Rule 111-4-1-.01 - Definitions(1)"Active" means that the Employee is receiving compensation or is on Approved Leave of Absence Without Pay through a department, school system, Local Employer, agency, authority, board, commission, county department of family and children services, county department of health, community service board, or Contract Employer and for whom the Employee's cost of Coverage is stated as a payroll Deduction or Reduction.(2)"Acts" or "The Acts" or "The Health Insurance Acts" mean the legislative Acts that establish the Health Insurance Plans for State Employees, Teachers, and Public School Employees and are designated in the Official Code of Georgia Annotated as Article 1 of Chapter 18 of Title 45 and Articles 880 and 910 of Chapter 2 of Title 20.(3)"Administrator" means the Department of Community Health or the Commissioner of the Department of Community Health.(4)"Administrative Services" means the services that are provided by contract for a self-insured Health Benefit Plan.(5)"Approved Leave of Absence Without Pay" means a period of time approved by the appropriate organizational official during which the Employee is absent from work and is not in pay status.(6)"Annual Required Contribution" means an actuarially determined amount to pay for future OPEB liability over a period of years.(7)"Beneficiary" means an Employee, Surviving Spouse, divorced or legally separated Spouse, or eligible Dependent child who loses Coverage under these regulations.(8)"Benefits" mean the schedule of Benefits of health care services eligible for approval of payments under the Options approved by the Board.(9)"Board of Community Health" or "Board" means the governing body authorized to exercise jurisdiction over the SHBP pursuant to O.C.G.A. § 31-2-3.(10)"Cafeteria Plan" means a plan which meets the requirements of the regulations of the Internal Revenue Service under Internal Revenue Code (IRC) 125.(11)"Certificated Capacity" means the Employee holds valid certification; is not assigned to a position that requires certification as a qualification; the Employee's compensation is determined, at least in part, based upon the certificate; and the Employee is a member of the Teachers Retirement System or other Public School Teacher retirement system.(12)"Certificated Position" means the Employee holds valid certification; is assigned to a position that requires certification as a qualification; the Employee's compensation is determined, at least in part, based upon the certificate; and the Employee is a member of the Teachers Retirement System or other Public School Teachers retirement system.(13)"Claim" means any bill, invoice, or other written statement from a specific provider for health care services or supplies submitted in accordance with the requirements of the SHBP for a specific eligible Member.(14)"Commissioner" means the Commissioner of the Department of Community Health as created by O.C.G.A. § 31-2-6.(15)"Contract Employee" means a person employed by one of the entities that contracts with the Board of Community Health to provide health benefit Coverage under the SHBP, and who is not considered to be an independent contractor.(16)"Contract Employer" means one of the organizational entities that has elected to contract with the Board of Community Health for inclusion of their Employees in the SHBP.(17)"Contribution" means the amount or percentage of salaries to be paid by an Employing Entity or State Department of Education for Employees and Retirees for health benefit Coverage.(18)"Coverage" means the type, Tier, and Option of contract offered to an Enrolled Member pursuant to the Health Insurance Acts. "Coverage" does not include TRICARE Supplemental Coverage.(19)"Covered Dependent" means any individual eligible under these regulations and for whom the Premium has been paid by the Employee, Retiree, or Extended Beneficiary.(20)"Creditable Coverage" means health insurance that may serve to reduce a Pre-existing Condition limitation period. Creditable Coverage shall include health plan offerings under the following type plans: group health plans; individual health policies; Health Maintenance Organizations (HMOs); Medicaid; Medicare; or other governmental health programs. Disease specific policies (i.e., cancer insurance), disability insurance, and insurance that provides incidental health insurance (i.e., auto insurance) is not Creditable Coverage.(21)"Deduction" or "Reduction" means the Premium amount to be remitted to the Administrator as the Employee's or Retiree's share of the cost of the elected Coverage.(22)"Dependent" means any eligible Spouse, Dependent child, or Totally Disabled Child.(23)"Employee" means any eligible, Active State Employee, Teacher, or Public School Employee.(24)"Employing Entity" means any department, school system, Local Employer, Contract Employer, agency, authority, board, commission, county department of family and children services, county department of health, community service board or retirement system that employs or issues an annuity check to an Employee, Contract Employee or Retiree as defined in these regulations.(25)"Enrolled Member" means the contract holder who may be the Employee, Retiree, Contract Employee, or Extended Beneficiary who is currently enrolled in Coverage and who has paid the necessary Deduction or Premium for such Coverage.(26)"Extended Beneficiary" means the individual who was covered as an Active or Retired Employee, Employee on Approved Leave of Absence Without Pay or person who was covered as a Spouse or eligible Dependent of an Active or Retired Employee or Employee on Approved Leave of Absence Without Pay on the day SHBP Coverage was lost as a result of a Qualifying Event under the requirements of federal law and regulation known as the Consolidated Omnibus Budget Reconciliation Act (COBRA), as amended.(27)"Fund" or "Health Benefit Fund" or "Health Insurance Fund" means the State Employees Health Insurance Fund, the Teachers Health Insurance Fund, and the Public School Employees Health Insurance Fund.(28)"Georgia Retiree Health Benefit Fund" or "GRHBF" means the fund which provides for costs of retiree post employment health insurance benefits. The fund shall be a trust fund of public funds; the Board in its official capacity shall be the fund's trustee; and the Commissioner in his or her official capacity shall be its administrator.(29)"Group" means all eligible Employees authorized under a specific chapter, article or part of the Official Code of Georgia Annotated for Coverage under the SHBP.(30)"Health Maintenance Organization" or "HMO" means an organization authorized and certified to provide services under Chapter 21 of Title 33 of the Official Code of Georgia Annotated.(31)"Local Employer" means a county or independent board of education, regional or county libraries of Georgia, the governing authority of the Georgia Military College, or Regional Educational Service Areas.(32)"Managed Care Plan" means plans that provide health Coverage through a specified network of providers with benefit differentials in cost sharing between in-network and out-of-network providers.(33)"Medicare Advantage" means an Option that is offered to Retirees and is approved through the Centers for Medicare and Medicaid Services (CMS) as a Medicare Advantage plan under the Medicare Prescription Drug, Improvement and Modernization Act of 2003 and federal regulations thereunder.(34)"Member" means a benefit eligible or ineligible Employee, former Employee, Retiree, or Extended Beneficiary.(35)"Option" means a type of benefit schedule or premium rating category that is offered to an eligible Member through the SHBP.(36)"Other Post Employment Benefits" or "OPEB" means retiree post-employment health insurance benefits.(37)"Partial Disability" means the Employee is unable to perform the normal, full-time duties of the individual's occupation or employment due to disability, but is certified by his/her physician to return to work on a part-time basis following a period of disability for a fixed period of time in that individual's occupation or in a modified work capacity.(38)"Payor, Primary" means the entity which is required by contract or law to reimburse or pay for covered health services without regard to any other benefit entitlement or contractual provision.(39)"Payor, Secondary" means the entity which does not have the primary liability for providing benefit reimbursement for covered health services.(40)"Plan" or "Health Insurance Plan" means the insurance Options formed by the combination of Health Insurance Plans for State Employees, Teachers, and Public School Employees.(41)"Plan Year" means the twelve-month period beginning on January 1, and ending on the following December 31. The Commissioner shall have the flexibility to modify the SHBP Plan Year.(42)"Pre-existing Condition" is a term defined by the Health Insurance Portability and Accountability Act of 1996 and regulations thereunder. In general, it means a sickness, injury, or other condition (except for pregnancy) for which medical advice, diagnosis, care or treatment was recommended or received within the six (6) months immediately before Coverage began under the Plan.(43)"Premium" means the Enrolled Member's cost as set by the Board of Community Health for the elected Coverage(44)"Public School Employee" means a person who is employed by the local school system, meets the eligibility requirements under these regulations and is receiving a salary for services.(45)"Qualifying Event" means an event as defined by federal law or regulation that authorizes: (a) eligibility for Extended Coverageor (b) change in coverage election under a health benefit plan. Qualifying Events include changes in employment or family status as outlined in Sections 111-4-1-.06, 111-4-1-.07, and 111-4-1-.08 of these regulations.(46)"Rate" means an amount set by the Board for the Enrolled Member Premium or an amount or percentage of salary set by the Board as the Employer's Contribution.(47)"Regular Insurance" means Options that are not Medicare Advantage Options.(48)"Retired Employee" or "Retiree" or "Annuitant" means a former State Employee, former Teacher, or former Public School Employee who met the eligibility criteria when Active or was included by specific legislation and who receives a monthly benefit from the Employees' Retirement System, Georgia Legislative Retirement System, Teachers Retirement System, Public School Employees Retirement System, Superior Court Judges Retirement System, District Attorneys' Retirement System, or local school system retirement system and an eligible and former Employee of a county department of family and children services or county department of health who receives a monthly benefit from the Fulton County Retirement System. In the case of a county health department Employee, the Employee must have been covered as an Active Enrolled Member and continued Coverage upon receiving an annuity from the Fulton County Retirement System. Retiree shall also include Enrolled Members who remit payment directly to the SHBP and who are eligible for Coverage as a Surviving Spouse of the eligible Employee or Retiree, and Extended Beneficiary who is eligible by virtue of State law, or an Annuitant whose monthly benefit from a retirement system is insufficient to pay the Premium for the Coverage in which enrolled.(49)"Retiring Employee" means a Enrolled Member who is eligible to receive an immediate retirement benefit payment from the Employees' Retirement System, Georgia Legislative Retirement System, Teachers Retirement System, Public School Employees Retirement System, Superior Court Judges Retirement System, District Attorneys' Retirement System or local school system retirement system or an Enrolled Member of a county department of family and children services or county department of health who is eligible to receive an immediate retirement benefit payment from the Fulton County Retirement System.(50)"Spouse" means an individual who is not legally separated, who is of the opposite sex to the Enrolled Member and who is legally married or who submits satisfactory evidence to the Administrator of common law marriage to the Employee or Retired Employee entered into prior to January 1, 1997 and is not legally separated.(51)"State Employee" means a person employed by the State or a community service board and who meets the eligibility definitions of these regulations and who is receiving a salary or wage for services rendered.(52)"State Health Benefit Plan" or "SHBP" means the health benefit plan administered by the Department of Community Health covering State Employees, Public School Teachers, Public School Employees, Retirees and their eligible Dependents, and other entities under The Acts for health insurance.(53)"Summary Plan Description" is a booklet that describes the health benefits and other provisions of the State Health Benefit Plan (SHBP) specific to the Coverage elected by the Enrolled Member.(54)"Surviving Spouse" means the living Spouse of a deceased Enrolled Member.(55)"Teacher" or "Public School Teacher" means a person employed by a local school system in a Certificated Position and who meets the eligibility definitions of these regulations and who is receiving a salary or wage for services rendered.(56)"Tier" means the number and relationship to the Enrolled Member of the persons enrolled under the Member's Coverage.(57)"Total Disability" means that the Enrolled Member is not able to perform any and every duty of the individual's occupation or employment or that the Dependent is not able to perform the normal activities of a person of like age or sex.(58)"TPA" or "Third-party Administrator" means an approved contractor for adjudicating paying Claims, and performing other administrative processes.(59) "TRICARE Supplemental Coverage" means insurance made available to Members who are eligible for SHBP Coverage and entitled to health care benefits under the TRICARE program, and for which premiums are collected by the Administrator and transferred to the company that sells the TRICARE Supplemental Coverage. TRICARE Supplemental Coverage provides health care benefits that are supplementary to health care benefits under TRICARE. The purchase of TRICARE Supplemental Coverage by eligible Members is facilitated by the Administrator and Employing Entities in accordance with the John Warner National Defense Authorization Act for Fiscal Year 2007 and implementing regulations. TRICARE Supplemental Coverage is a voluntary, unsubsidized benefit and is not endorsed or subsidized by the Administrator or any Employing Entity. The Administrator and Employing Entities provide minimal administrative duties with regard to TRICARE Supplemental Coverage, which duties are limited to providing information about the TRICARE Supplemental Coverage to Members and facilitating the collection of premiums for such coverage and transmittal of the premiums to the company that sells the TRICARE Supplemental Coverage. Neither the Board, nor the Administrator nor any Employing Entity provides any incentive to Members to enroll in TRICARE Supplemental Coverage. Neither the Board, nor the Administrator, nor any Employing Entity receives any compensation or consideration for offering TRICARE Supplemental Coverage. TRICARE Supplemental Coverage is not considered SHBP Coverage.Ga. Comp. R. & Regs. R. 111-4-1-.01
O.C.G.A. Secs. 20-2-881, 20-2-892, 20-2-911, 45-18-2, Health Insurance Portability and Accountability Act of 1996 (HIPAA), Consolidated Omnibus Budget Reconciliation Act (COBRA). Patient Protection and Affordable Care Act (PPACA); John Warner National Defense Authorization Act for Fiscal Year 2007.
Original Rule entitled "Definitions" adopted. F. Apr. 18, 2005; eff. May 8, 2005.Repealed: New Rule of same title adopted. F. Jan. 22, 2007; eff. Feb. 11, 2007.Amended: F. Oct. 15, 2007; eff. Nov. 4, 2007.Repealed: New Rule of same title adopted. F. Apr. 14, 2010; eff. May 4, 2010.Amended: F. Jan. 26, 2011; eff. Feb. 16, 2011.Amended: F. Jan. 17, 2012; eff. Feb. 6, 2012.