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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 20

ENROLLMENT RULES

101-020-0002

Plan Effective Dates, Employee Eligibility Continuation, and Plan 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) PEBB’s eligible employee benefits are in whole month increments for coverage and premium cost. There is no daily prorated coverage or monthly cost. PEBB’s core benefits are part of an Internal Revenue Service Code 125 Cafeteria plan. The premium contribution taken from the employee’s monthly pay must be in advance of the coverage. Employees work one month to earn coverage for the following month.

(3) The plan coverage effective date for newly eligible employees or for employees who receive approved qualified midyear changes is the first of the month following the later of, the agency’s receipt of all appropriate forms as required or electronic enrollment, 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.

(4) Continuation of Coverage requirements. A benefit eligible employee continuing employment:

(a) Within a current stability period remains benefit eligible for that stability period regardless of the number of paid regular status hours accrued in the month.

(b) In a permanent benefit eligible position, but who is not within a current stability period, must accrue a minimum of 80 paid regular status hours in a month to qualify for benefit coverage in the following month. The exception to the 80 hours is a newly eligible employee during the initial month of eligibility and some individuals during their return to work month. If the employee accrues less than 80 paid regular status hours in a given month, the employee’s benefits will end the last day of that month. The agency must send the employee a self-pay COBRA Enrollment Notice.

(5) 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.

(6) 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.

(7) Active benefit eligible employee core benefit termination dates:

(a) When an employee terminates employment, benefit coverage for the employee and covered family members will end regardless of whether the employee is within a current stability period as follows:

(A) On the last day of the month, when the employee accrues less than 80 paid regular status hours during the month the employment terminates.

(B) On the last day of the following month, when the employee accrues more than 80 paid regular status hours during the month the employment terminates.

(b) When the employee is a temporary or impermanent worker who is benefit eligible for the current stability period and has no paid regular status hours for at least 13 weeks, or for a period at least four weeks and longer than the prior period during which the employee was working, the employee’s benefits will end the last day of the month of that period. If the employee returns to work for the employer the employee must be considered a new employee.

(c) For employees of educational organizations, the time period applicable under this subsection is either 26 weeks or, if the employee’s prior period of employment was less than 26 weeks, a period that is at least four weeks long and one week longer than the prior period of employment.

(d) When an employee is in an employer approved period of leave without pay, (e.g., FMLA, CBIW), or is in a benefit eligible current stability period a termination of coverage occurs when the employee’s premium share is more than 30 days late. In order to terminate the coverage the agency:

(A) Must provide written notice to the employee that payment has not been received. The notice must be mailed to the employee at least 15 days before coverage terminates and the notice must advise the employee that coverage will be dropped on a specified date at least 15 days after the letter date, unless the payment is received by that specified date (30 days).

(B) When the employee has received the 15 day notice and payment is not received by the due date, coverage is terminated retroactively to the last day of the last month that employee premium was received.

(C) When coverage is terminated because of the employee’s failure to pay the premium share timely and the employee later returns from the leave within 12 months, the agency must reinstate employee to the benefits equivalent to those the employee would have if the leave had not been taken and premium payments missed. See OAR 1010-20-0045 Returning to Work.

Example: John is in a benefit eligible current stability period. His August premium share was paid with his August 1 pay (July pays August). John starts a leave without pay on August 1. His current stability period status allows John to continue enrollment in his health benefits for September, but only if he pays his premium share to his agency on time. His agency requires the following month premium share payment by August 27. John’s agency does not receive his payment, and the agency sends John a notice of non-payment by September 5. The notice provides a 15 day notice that payment must be made to the agency by September 28 or his enrollment will retroactively terminate to August 31 (the last day of the last month that premium was paid). John’s payment is not received within 30 days. John’s enrollment is terminated back to August 31 and he is sent a COBRA Election Notice. If the agency paid the premiums for September, reconciliation adjustments are made by PEBB and the agency. John returns to work in the middle of September. Upon John’s return to work, his previous benefits will be reinstated for an October 1 effective date, and he does not need to work 80 hours in the month of return for benefits in the following month because he came back within his current stability period status. (If John was not in a current benefit eligible stability status and was not in a leave without pay connected to a FMLA, CBIW, or other protected leave, he would need to work 80 hours in the month of return because of his leave without pay status was not within a protected leave class.)

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

(9) 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; PEBB 3-2014(Temp), f. & cert. ef. 11-12-14 thru 5-10-15

101-020-0005

Newly Hired and Newly Eligible Employee

(1) A newly hired or a newly eligible active 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 hired benefit eligible employee: or newly eligible employee can enroll in benefit plans for the following month regardless of the number of hours worked in the month of eligibility. In the months following eligibility to continue to receive coverage a benefit eligible employee:

(a) Who is not in a current benefit eligible stability period must meet the requirement of a minimum of 80 hours in paid regular status in each month to receive benefits the following month.

(b) Who is in a current benefit eligible stability period is eligible for benefits the following month regardless of the number of paid regular status hours.

(c) 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.

(d) 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 into a benefit eligible position and she 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 into a benefit eligible position and he 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; PEBB 3-2014(Temp), f. & cert. ef. 11-12-14 thru 5-10-15

101-020-0012

Working in Two or More Positions or for Two or More PEBB Participating Organizations

(1) An individual working in two or more positions or for two or more PEBB participating organizations must work at least half-time or be in a benefit eligible current stability period to be eligible for any PEBB-sponsored benefit plans. The exception is an eligible employee in a job share position. An employee is not eligible for more benefits than what one full time employee is eligible for.

(2) The eligible employee must enroll in benefit plans at the PEBB participating organization with the highest percentage of the FTE position.

(a) When the employee has equal FTE percentages with more than one PEBB participating organization, the employee must enroll in benefit plans through the organization with the earlier appointment date.

(b) When the employee has equal FTE percentages and simultaneous dates of employment with two or more PEBB participating organizations, the employee may choose to enroll in benefit plans through one of the organizations.

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 1-2001, f. & cert. ef. 9-6-01; PEBB 1-2004, f. & cert. ef. 7-2-04; PEBB 3-2004, f. & cert. ef. 10-7-04; Renumbered from 101-040-0015, PEBB 2-2007, f. 9-28-07, cert. ef. 10-1-07; PEBB 3-2014(Temp), f. & cert. ef. 11-12-14 thru 5-10-15

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

101-020-0020

Newborn and Adopted Child Enrollment

(1) An eligible employee's biological newborn child receives PEBB-sponsored medical and dental insurance coverage under the newborn's own coverage from the moment of birth through the first 31 days of life without completing PEBB forms. To continue coverage beyond the first 31 days of coverage the eligible employee must enroll the newborn child to their benefit plans within 30 days from the date of birth by submitting the correct enrollment update forms.

(2) An eligible employee's newly adopted child receives PEBB-sponsored medical and dental insurance coverage under the adopted child's own coverage from the date of the adoption decree or date of placement for adoption through the first 31 days without completing PEBB forms. To continue coverage beyond the first 31 days of coverage the eligible employee must enroll the adopted child to their benefit plans within 30 days from the date of the decree or placement by submitting the correct enrollment update forms. Placement for adoption requires the submission of an Affidavit of Dependency with enrollment forms with legal documentation of the placement.

(a) The eligible employee must submit the adoption agreement or placement agreement with the enrollment forms to the agency. Upon adoption completion, a copy of the finalized adoption document must be submitted to the employee’s agency.

(b) Claims payment will not occur prior to the adoption decree or placement for adoption date.

(3) A request to enroll a biological newborn or newly adopted child beyond 30 days of the date of birth, adoption decree, or placement for adoption is late enrollment as specified in OAR 101-020-0040.

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 1-2000, 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 1-2005, f. & cert. ef. 4-14-05; PEBB 2-2007, f. 9-28-07, cert. ef. 10-1-07; PEBB 2-2008, f. & cert. ef. 8-1-08; PEBB 1-2013, f. & cert. ef. 9-24-13

101-020-0025

Removing an Ineligible Individual from Benefit Plans

(1) All eligible employees have 30 days from the date a spouse, domestic partner, or dependent child loses eligibility to remove the individual from PEBB coverage. When agencies receive update forms to remove ineligible individuals within the required 30 days coverage terminations are prospective, ending the last day of the month following agency receipt of the appropriate forms.

Example: Ann’s divorce is final on June 6 and she submits the update form to remove her ex spouse to her agency on June 22. The agency terminates Ann’s former spouse PEBB coverage effective June 30. Ann’s former spouse will receive a COBRA notice of availability.

(2) An employee’s failure to report a spouse, domestic partner, or dependent child’s loss of eligibility within 30 days of the event is an intentional misrepresentation of a material fact of enrollment by the employee. PEBB will rescind all coverage back to the last day of the month and plan year when eligibility was lost. Ineligible individuals removed more than 60 days from the eligibility loss date will receive a COBRA unavailability letter due to the employee’s late notification.

(a) At an agency’s discretion, an employee may become liable to repay the agency for premiums paid by the agency while the individual was ineligible.

(b) An employee may become liable for repayment of insurance claims incurred and paid by a plan for the ineligible individual according to contract agreements between PEBB and the plan.

(c) An employee may face disciplinary action by an agency.

Example: Ann’s divorce is final on June 6. Ann submits her update form to her agency October 10. The agency forwards the update forms to PEBB. PEBB terminates the ineligible individual’s coverage the last day of the month that the divorce was final. The ex spouse will receive a COBRA unavailability letter.

(3) Premium refunds to agencies:

(a) Premium refunds for rescinded coverage may be available according to PEBB’s contract agreement with each plan.

(b) An agency will not receive a premium equivalent refund from a PEBB self-insured plan for an ineligible individual whose coverage is rescinded.

(3) A 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, eligibility violations, or policy term violations. Violations include but are not limited to, fraud, material misrepresentation, or concealment. When a plan removes an employee from coverage for violations:

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

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

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

(4) When discovered, PEBB may rescind coverage for individuals identified as ineligible to the end of the month that eligibility is lost, whether or not requested by the employee within the 30 day period.

Example 1: Cindy’s divorce was final September 14. Cindy did not submit update forms; instead, she removed her spouse’s coverage during open enrollment in October. Open Enrollment removal by the employee will result in continued coverage for the former spouse until December 31 of the current plan year. PEBB and the agency identify and verify the former spouse as ineligible for coverage early in December. PEBB retro terminates the ex-spouse’s coverage to September 30. The ex spouse receives a notice of COBRA unavailability due to the late employee notification. Cindy may be responsible for claims paid or agency premiums paid for her former spouse after September 30.

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; 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 1-2013, f. & cert. ef. 9-24-13

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

101-020-0040

Late Enrollment

(1) Late enrollment occurs when an eligible employee fails to enroll themselves, eligible family members, domestic partner, or a domestic partner’s child in benefit plans within the required time period. Excluding section (4) of this rule, PEBB must review all late enrollment requests.

(2) An enrolled employee requesting late enrollment for a family member, domestic partner, or domestic partner’s dependent child must provide supporting documentation that shows an inability to enroll the individual when first eligible because of circumstances beyond the employee’s control.

(3) A newly eligible employee approved for late enrollment receives only employee basic life insurance coverage and may only elect medical and dental coverage for themselves, spouse, domestic partner, or dependent children. If late enrollment is approved, benefit coverage is effective the first of the month following receipt of the completed enrollment forms.

(4) Following receipt of the completed forms, agencies are responsible for approving the late enrollment of the employee's biological newborn dependent child during the first twelve months of life. The enrollment is always retroactive to the first of the month following the date of birth.

Stat. Auth.: ORS 243.061 - 243.302
Stats. Implemented: ORS 243.061 - 243.302, 659A.060 - 659A.069, 743.600 - 743.602 & 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 1-2006, f. & cert. ef. 11-28-06; 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

101-020-0045

Returning to Work

(1) Refer to the following rules for an employee returning to 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) A benefit eligible employee who is not in a current benefit eligible stability period and is returning to paid regular status must work at least half-time in the month of return to be eligible for core benefits and optional plan coverage the following month if returning from:

(a) A leave without pay that is not listed in subsection (1) of this rule and has a break in coverage; or

(b) A reduction in hours below benefit eligibility criteria, unless the employee is a benefit eligible employee in a job share position.

(3) Any benefit eligible employee returning to paid regular status within 30 days without a break in core coverage from a leave not listed in (1) of this rule or from an employment termination without a break in coverages will have all previous coverage reinstated. The employee cannot make benefit plan changes. A benefit eligible employee who:

(a) Is not in a current benefit eligible stability period, must work at least half-time in the month of return for benefits to be active the following month.

(b) Is in a current benefit eligible stability period will receive benefits in the month following the return to work regardless of the number of paid regular status hours in the month of return.

Example 1: Gary is employed by an agency and receives PEBB benefits. On May 20 Gary begins a leave without pay that does not provide for continued benefits throughout the leave. Gary worked more than 80 hours in May, and the agency correctly schedules his benefit coverage end date as June 30. Gary returns to paid regular status June 5, within 30 days of the leave start and with no break in core coverage. The agency will reinstate Gary’s coverage with an effective date of July 1. If Gary is in a current benefit eligible stability period, his return to paid regular status will reinstate his coverage for July 1. If he is not in a current benefit eligible stability period, he must work 80 hours in June for his coverage continuation in July. Gary cannot make any election changes to his enrollments.

Example 2: Mark retires and terminates employment at his agency on June 2. Mark has not worked 80 hours in the month of June; therefore, his agency ends his coverage on June 30. Mark is rehired by an agency into a benefit eligible position, and his hire date is July 1. This is less than 30 days; however, a break in coverage occurred on June 30. Even if Mark is in a current benefit eligible stability period his benefits will not be reinstated until August 1.

(4) A temporary or impermanent position benefit eligible employee who is in a current benefit eligible stability period has no hours of service for either 13 weeks, or a period lasting at least four weeks and longer than the employee’s prior employment, is considered a new employee upon return to regular pay status. Benefits are not reinstated.

(5) A permanent previously benefit eligible employee returning to a permanent benefit eligible position within 12 months of the prior core benefit termination date is not required to work at least half-time in the month of 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. The reinstatement excludes Health and Dependent Care Flexible Spending Accounts, Commuter Accounts, and Long Term Care. The employee may make midyear plan changes to their enrollments within 30 days of the return to work date. This rule shall apply whether or not the employee is benefit eligible for the current stability period.

(6) Any previously active benefit eligible employee returning to paid regular status in a benefit eligible position after a termination of core benefits of 12 months or longer 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; PEBB 3-2014(Temp), f. & cert. ef. 11-12-14 thru 5-10-15

101-020-0047

Transfer

(1) When an eligible employee transfers from one PEBB participating organization to another, the organization losing the employee must pay the benefit amount for the month following the transfer, regardless of hours worked at that organization.

Exception: An eligible employee transfers mid-month from part-time to full time and submits enrollment forms to the gaining organization prior to the end of the month. In this case, the gaining organization pays the full benefit amount for the month following the transfer.

(2) All PEBB benefit plan elections transfer from the PEBB organization losing the employee to the organization gaining the employee without a lapse in insurance coverage.

(3) Benefit plan changes or elections are not permitted solely due to a transfer.

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 1-2001, f. & cert. ef. 9-6-01; 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; Renumbered from 101-040-0020, PEBB 2-2007, f. 9-28-07, cert. ef. 10-1-07

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

101-020-0060

Dependent Care Flexible Spending Account

(1) An eligible employee may enroll in a pretax Dependent Care Flexible Spending Account (Dependent Care FSA). The employee must enroll each year during open enrollment to participate in a Dependent Care FSA in the new plan year. The employee may enroll for Dependent Care when:

(a) Their expenses qualify for reimbursement for:

(A) The care and well-being of a dependent child under the age of 13; or

(B) The care of a disabled dependent who is incapable of self-care and who spends at least eight hours per day in the employee's home; and

(b) The employee is:

(A) Single, or

(B) Married, and the expenses are necessary for both the eligible employee and the spouse to work, or

(C) Married, and the spouse is either disabled, actively seeking employment, or a full time student for some part of each of five months during the year.

(2) An eligible employee may not allocate more than $5,000 to any pretax Dependent Care FSA per plan year or more than $2,500 per plan year if married and filing a separate income tax return.

(3) PEBB requires a minimum monthly contribution amount to participate. An employee may make only one contribution in each month. An employee may not change their monthly contribution unless they experience a qualified mid-year plan change event.

(4) The Dependent Care FSA period of coverage is the plan year. The exception is for employees who terminate participation, in which case it means the portion of the plan year before the active participation end date. Active participation ends the last day of the month that a contribution is received for that month.

(5) Reimbursement of eligible expenses may occur only for the period of coverage in which the participation was active, provided the claim is filed within the eligible plan year. The exception is eligible expenses incurred in the month following participation or cessation of eligibility, if the month is in the current plan year (not the grace period) and the eligible employee files a claim within 90 days after the date participation ends.

(6) Final contribution at termination of employment or leave.

(a) An OSPS employee will not have a contribution taken from their final paycheck.

Example: Ann’s last day of work is September 16. Her final check will not have a contribution taken. Ann’s participation ends September 30 and her period of coverage could be through October 31.

(b) An OUS employee who meets the 80-hour work rule will have a contribution taken from their final paycheck, in accordance with OAR 101-020-0002.

Example 1: Ann’s last day of work is June 6. She has less then 80 hours of work for the month. Ann’s final check will not have a contribution taken. Ann’s participation ends May 31 and her period of coverage could be through June 30.

Example 2: Ann’s last day of work is June 20. She has more than 80 hours of work for the month. Ann’s final check will have a contribution taken. Ann’s participation ends June 30, and her period of coverage could be through July 31.

(7) The Dependent Care FSA is subject to the "Use It or Lose It" rule. Any funds remaining in the account beyond March 31, of the following plan year forfeit to PEBB

(8) An eligible employee who separates from the employer and later returns to work within 12 months of the separation is not reinstated in the Dependent Care FSA. They may enroll within 60 days of their eligibility date.

Stat. Auth.: ORS 243.061 - 243.302
Stats. Implemented: ORS 243.061 - 243.302
Hist.: PEBB 1-1999, f. 12-8-99, cert. ef. 1-1-00; 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; Renumbered from 101-040-0050, PEBB 2-2007, f. 9-28-07, cert. ef. 10-1-07; PEBB 3-2009, f. 9-29-09 cert. ef. 10-1-09

101-020-0065

Health Flexible Spending Arrangement

(1) An eligible employee may enroll in a pretax Health Flexible Spending Arrangement (Health FSA). The employee must enroll each year during open enrollment to participate in a Health FSA in the new plan year. The Board determines the annual maximum contribution amounts.

(2) PEBB requires a minimum monthly contribution amount to participate. An employee may make only one contribution in each month. An employee may not change their monthly contribution unless they experience a qualified mid-year plan change event.

(3) An eligible employee approved for FMLA, CBIW, or active Military Duty Leave can request to prepay their Health FSA contribution if prepayment:

(a) Totals the required contribution amount for the leave period;

(b) Is for the current plan year;

(c) Is completed by the last paycheck prior to the start of the leave and;

(d) Is requested and submitted on the appropriate form to PEBB.

(4) An eligible employee may request a qualified reservist distribution from a Health FSA account when ordered or called to active military duty for a period of at least 180 days or for an indefinite period. The eligible employee must be a member of the Army National Guard of the United States, the Army Reserve, the Navy Reserve, the Marine Corps Reserve, the Air National Guard of the United States, the Air Force Reserve, the Coast Guard Reserve, or the Reserve Corps of the Public Health Service.

(a) The following conditions must be met by the eligible employee in order to elect the qualified reservist distribution:

(A) The order or call to active military duty is on or after the plan year date of January 1, 2009.

(B) Contributions to the Health FSA account for the plan year as of the date of the request for a distribution exceed the reimbursements received from the Health FSA Account for the plan year as of that date.

(C) The agency receives a copy of the order or call to active duty along with the distribution request form. An order or call to active duty of less than 180 days duration must be supplemented by subsequent calls or orders to reach a total of 180 or more days.

(D) During the period beginning with the date of the order or call to active duty and ending on the last eligible day of the plan year during which the order or call occurred, the employee submits a qualified reservist distribution election form to the agency.

Example: An eligible employee is called to active duty on September 13, 2009 and wants a Health FSA qualified reservist distribution. The employee must request the qualified reservist distribution between September 13, 2009 and March 31, 2010.

(b) The distribution amount paid to the eligible employee is equal to the contributions to the Health FSA Account for the plan year as of the date of the distribution request, minus any reimbursements received by the employee for the plan year as of that date. A qualified reservist distribution is included in an eligible employee’s gross income and reported as wages for the year it is paid.

Example: An eligible employee elects Health FSA benefits of $1,000 for the 2009 plan year, and during the first six months of the plan year, makes Health FSA contributions of $500 and receives Health FSA reimbursements of $200 for substantiated medical care expenses. The employee is called to active duty for an indefinite period and on June 30 requests a reservist distribution from the agency. The employee will receive a distribution of $300, and the agency must add that amount to the employees’ taxable wages for the 2009 tax year.

(c) An employee forfeits the right to receive reimbursements for medical care expenses incurred during the period that begins on the date of the distribution request and ending on the last day the Plan Year. The Health FSA Account is closed as of the date of request for a reservist distribution.

(5) The Health FSA period of coverage is the plan year. The exception is for employees who terminate participation, in which case it means the portion of the plan year before the active participation end date. Active participation ends the last day of the month that a contribution is received for that month.

(6) Reimbursement of eligible expenses may occur only for the period of coverage in which participation was active, provided the claim is filed within the eligible plan year. OUS and academic OSPS employees that contribute during the plan year based on 9 or 10-month contributions are considered actively participating during the months of no contribution, as scheduled at the time of enrollment.

(7) Final contribution at termination of employment or leave without prepayment.

(a) An OSPS employee will not have a contribution taken from their final paycheck.

Example: Ann’s last day of work is September 16. Her final check will not have a contribution taken. Ann’s participation ends September 30 and her period of coverage is through September 30.

(b) An OUS employee who meets the 80-hour work rule will have a contribution taken from their final paycheck, in accordance with OAR 101-020-0002.

Example 1: Ann’s last day of work is June 6. She has less then 80 hours of work for the month. Ann’s final check will not have a contribution taken. Ann’s participation ends May 31 and her period of coverage is through May 31.

Example 2: Ann’s last day of work is June 20. She has more than 80 hours of work for the month. Ann’s final check will have a contribution taken. Ann’s participation ends June 30, and her period of coverage is through June 30.

(8) The Health FSA is subject to the "Use It or Lose It" rule. Any funds remaining in the account beyond March 31 following the plan year forfeit to PEBB.

(9) An eligible employee ending employment or on leave of absence may continue to participate in the Health FSA up to the end of the current plan year through COBRA if:

(a) There is a positive balance in the eligible employee’s account; and

(b) The eligible employee self-pays contributions to the account post-tax.

(10) An eligible employee who separates from the employer and later returns to work within 12 months of the separation is not reinstated in the Health FSA. They may enroll within 60 days of their eligibility date.

Stat. Auth.: ORS 243.061 - 243.302
Stats. Implemented: ORS 243.061 - 243.302
Hist.: PEBB 2-2004(Temp), f. 7-13-04, cert. ef. 8-31-04 thru 2-27-05; PEBB 3-2004, f. & cert. ef. 10-7-04; PEBB 3-2005, f. 8-31-05, cert. ef. 9-1-05; Renumbered from 101-040-0055, PEBB 2-2007, f. 9-28-07, cert. ef. 10-1-07; PEBB 3-2009, f. 9-29-09 cert. ef. 10-1-09

101-020-0066

Public Employees' Benefit Board Appeal Procedure

(1) Eligible employees may submit appeal requests to PEBB concerning PEBB policy, eligibility, or plan enrollments. PEBB staff and the Board Appeals Subcommittee use relevant state and federal regulations, policy, PEBB’s documented Internal Revenue Code (IRC) 125 Cafeteria plan, and Oregon Administrative Rules to provide appeal decisions.

(2) PEBB does not accept appeals related to contracted plans or plan administrators, such as but not limited to medical, dental, life, disability, COBRA, and long term care, services, decisions, or claims. The Board’s Appeal Committee may hear appeals concerning benefit design.

(3) If PEBB rescinds plan coverage due to an individual’s ineligibility for coverage, the ineligible individual may appeal the rescission decision to PEBB using this rule. Until the appeal process for the rescission is exhausted the individual’s premium and claim payments will continue as if the rescission had not occurred. Upon final appeal determination and the rescission is upheld the employee will be responsible to pay all claims and premium payments paid by the Plan or PEBB during the period of ineligibility.

(4) Eligible Employees, or individuals who believe they received an incorrect or unfair decision from PEBB staff, an employing agency, retiree plan administrator, or an individual notified of a rescission have three levels of PEBB appeal.

(a) Level One: An eligible employee who believes he or she received an incorrect or unfair decision from PEBB, an employing agency, or retiree plan administrator, or an individual notified of a rescission may appeal the decision to PEBB. The appeal must be within 30 days the decision or action considered by the employee or individual as unfair or incorrect.

(A) The employee or individual must submit the appeal to PEBB using the correct forms and provide any supporting documentation for the appeal.

(B) A PEBB Benefit Analyst will review the appeal documents and may request additional information from the employee, individual, employer, or plan. Information requested from the employee must be received within 10 business days or PEBB will close the appeal.

(C) The analyst will complete the review of the appeal within 30 days from the date PEBB receives all necessary appeal documentation. PEBB will notify the employee or individual of any delay.

(D) When the review is complete, the analyst will provide a written letter of explanation and determination to the employee or individual. If the appeal is denied, continued appeal steps will be included in the document.

(b) Level Two: An eligible employee or an individual who is dissatisfied with a Level One appeal determination may within 30 days of the level one determination letter request a Level Two review from the PEBB Plan Design Manager.

(A) The employee or individual must submit the request to the Plan Design Manager in writing and provide any new supporting documentation. The manager may request additional information from the employee, the employer, or plan. Information requested from the employee must be received within 10 business days or PEBB will close the appeal.

(B) The Plan Design Manager will review the request and determine whether to provide a determination to the employee or individual, or to move the request directly to the third level of appeals.

(C) If the Plan Design Manager completes a review, the employee or individual will receive a written letter of explanation and determination. If the appeal is denied, continued appeal steps will be included in the document.

(D) If the Plan Design Manager sends the appeal directly to Level Three without providing a determination, the employee will receive written notice.

(c) Level Three: An eligible employee or individual receiving both a first and second level appeal denial can request that the Board Appeals Subcommittee review the appeal. The Subcommittee can also review appeals submitted directly to them by the Plan Design Manager. The Board Appeals Subcommittee will provide a final decision to the employee or the individual.

(A) An employee or individual requesting a Level Three review must submit the request in writing to the Plan Design Manager within 30 days of the Level Two determination letter date.

(B) The Subcommittee appeal determination requires a majority vote of the members. If an agreement cannot be reached, the appeal may be referred to the full Board. Decisions by the full Board require a majority vote. The Appeals Subcommittee may render a decision to the employee or individual and also refer the issue to the full Board for a benefit policy review.

(C) When the Subcommittee completes a review, or in the case of a full Board review, the employee or individual will receive a written explanation and determination within 30 days after the meeting.

(5) An individual may appeal the Subcommittee or Board’s decision as provided under the Oregon Administrative Procedures Act, ORS Chapter 183

Stat. Auth.: ORS 243.061 - 302
Stats. Implemented: ORS 243.061 - 302
Hist.: PEBB 3-2010, f. 9-23-10, cert. ef. 10-1-10; PEBB 1-2013, f. & cert. ef. 9-24-13

101-020-0070 [Renumbered to 101-030-0070]

The official copy of an Oregon Administrative Rule is contained in the Administrative Order filed at the Archives Division, 800 Summer St. NE, Salem, Oregon 97310. Any discrepancies with the published version are satisfied in favor of the Administrative Order. The Oregon Administrative Rules and the Oregon Bulletin are copyrighted by the Oregon Secretary of State. Terms and Conditions of Use

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