Oregon Bulletin
April 1, 2011
Rule
Caption: Suspends/adopts rules to support
program integrity efforts and clarifies audit processes for accurate benefit
program enrollment.
Adm.
Order No.: PEBB 1-2011(Temp)
Filed with Sec. of
State: 3-9-2011
Certified to be
Effective: 3-9-11 thru 8-4-11
Notice Publication
Date:
Rules Adopted: 101-015-0006, 101-020-0026
Rules Suspended: 101-015-0005, 101-020-0025
Subject: Suspends OAR 101-015-0005 and 101-020-0025 and adopts
101-015-0006 and 101-020-0026 for purposes of supporting PEBB’s program
integrity efforts and clarifying routine audit process to be used to verify
accurate enrollment in benefit programs at any time of the year.
Rules Coordinator: Cherie Taylor—(503) 378-6296
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;
Suspended by PEBB 1-2011(Temp), f. & cert. ef. 3-9-11 thru 8-4-11
101-015-0006
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. An eligible spouse, domestic partner, or dependent child is
enrolled only after being 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 or 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 -
243.302, 659A.060 - 659A.066, 743.600 - 743.602 & 743.707
Hist.: PEBB 1-2011(Temp), f. &
cert. ef. 3-9-11 thru 8-4-11
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;
Suspended by PEBB 1-2011(Temp), f. & cert. ef. 3-9-11 thru 8-4-11
101-020-0026
Terminating Coverage due to a
Midyear Plan Change Event, Eligibility Verifications, 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, the employee’s agency must terminate the coverage prospectively.
Coverage ends 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 either the medical or other eligibility 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 ex-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’s
coverage must terminate retroactively. The agency will send Mary’s forms to
PEBB to process and 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 (2)(b)(A) of 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 the months of
non-refunded premium and according to her agency’s policy, Ann may be
responsible to repay the agency’s premium cost for her ex-spouse or responsible
to pay an imposed imputed value tax for the months of coverage not refunded.
(4) PEBB may at any time request information from an
individual receiving PEBB coverage or from the eligible employee under whom
that individual is enrolled, to verify that the individual is eligible under
these rules. Based on the information provided, PEBB may determine the
individual’s eligibility for coverage under a PEBB sponsored plan.
(a) PEBB’s verification process may require submission
of any information related to determining eligibility, including but not
limited to a written certification or requested verification documents.
Verification documents may include, but are not limited to, a birth
certificate, adoption order, placement agreement, guardianship order, physician
documentation of an overage child’s disability, marriage certificate, tax
return, certificate of registered domestic partnership, or affidavit of
domestic partnership. During the verification process, employees and other
persons enrolled to receive PEBB benefits must, within the time period set
forth in PEBB’s request for information, furnish such information as PEBB may
request for the purpose of eligibility verification.
(b) PEBB will terminate coverage for individuals that
do not respond as required to verification requests or if the verification
process determines that an individual is ineligible to receive PEBB coverage.
(c) PEBB will terminate coverage according to this rule
or at any time an ineligible individual is discovered receiving PEBB coverage,
whether or not the employee requested termination. Termination of coverage will
be retroactive if so required by this rule, except that during a verification process
PEBB may announce a period of time during which member-initiated disenrollment
of ineligible individuals will be prospective only.
(d) Paragraph (4)(a) of this rule applies only to an
individual enrolled in PEBB as a spouse, domestic partner, or dependent child.
PEBB may use a contractor to perform any function described in paragraph (4)(a)
of this rule. A PEBB member or individual enrollee is not required to pursue
any internal appeals process provided by the contractor for relationship
eligibility verification before filing an appeal to PEBB under OAR
101-020-0066.
(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 1-2011(Temp), f. &
cert. ef. 3-9-11 thru 8-4-11
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.
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