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The Oregon Administrative Rules contain OARs filed through April 15, 2013 
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OREGON HEALTH AUTHORITY,
PUBLIC EMPLOYEES'
BENEFIT BOARD
OREGON HEALTH AUTHORITY,
PUBLIC EMPLOYEES'
BENEFIT BOARD
ENROLLMENT RULES
101-020-0002
Eligible Employee Plan Effective and 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) The active plan coverage effective date for newly eligible employees or for employees who have qualified mid year change events is the first of the month following the later of the agency’s receipt of all appropriate forms as required by the employee’s enrollment elections or electronic equivalent, 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.
(3) 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.
(4) 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.
(5) Active eligible employee core benefit termination dates:
(a) If an active eligible employee accumulates less than 80 paid regular hours in a month and is not within an employer’s approved leave with core benefit continuation, or terminates employment, benefit coverage in effect that month will end the last day of the month.
(b) If an active eligible employee accumulates 80 or more paid regular hours in a month, and is in a leave without pay status that is not within an employer’s approved leave with core benefit continuation, or terminates employment, the core benefit coverage in effect that month ends the last day of the following month.
(6) Self-pay individuals and retired employees’ benefits terminate the last day of the last period for which the required premium contribution is paid.
(7) 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
101-020-0005
Newly Hired and Newly Eligible Employee
(1) A newly hired or newly eligible 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 eligible employee:
(a) May enroll in benefit plans for the following month regardless of the number of hours worked in the month of eligibility; however, the employee must meet the requirement of a minimum of 80 hours in paid regular status in the following months to continue to receive coverage.
(b) 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.
(c) 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 and 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 and 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
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 to be eligible for any PEBB-sponsored benefit plans. The exception is eligible employees in job share positions. An employee is not eligible for more benefits than what one full time employee would receive.
(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
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 add the newborn child to their benefit plans within 60 days from the date of birth by submitting the completed 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 add the adopted child to their benefit plans within 60 days from the date of the decree or placement by submitting the completed enrollment update forms.
(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 documents must be filed with the agency.
(b) Claims payment will not occur prior to the date of decree or placement.
(3) A request to enroll a biological newborn or newly adopted child beyond 60 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
101-020-0025
Removing an Ineligible Individual from Benefit Plans
(1) An ineligible individual must be removed from insurance coverage within 60 days of the loss of eligibility. The eligible employee is responsible for removing ineligible individuals from their insurance coverage by submitting completed enrollment update forms to the agency. Insurance coverage ends the last day of the month that eligibility is lost.
(2) PEBB must review all requests to remove an ineligible individual submitted after 60 days of the loss of eligibility. A COBRA unavailability letter will be sent to ineligible individuals removed due to late notification by the eligible employee.
(3) An eligible employee may be responsible to repay claims paid by benefit plans for an ineligible individual during any period of ineligibility.
(4) PEBB will remove individuals identified as ineligible from insurance coverage retroactive to the end of the month that eligibility is lost, whether or not requested by the employee within the 60 day period.
Example 1: Cindy’s divorce was finalized September 14. The spouse lost PEBB eligibility September 30 due to the divorce. Cindy did not submit update forms, instead she removed her spouse during Open Enrollment in October. This resulted in continued coverage for the former spouse to January 1 of the new plan year. The error was identified, PEBB removed Cindy’s former spouse from coverage effective September 30 and a COBRA unavailability letter was sent to the former spouse. Cindy may be responsible for claims paid for her former spouse after September 30.
Example 2: John’s dependent child, who is not disabled, reaches age 24, PEBB automatically removes the child from coverage the last day of the month in which the child turned 24.
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. 12-10-12, 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
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 active or 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) An eligible employee returning from a (i) leave without pay not in (1) of this rule, or a (ii) reduction in hours below benefit eligibility criteria must work at least half-time in the month of return to be eligible for core benefits and optional plan coverages the following month. The exception is eligible employees in job share positions.
(3) An eligible employee returning to paid regular status within 30 days without a break in core benefit plan coverage will have all the employee’s previous coverage reinstated and cannot make benefit plan changes.
Example: Gary begins leave without pay on May 20 and is not planning to return until the fall. Gary worked more than 80 hours in May, and the agency correctly schedules his coverage end date as June 30. However, Gary returns to work on May 25 (within 30 days and with no break in core plan coverages). The agency will reinstate Gary’s coverage with an effective date of July 1. Gary cannot make any election changes to his enrollments. Gary will need to work at least 80 hours in June for coverage continuation in July.
(4) An eligible employee returning to paid regular status within 12 months of the core benefit coverage termination date following a layoff or termination of employment is not required to work at least half-time in the month they 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. This excludes Health and Dependent Care Flexible Spending Accounts and Long Term Care. The employee may make midyear plan changes within 30 days of the date they return to work.
(5) An eligible employee returning to active or paid regular status after 12 months from the core benefit coverage termination date 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
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, the Operations Subcommittee, and the Board 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.
(3) Beginning in 2011, 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, if 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 notified of coverage rescission, have four 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 within 30 days of that decision.
(A) The employee or individual must submit the appeal to PEBB using the correct forms and provide any supporting documentation for appeal. .
(B) A PEBB Benefit Analyst will review the appeal documents and may request additional information from the employee, individual or the employer. PEBB must receive information requested from the employee or individual within 10 business days or the appeal is closed.
(C) The analyst will complete review of the appeal within 30 days of the date PEBB receives all the necessary appeal documentation or notify the employee or individual if a decision will require longer than 30 days.
(D) When complete, the analyst will provide a written explanation and determination to the employee.
(b) Level Two: An eligible employee or an individual notified of rescission who is dissatisfied with a Level One appeal determination may within 30 days of the 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 that would support the request. The manager may request additional information from the employee or the employer. Requested information from the employee or individual must be received with 10 business days or the appeal is closed.
(B) The Plan Design Manager will review the request and determine whether to provide a determination to the employee or move the request directly to Level Three. The Plan Design Manager may request that the Administrator or the Administrator’s designee assist in the appeal review and determination.
(C) When the Plan Design Manager completes a review, the employee or rescission individual will receive a written explanation and determination within 30 days of PEBB receiving all the necessary appeal documentation. When the Plan Design Manager sends the appeal to Level Three without providing a determination, the employee will receive notice.
(c) Level Three: An eligible employee or a plan rescission individual receiving both a first and second level denial may request that the Operations Subcommittee review the appeal. The Subcommittee may review appeals submitted directly by the Plan Design Manager.
(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 Operations Subcommittee may recommend a review and determination of the appeal by the Board without providing a decision to the employee or individual. The employee or individual will receive notice of the recommendation.
(C) When the Subcommittee completes a review, the employee or individual will receive a written explanation and determination within 30 days after the next regularly scheduled meeting.
(d) Level Four: An eligible employee dissatisfied with a determination by Operations Subcommittee or a rescission individual may request a review and determination of the appeal by the Board. The Board may review appeals submitted directly by the Operations Subcommittee.
(A) An employee or individual requesting a Level Four review must submit the request in writing to the Plan Design Manager within 30 days of the Operations Subcommittee determination letter date.
(B) When the board completes a review, the employee or individual will receive a written explanation and determination within 30 days after the next regularly scheduled meeting. Should the decision require longer than 30 days the Board will send notice to the employee.
(5) An individual may appeal the 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
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