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Oregon Bulletin

September 1, 2011

 

Oregon Health Authority,
Public Employees’ Benefit Board
Chapter 101

Rule Caption: Suspends/adopts rules to sustain program integrity efforts and clarify audit processes for accurate benefit programs enrollments.

Adm. Order No.: PEBB 2-2011(Temp)

Filed with Sec. of State: 8-5-2011

Certified to be Effective: 8-5-11 thru 1-31-12

Notice Publication Date:

Rules Amended: 101-015-0005, 101-020-0025

Subject: Amends OAR 101-015-0005 and 101-020-0025 for purposes of sustaining PEBB’s program integrity efforts and clarifying routine audit processes used to verify accurate benefit programs enrollments at any time of the year.

Rules Coordinator: Chérie 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 date of 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. If the new employee works more than a 90-day continuous work period, the employee can submit enrollment forms and the effective date of the enrollment is 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 243.061-302, 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; PEBB 2-2011(Temp), f. & cert. ef. 8-5-11 thru 1-31-12

101-020-0025

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 remove 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, or 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 will 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 as a midyear plan change choose 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; PEBB 2-2011(Temp), f. & cert. ef. 8-5-11 thru 1-31-12

 

Rule Caption: Suspension of OEBB OAR 101-015-0025.

Adm. Order No.: PEBB 3-2011(Temp)

Filed with Sec. of State: 8-11-2011

Certified to be Effective: 8-11-11 thru 2-7-12

Notice Publication Date:

Rules Suspended: 101-015-0025

Subject: Suspends OAR 101-015-0025, allowing OAR 101-015-0026 to become the appropriately guiding rule for domestic partnerships.

Rules Coordinator: Linda Pavis—(503) 378-2349, ext. 325

101-015-0025

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.

(g) Electronically enroll or submit enrollment forms to the agency at the appropriate time as defined by PEBB enrollment rules. The employee and domestic partner must jointly complete and submit to the agency a notarized PEBB Affidavit of Domestic Partnership form, within five business days of the electronic enrollment date or the date the agency received the enrollment forms. If the affidavit is not received, coverage will terminate for the domestic partner retroactive to the effective date.

(h) 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 form along with enrollment or update forms to the agency. If the affidavit is not received within 5 business days of the electronic enrollment date or the date the agency received the forms, coverage will terminate for the domestic partner’s eligible children retroactive to the effective date.

(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 60 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 60 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, 659A.060-069, 743.600-602 & 743.707

Hist.: PEBB 2-2007, f. 9-28-07, cert. ef. 10-1-07; PEBB 1-2008(Temp), f. 2-4-08, cert. ef. 2-4-08 thru 8-1-08; PEBB 2-2008, f. & cert. ef. 8-1-08; Suspended by PEBB 5-2010(Temp), f. 9-23-10, cert. ef. 10-1-10 thru 3-29-11; Suspended by PEBB 3-2011(Temp), f. & cert. ef. 8-11-11 thru 2-7-12

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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