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The Oregon Administrative Rules contain OARs filed through November 15, 2014
 
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OREGON HEALTH AUTHORITY,
PUBLIC EMPLOYEES' BENEFIT BOARD

 

DIVISION 15

ELIGIBILITY

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(18).

(b) A permanent position seasonal or intermittent employee who meets the following requirements:

(A) An individual hired for the first time if expected to work a 90-day continual period and works 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; or

(B) An individual hired for the first time working at least half-time or in a position classified as job share and who was not expected to work a 90-day or more continual period, and works more than a 90-day continual period. When the eligible employee submits enrollment forms to their agency, the employee is retro enrolled in benefits to the first day of the month following the individual’s hire date; or

(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) An appointed temporary or impermanent employee who (i) as of the date of hire, is expected to work an average of 30 or more hours per week for a 90-day continual period, or (ii) has worked an average of 30 hours or more per week for an initial measurement period, and is in a subsequent benefit eligible stability period.

(d) A current spouse, domestic partner, or an eligible dependent child listed by the person who is eligible under subsection (1)(a), (b), (c), or (d) of this rule 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).

(e) 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 family members 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; Administrative correction 2-24-12; PEBB 3-2014(Temp), f. & cert. ef. 11-12-14 thru 5-10-15

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

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