An eligible employee who returns to work within 24 months will have available previous optional plan enrollments reinstated retroactive to the first day of the month the employee returns. A returning employee is not required to work at least half-time in the month they return to be eligible for benefits the following month.

(a) The employee must self-pay premiums for optional insurance plan reinstatements for the month in which they return.

(b) An employee returning to work will not be reinstated in Long Term Care or any FSA, unless contributions to their Health FSA while on military leave continued.

(c) The employee may make midyear plan changes within 30 days of the date they return to work.

(5) A COBRA qualifying event occurs when an eligible employee:

(a) Is no longer in active duty status or paid regular status, and does not return to work following the allowed decompression time;

(b) Remains in active duty status after 24 months of active duty, or;

(c) Terminates employment.

Stat. Auth.: ORS 243.061 - 302

Stats. Implemented: ORS 243.061-302 & 408.240

Hist.: PEBB 1-2003, f. & cert. ef 12-4-03; PEBB 1-2004, f. & cert. ef. 7-2-04; PEBB 3-2004, f. & cert. ef. 10-7-04; PEBB 3-2005, f. 8-31-05, cert. ef. 9-1-05; PEBB 2-2007, f. 9-28-07, cert. ef. 10-1-07; PEBB 2-2008, f. & cert. ef. 8-1-08; PEBB 3-2009, f. 9-29-09 cert. ef. 10-1-09; PEBB 7-2010, f. 12-10-10, cert. ef. 1-1-11

101-030-0070

Life, Disability, and Accidental Death and Dismemberment Insurance — Continuation of Coverage

(1) When an eligible employee separates from state service optional life insurance coverage may continue through the plan, not PEBB, as follows:

(a) Portability. An eligible employee terminating employment, other than for disability or retirement, may continue the employee’s optional employee, spouse, and domestic partner life insurance coverage at the group rate, plus billing fees. The policy remains a term life insurance policy. The employee must apply directly to the plan within 60 days of the date coverage ends. Portability is not available for basic life or dependent life coverage. A survivor of a covered eligible employee may continue optional life insurance through the carrier upon the death of the employee.

(b) Conversion Rights. An eligible employee terminating employment for any reason, including disability or retirement, or experiencing a reduction in hours to less than 80 paid regular hours in the month, may be eligible to convert the employee’s life insurance coverage to an individual whole life insurance policy. The employee must apply directly to the plan within 60 days of the date insurance coverage ends. A survivor of a covered eligible employee may convert life insurance coverage to a whole life insurance policy through the plan upon the death of the employee.

(c) Retiree Life Insurance Option. An eligible employee who retires may purchase the Retiree Life Insurance Option without submitting evidence of insurability. The employee must apply directly to the insurance plan within 60 days of the date insurance coverage ends.

(d) Transfer of Premium Payment for Optional Employee Life Insurance. When two active eligible employees are married or in a domestic partnership and both are state employees, one employee can transfer their optional life insurance coverage to the other employee’s life insurance coverage or to themselves upon:

(A) Terminating employment for any reason;

(B) Beginning an active military leave;

(C) Divorce;

(D) Termination of their domestic partnership, or;

(E) Retirement. The remaining employed eligible employee must submit the completed applicable form to the employee’s agency within 60 days of the date of the above events.

(2) There are no portability, conversion, or rollover continuation options for short term or long term disability or accidental death and dismemberment insurance coverage.

Stat. Auth.: ORS 243.061–302

Stats. Implemented: ORS 243.061–302

Hist.: PEBB 2-2007, f. 9-28-07, cert. ef. 10-1-07; Renumbered from 101-020-0070, PEBB 7-2010, f. 12-10-10, cert. ef. 1-1-11

Notes
1.) This online version of the OREGON BULLETIN is provided for convenience of reference and enhanced access. The official, record copy of this publication is contained in the original Administrative Orders and Rulemaking Notices filed with the Secretary of State, Archives Division. Discrepancies, if any, are satisfied in favor of the original versions. Use the OAR Revision Cumulative Index found in the Oregon Bulletin to access a numerical list of rulemaking actions after November 15, 2010.

2.) Copyright 2011 Oregon Secretary of State: Terms and Conditions of Use

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