Oregon Bulletin
Rule
Caption: Amends OEBB’s qualified status
change rule.
Adm.
Order No.: OEBB 11-2011
Filed with Sec. of
State: 6-22-2011
Certified to be
Effective: 6-22-11
Notice Publication
Date: 4-1-2011
Rules Amended: 111-040-0040
Rules Repealed: 111-040-0040(T)
Subject: OAR 111-040-0040 is amended to include a qualified
status change which allows an OEBB member to make a change to their benefit
selections outside of the annual open enrollment when their spouse/domestic
partner’s annual open enrollment or plan year is different from OEBB’s.
Rules Coordinator: April Kelly—(503) 378-6588
111-040-0040
Qualified Status Changes (QSC’s)
(1) Active eligible employees experiencing a change in
family or work status as noted below after annual enrollment, or anytime during
the plan year, have 31 calendar days beginning on the date of the event to make
changes. If the event is gaining a child, as defined by 111-040-0040(2)(c), or
results in a loss of eligibility, the eligible employee has 60 calendar days
after the event to make changes.
(2) The eligible employee can only make changes that
are consistent with the event for themselves and/or dependents.
(3) The employee must report the Qualified Status
Change (QSC) to the employee’s Educational Entity within the specified
timeframe. Failure to report a QSC that will result in removal of a spouse,
domestic partner, or child within the timeframe stated in 111-040-0040(1) may
be considered intentional misrepresentation, and OEBB may retroactively
terminate the individual’s coverage back to the last day of the month in which
the individual lost eligibility. Please refer to the QSC matrix for details on
what changes can occur with each event.
(4) Qualified Status Changes which allow the employee
to make changes to his or her coverage are:
(a) Gain spouse by marriage or domestic partner by
meeting domestic partner eligibility;
(b) Loss of spouse or domestic partner by divorce,
annulment, death or termination of domestic partnership,
(c) Gain a child by birth, placement for/or adoption,
or Domestic Partner’s children (by affidavit of domestic partnership),
(d) Active eligible employee starts new employment and
gains eligibility;
(e) Change in employment status by active eligible
employee which affects eligibility;
(f) Active eligible employee ends employment or other
change in employment status resulting in a loss of eligibility;
(g) Spouse or domestic partner starts new employment or
other change in employment status which affects eligibility;
(h) Spouse or domestic partner’s employment ends or
other change in employment status resulting in a loss of eligibility under
their employer’s plan;
(i) Event by which a child satisfies eligibility
requirements under OEBB plans (for a list of requirements see 111-010-0015);
(j) Event by which a child ceases to satisfy
eligibility requirements under OEBB plans (for a list of requirements see
111-010-0015),
(k) Changes in the residence of the active eligible
employee, spouse, domestic partner, or child (i.e., moving out of the service
area of an HMO);
(l) Reinstatement of coverage. Reinstatement can be
used in the following situations:
(A) Military (USERRA):
(B) When coverage was continued under COBRA
(C) When coverage was terminated in error and there is
no lapse in coverage.
(m) Significant changes in cost of the eligible
employee’s or early retiree’s current plan and tier level that result in a
negative impact of 10 percent or more to:
(A) The amount an active eligible employee or early
retiree must contribute toward benefits.
(B) The amount a spouse or domestic partner must
contribute toward his or her group health insurance plan cost.
(n) Different Open Enrollment/Plan Year under a
spouse/domestic partner’s employer plan.
(o) Related laws or court orders. For example:
Qualified Medical Child Support Order (QMSCO), Medicare, HIPAA, or Family
Health Insurance Assistance Program (FHIAP). Changes are determined by the
applicable law or court order.
(5) Changes in coverage, or contribution amounts that
result in a reduced amount that an employee or eligible dependent must
contribute toward benefits, do not constitute a Qualified Status Change.
(6) The following applies to the Long Term Care benefit
plans only:
(a) Cancel the plan at anytime without a QSC event.
(b) Plan additions or changes require a QSC event as
defined 111-040-0040(2). The addition of a plan or change in plans with a QSC
is subject to a medical evidence review by the LTC carrier.
Stat. Auth.: ORS 243.860 - 243.886
Stats. Implemented: ORS 243.864
Hist.: OEBB 14-2008, f. &
cert. ef. 8-15-08; OEBB 10-2009(Temp), f. 5-4-09, cert. ef. 5-5-09 thru
10-31-09; OEBB 11-2009, f. & cert. ef. 7-31-09; OEBB 17-2009(Temp), f.
& cert. ef. 10-7-09 thru 4-4-10; OEBB 22-2009, f. & cert. ef. 12-17-09;
OEBB 2-2010(Temp), f. & cert. ef. 3-3-10 thru 8-29-10; OEBB 6-2010, f.
& cert. ef. 8-3-10; OEBB 9-2010(Temp), f. & cert. ef. 8-3-10 thru
1-29-11; OEBB 12-2010(Temp), f. 9-30-10, cert. ef. 10-1-10 thru 1-29-11; OEBB
3-2011, f. & cert. ef. 2-11-11; OEBB 7-2011(Temp), f. & cert. ef.
2-15-11 thru 8-13-11; OEBB 11-2011, f. & cert. ef. 6-22-11
Rule
Caption: Amends OEBB’s Eligibility and
Policy Term Violation rules.
Adm.
Order No.: OEBB 12-2011
Filed with Sec. of
State: 6-22-2011
Certified to be
Effective: 6-22-11
Notice Publication
Date: 4-1-2011
Rules Amended: 111-080-0040, 111-080-0045, 111-080-0050
Rules Repealed: 111-080-0040(T), 111-080-0045(T), 111-080-0050(T)
Subject: Amendments to 111-080-0040, 0045 and 0050 include the
addition of new terminology used by OEBB to define an intentional and
unintentional violation, as well as the consequences of each should they occur.
Rules Coordinator: April Kelly—(503) 378-6588
111-080-0040
Eligibility and Policy Term
Violations — Definitions
For the purposes of OAR 111-080-0045 and 111-080-0050,
the following definitions will apply:
(1) “Eligibility or Enrollment Violations” means and
includes a violation of the Oregon Educators Benefit Board’s eligibility or
enrollment rules or policies including fraud or material misrepresentation.
Misstatements, misrepresentations, omissions or concealments on the part of the
OEBB member are not fraudulent unless they are made with intent to knowingly
defraud. OEBB has primary responsibly in investigating such violations. If an
Eligibility Violation is considered a violation of the insurance carrier’s
policy, then the violation may also be considered a Policy Term Violation, and
OAR 111-080-0050 would also apply.
(A) “Intentional Violation” is a violation that has
occurred in which OEBB has electronic or written documentation that the
eligible employee took action resulting in a non-eligible member being enrolled
in OEBB benefits.
(B) “Unintentional Violation” is a violation that has
occurred in which the eligible employee was not aware that such violation had
occurred and there is no evidence of the eligible employee completing a paper form or logging in and enrolling an
ineligible member in OEBB benefits.
(2) “Policy Term Violations” means and includes a
violation of the insurance carrier’s policy terms. The insurance carrier has
primary responsibility in investigating such violations.
Stat. Auth: ORS 243.860 –
243.886
Stats. Implemented: ORS
243.864(1)(a)
Hist.: OEBB 16-2010, f. &
cert. ef. 12-10-10; OEBB 8-2011(Temp), f. & cert. ef. 2-15-11 thru 8-13-11;
OEBB 12-2011, f. & cert. ef. 6-22-11
111-080-0045
Eligibility Violations
(1) Unintentional Violation:
(A) OEBB will remove from coverage an ineligible OEBB
member due to eligibility or enrollment violations. Removal from all benefit
plans will be retroactive to the date the individual is determined to have no longer been eligible, or the
effective date of coverage if eligibility criteria was never met unless in
conflict with federal healthcare reform.
(B) When
an eligibility or enrollment violation has been discovered and investigated,
OEBB will notify the member and the Educational Entity with the outcome. If the
outcome includes rescission of coverage, OEBB will give a 30 day notice of such
rescission prior to terminating coverage retroactively to the date the member
was no longer eligible for benefits.
(C) The member may be responsible for any claims paid
during the period of time the member was enrolled inappropriately.
(2) Intentional Violation:
(A) The ineligible member shall be removed from
coverage by OEBB. The ineligible member’s coverage will be retroactively
terminated to the date the individual is determined to have no longer been
eligible, or the effective date of coverage if eligibility criteria was never
met.
(B) OEBB may terminate the eligible employee along with
remaining dependents from all plans excluding basic and mandatory plans
selected by the educational entity. This will be a prospective termination
lasting for a period of 12 months. The prospective termination will be
effective the first day of the following month that the Intentional Violation
was discovered.
Stat. Auth: ORS 243.860 –
243.886
Stats. Implemented: ORS
243.864(1)(a)
Hist.: OEBB 16-2010, f. &
cert. ef. 12-10-10; OEBB 8-2011(Temp), f. & cert. ef. 2-15-11 thru 8-13-11;
OEBB 12-2011, f. & cert. ef. 6-22-11
111-080-0050
Policy Term Violations
(1) An OEBB-contracted insurance carrier may remove
from coverage and/or deny the claims of an OEBB member due to policy term
violations. Removal from coverage for policy term violations is at the
discretion of the insurance carrier.
(A) If a policy term violation results in a termination
from the plan or carrier that the violation was committed, it will not prevent
the member from continuing enrollment in other OEBB types of coverages (e.g.,
medical, dental, vision, life, etc.), as long as they remain an employee and
eligible for these benefits.
(B) If an eligible employee commits a policy term
violation and loses coverage, OEBB will remove the entire family from the
insurance plan since the benefits are extended to his or her dependents through
the eligible employee. If the eligible employee chooses to, and it is offered,
they can enroll in a different carrier plan (if applicable) during open
enrollment and cover themselves and dependents during the upcoming plan year.
(C) If a dependent commits a policy term violation,
OEBB will remove only the dependent from the insurance plan. If the eligible
employee chooses to and it is offered, they can enroll in a different carrier
plan (if applicable) during open enrollment and cover the dependent during the
upcoming plan year, or as defined by the carrier.
(D) The OEBB member who is removed from an OEBB
sponsored insurance plan may appeal the decision through the carrier that
terminated coverage.
(E) When a policy term violation has been discovered
and investigated, the applicable insurance carrier will notify OEBB and the
member with the outcome.
(2) The insurance carrier may do the following when a
member has violated a provision of the policy the OEBB member has enrolled in,
committed fraudulent activity or misrepresentation:
(A) The insurance carrier may retain the value of any
expenditure it made related to the member who committed the fraudulent activity
or misrepresentation.
(B) The insurance carrier may deny future enrollments
of the individual in accordance with the carrier’s policies.
Stat. Auth: ORS 243.860 - 243.886
Stats. Implemented: ORS
243.864(1)(a)
Hist.: OEBB 16-2010, f. &
cert. ef. 12-10-10; OEBB 8-2011(Temp), f. & cert. ef. 2-15-11 thru 8-13-11;
OEBB 12-2011, f. & cert. ef. 6-22-11
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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