Rule 111-4-1-.04 - Eligibility for Coverage(1) Active Employees. Employees who are actively at work or on approved leave of absence and have not terminated their employment may participate in the SHBP if classified as the following: (a) Full-Time.1. State Employees who work a minimum of thirty (30) hours per weeks are considered full-time.2. A regular full-time Employee who receives a salary or wage payment from a state department, board, agency, commission, the general assembly, a community service board, or a local government or other organization to which the Department of Community Health provides SHBP coverage through a contract authorized by the Board of Community Health; except contingent workers of the Labor Department, specially classified Employees of the Jekyll Island State Park Authority, Employees working as an independent contractor or on a temporary, seasonal, or intermittent basis and Employees whose duties are expected to require less than nine (9) months of service.3. A regular full-time Employee who receives a salary or wage payment from a state authority that participates in the Employees' Retirement System;4. Part-time Employees of the General Assembly who had coverage prior to January 1981, and Administrative and clerical personnel of the General Assembly;5. A full-time district attorney, assistant district attorney who was appointed pursuant to O.C.G.A. § 15-18-14, or district attorneys' investigators appointed pursuant to O.C.G.A. § 15-18-14.1 of the superior courts of this state;6. A full-time Employee who receives a salary or wage payment from a county board of health or a county board of family and children services that receives financial assistance from the Department of Human Resources; except for sheltered workshop Employees;7. Full-time secretaries and law clerks who are employed by district attorneys and judges and are employed under O.C.G.A. §§ 15-6-25 through 15-6-28 and O.C.G.A. §§ 15-18-17 through 15-18-19.(b) Teachers who are employed not less than half time, which must be at least seventeen and a half (171/2) hours per week, in the public school systems of Georgia are eligible to participate under these regulations. An eligible teacher shall not include any independent contractor, emergency or temporary person and is further defined as: 1. A person employed in a professionally Certificated Capacity or Position in the public school systems of Georgia;2. A person employed by a regional or county library of Georgia;3. A person employed in a professionally Certificated Capacity or Position in the public vocational and technical schools operated by a local school system;4. A person employed in a professionally Certificated Capacity or Position in the Regional Educational Service Areas of Georgia;5. A person employed in a professionally Certificated Capacity or Position in the high school program of the Georgia Military College.(c) Public School Employees who are employed by a local school system that have elected to participate in the Plan, and are not considered independent contractors, are eligible to enroll under the conditions of these regulations. 1. An Employee who is eligible to participate in the Public School Employees Retirement System as defined by Paragraph (20) of O.C.G.A. § 47-4-2may enroll, provided the Employee works the greater of at least 60 percent of the time required to carry out the duties of such position or a minimum of fifteen (15) hours per week and is not employed on an emergency or temporary basis.2. An Employee who holds a non-certificated public school position and who is eligible to participate in the Teachers Retirement System (or other independent local school retirement system), provided the Employee is not employed on an emergency or temporary basis and the Employee works at least 60 percent of the time required to carry out the duties of such position or a minimum of twenty (20) hours per week, whichever is greater may enroll.(d)Local Boards of Education that elect to provide group medical insurance for members of the local board of education, their spouses, and dependents in accordance with O.C.G.A. § 45-18-5are eligible to enroll under the conditions of these regulations. Collection and remittance of Enrolled Member premium and employer contribution amounts shall be in accordance with O.C.G.A. § 20-2-55 and these regulations.(2)Retired Employees. Any Employee who was eligible to participate under 111-4-1-.04(1)(a), 111-4-1-.04(1)(b), or 111-4-1-.04(1)(c) and who was enrolled in the Plan at the time of retirement shall be eligible to continue coverage if: (a) The Retired Employee is eligible to immediately receive an annuity from the Employees' Retirement System, Georgia Legislative Retirement System, Judicial Retirement System, Superior Court Judges or District Attorneys' Retirement System, Teachers Retirement System, Public School Employees Retirement System, any local school system teachers retirement system, or other retirement system with which the Board is authorized to contract; or(b) The Retired Employee as an Employee of a county department of family and children services or a county department of health is eligible to receive an annuity from the Fulton County Retirement System.(3)Eligibility for Coverage as an Enrolled Member and a Dependent. In the situation where both husband and wife are eligible to be covered under the SHBP as an Enrolled Member, each may enroll as a Member and enroll the eligible dependents. The benefits provided under the SHBP will be coordinated in accordance with the Coordination of Benefits or the Medicare Coordination of Benefits provisions of the Summary Plan Description. In no case shall the sum of the total benefits provided by the SHBP exceed the reasonable charges for covered services.(4)Eligibility for Coverage as an Enrolled Member Limited. In the situation where the Enrolled Member is entitled to Coverage under the SHBP as an Active Employee under a health insurance act and Retired Employee under a different health insurance act, or any combination of provisions, the Member may choose among the Active Employee provisions under which the Member will be covered, but may not choose Coverage as a Retiree or Beneficiary of a Retiree as long as the Member is eligible for Coverage under one of the Active Employee provisions. In no circumstance shall the individual be an Enrolled Member under more than one provision of these regulations.(5)Eligibility for Coverage as an Active Employee with Two (2) Employing Entities. Dual eligibility and overlapping Coverage shall be handled as follows: (a)Dual Eligibility. In the situation where the Enrolled Member is eligible for Coverage under the SHBP as an Active Employee of two (2) separate Employing Entities, the Employee may, during the annual Open Enrollment period, elect which Employing Entity shall deduct the Employee Premium in the upcoming Plan Year. Each Employing Entity is responsible for remitting Employer Contribution amounts in accordance with 111-4-1-.02(3)(d) of these regulations.(b)Overlapping Coverage. In the situation where the Enrolled Member experiences a period of overlapping Coverage as a result of transferring employment between two (2) separate Employing Entities, the Coverage effective date with the second Employer shall determine the Coverage termination date with the first Employer. The Employing Entities shall be responsible under this provision for deducting or refunding Employee Premiums as appropriate.(6)Employees on Leave Without Pay. Active Employees who are Enrolled Members of the SHBP may continue the Coverage in which enrolled during a period of "Approved Leave of Absence Without Pay", subject to the conditions in these regulations. Enrolled Employees who are on suspension or Approved Leave of Absence Without Pay who did not continue Coverage shall not be eligible to enroll or re-enroll for Coverage while on Approved Leave of Absence Without Pay under any provision of these regulations except during the annual Open Enrollment period. Except for military leave Coverage shall not be extended for an Employee who is self employed or gainfully employed by another party during a period of Approved Leave of Absence Without Pay. A request to continue Coverage while on Approved Leave Without Pay must be received by the Employing Entity within thirty-one (31) calendar days of the termination of paid Coverage through payroll Deductions. Employees who qualify for continued Coverage under multiple leave types may continue Coverage under a combination of leave types; however, the total period of Coverage on Approved Leave of Absence Without Pay shall not exceed twelve (12) calendar months, unless otherwise noted in these provisions. Premium payments must be in an amount sufficient to provide continuous Coverage between termination of paid Coverage through payroll Deductions and the beginning of Approved Leave of Absence Without Pay Coverage. When an Employee on Approved Leave of Absence Without Pay enrolls during the annual Open Enrollment, Period the twelve (12) calendar month Coverage period shall be reduced by the number of prior months of Approved Leave of Absence Without Pay during which the Employee did not elect to participate in the SHBP. Employees on Leave Without Pay must timely submit required Premiums to the Employing Entity, and the Employing Entity must timely pay required Employer Contributions associated with such Employees. An Employee's failure to timely submit a required Premium to the Employing Entity causes a loss of eligibility for Coverage, and the Employing Entity must timely notify the Administrator of loss of eligibility in accordance with these regulations. (a)Disability Leave. A disability leave is the period of time an Approved Leave of Absence Without Pay has been granted to the Employee due to personal illness, accident or disability. Coverage may be continued under this paragraph for the period of disability, but not longer than twelve (12) consecutive calendar months. Certification of the disability period by a licensed physician shall be required to continue coverage under this provision.(b)Reduced Working Hours Due to Partial Disability. A Partial Disability leave is the period of time during which an Employer approves an Employee's return to work on a part-time basis from a period of disability leave or paid leave if the part-time work is part of a process to gradually return the Employee to full-time work. Coverage may be continued under this provision for the period of disability approved by a licensed physician, but not longer than twelve (12) consecutive calendar months, inclusive of any time from a period of disability leave without pay. Certification of the Partial Disability period shall be required to continue coverage under this provision.(c)Leave of Absence for the Employer's Convenience. Employer's convenience leave is a period of time during which an Approved Leave of Absence Without Pay has been granted by the appropriate organizational official due to a regular programmatic plan for Employee absence and pursuant to appropriate regulation. The Employee may continue the Coverage such leave of absence, but not longer than twelve (12) consecutive calendar months.(d)Educational Leave. Educational leave is the period of time during which an Approved Leave of Absence Without Pay has been granted by the appropriate organizational official for educational or training purposes. The Employee may continue the Coverage under such leave for the period of absence, but not longer than twelve (12) consecutive calendar months.(e)Family Medical Leave. Family medical leave is the period of time during which an Approved Leave of Absence Without Pay has been granted to the Employee by the appropriate organizational official for personal illness, the care of the Employee's child after birth or placement for adoption or the care of an Employee's seriously ill Spouse, child, or parent. An Employee's personal illness, if properly certified and approved may be granted under the disability leave provisions. Coverage while on Approved Leave of Absence Without Pay for family medical leave may be continued for the period of approved leave, but not longer than twelve (12) weeks in any twelve (12) consecutive month period.(f)Military Leave. Military leave is the period of time during which an Approved Leave of Absence Without Pay has been granted by the appropriate organization official when an Employee is ordered to military duty or the period, as provided by law, during which an Employee is attending military training. Military leave also applies to an Employee who qualifies for an exigency leave or service member care leave, as defined under Federal law. The Employee may continue the Coverage under such leave for the period of absence.(g)Suspension or Other Leave of Absence. Suspension or other leave of absence is the period of time during which suspension is in effect or an Approved Leave of Absence Without Pay has been granted by the appropriate organization official for the Employee's convenience. The Employee may continue the Coverage for the period of suspension or approved leave, but not to exceed twelve (12) calendar consecutive months, provided the Employee is not self employed or gainfully employed by another party during such leave of absence.(h)Extensions of Leave of Absence. If the Employee is unable to return to work at the expiration of the approved leave and the maximum period has not been exhausted, a request to extend the leave of absence may be filed. The Administrator must receive the Employee's request for extension no later than thirty-one (31) calendar days following expiration of Coverage under the leave of absence. The Employing Entity must certify approval of the extension. The attending physician must complete a new disability certification for an extension of a disability leave.(i)Sequential Periods of Leave. Health benefits may be continued during sequential types of leave, provided that continuation of health benefits during continuous, sequential periods of time shall not exceed the time limitation of the most recently approved type of leave.(j)Premiums. Premiums for continued Coverage during a period of Approved Leave of Absence Without Pay shall be paid monthly to the Employing Entity. When establishing the monthly Premium amount to be paid by the Employee, the Board may add a processing fee. The Premium Rate, excluding the processing fee, shall be based on the type of approved leave. The Premium Rate for disability, family leave or military leave of absence shall be the same as the Employee Deduction; the Premium Rate for all other types of leave shall be the total cost of coverage as set forth in Board resolution. Failure to pay the full Premium to the Employing Entity within the allotted time shall result in loss of eligibility for Coverage.(7)Spouse. An Active Employee shall be entitled to enroll the Employee's Spouse upon employment, during Open Enrollment, or under conditions specified in Section 111-4-1-.06 of these regulations. A Retiree shall be entitled to continue Coverage for the Spouse upon retirement or may enroll the Spouse in accordance with Section 111-4-1-.06(5) or 111-4-1-.06(6). The Administrator shall require the Social Security Number for the Spouse as well as appropriate documentation from an Enrolled Member in order to verify a Spouse's eligibility for Coverage.(8)Dependent Child. An Active Employee shall be entitled to enroll eligible Dependent children upon employment, during Open Enrollment, or under conditions specified in Section 111-4-1-.06 of these regulations. A Retiree shall be entitled to continue Coverage for eligible Dependent children upon retirement or may enroll eligible Dependent children in accordance with Section 111-4-1-.06(5). The Administrator shall require the Social Security Number for every child, starting at age two, as well as appropriate documentation from an Enrolled Member in order to verify a Dependent child's eligibility for Coverage. An eligible Dependent child must meet one of the following definitions; (a) A natural child, for which the natural guardian has not relinquished all guardianship rights through a judicial decree. Eligibility begins at birth and ends at the end of the month in which the child reaches age twenty-six (26);(b) An adopted child. Eligibility begins on the date of legal placement for adoption and ends at the end of the month in which the child reaches age twenty-six (26);(c) A stepchild. Eligibility begins on the date of marriage to the natural parent and ends at the end of the month in which the child reaches age twenty-six (26), or at the end of the month in which he or she loses status as the stepchild of the Enrolled Member, whichever date is earlier; or(d) Guardianship. A child for whom the Enrolled Member is the legal guardian. Eligibility begins on the date the legal guardianship is established and ends at the end of the month in which the child reaches age twenty-six (26), or at the end of the month in which the legal guardianship terminates, whichever is earlier. Certification documentation requirements are at the discretion of the Administrator. However, a judicial decree from a court of competent jurisdiction is required unless the Administrator concludes that documentation is satisfactory to establish legal guardianship and financial dependence and that other legal papers present undue hardship on the Member or living natural parent(s).(9)Totally Disabled Child. An Enrolled Member shall be entitled to apply for Coverage of a natural child, legally adopted child or stepchild age twenty-six (26) or older if the child was physically or mentally disabled before age twenty-six (26), continues to be physically or mentally disabled, lives with the Enrolled Member or is institutionalized and depends primarily on the Enrolled Member for support and maintenance. (a)Application Period. The Enrolled Member may apply for Coverage during Open Enrollment, as a New Hire, or as the result of a Qualifying Event. At all other times, an Enrolled Member whose Totally Disabled Child was a covered dependent on the Member's Family Plan prior to turning age twenty-six (26) must apply for continuation of Coverage and include all supporting documentation no later than thirty-one (31) calendar days following the end of the month in which the child reaches age twenty-six (26). If the Enrolled Member fails to complete the request within the allotted time, eligibility for Coverage until the next Open Enrollment is limited to the conditions outlined for Extended Beneficiaries.(b)Documentation and Approval. The Administrator shall require documentation as necessary to provide certification that the child was physically or mentally incapable of sustaining, self-supporting employment because of the physical or mental disability before age twenty-six (26), continues to be physically or mentally incapable of sustaining, self-supporting employment because of the physical or mental disability, and lives at the Enrolled Member's home or is institutionalized. The documentation may include but is not limited to certification from a qualified medical practitioner that outlines the physical and psychological history, diagnosis, and provides an estimate of length of time for disability, and an estimate of the child's earning capacity. If the documentation is satisfactory to substantiate the physical or mental disability as required in these regulations, the Administrator may approve Coverage for the period of incapacitation. The Administrator may require periodic recertification of the disabling condition and circumstances, provided the recertification is not more frequent than each twelve (12) calendar months or at the end of the projected disability period if that date is less than twelve (12) calendar months.(10)Surviving Beneficiary. An Enrolled Member's Surviving Spouse and eligible Dependent children, who were included in the Coverage by the Enrolled Member immediately before death, may continue Coverage provided an application for continuing Coverage is received by the Administrator within ninety (90) calendar days following Coverage termination as a result of the death of the Enrolled Member in the situations set forth below. In the application, the Surviving Spouse shall be required to list all eligible Covered Dependents who will continue Coverage and shall not be allowed to add any future spouse or children not listed. Surviving Covered Spouses and Dependent children are entitled by federal law to continue Coverage under the Extended Beneficiary provisions set forth in Section 111-4-1-.08. By electing to continue coverage under any of these Surviving Beneficiary provisions, the Surviving beneficiary waives rights to continuation coverage under the Extended Beneficiary provisions of Section 111-4-1-.08. (a) The Surviving Spouse of an Active Employee may continue Coverage for him or herself and surviving eligible Covered Dependent children if the Spouse is eligible to immediately receive a monthly benefit payment from a state supported retirement system in an amount sufficient to pay the Premium established by the Board. The Spouse must elect to continue Coverage as a Surviving Spouse under this provision or as an Employee as a result of the Spouse's own employment, and cannot elect double or dual Coverage under separate provisions of the SHBP. Eligibility of Dependent children shall terminate in accordance with provisions for Dependent children of these regulations. An election to take a lump sum distribution rather than the monthly Annuity negates eligibility to continue Coverage as a Surviving Spouse(b) The Surviving Spouse of an Annuitant may continue Coverage for him or herself and surviving eligible Covered Dependent children if the Spouse is eligible to immediately receive a monthly benefit payment from a state supported retirement system in amount sufficient to pay the Premium established by the Board. The Surviving Spouse must elect to continue Coverage as a Surviving Spouse under this provision or as an Employee as a result of the Spouse's own employment, and cannot elect double or dual Coverage under separate provisions of the SHBP Eligibility of Dependent children shall terminate in accordance with provisions for Dependent children. An election to take a lump sum distribution rather than the monthly Annuity negates eligibility to continue Coverage as a Surviving Spouse.(c) Upon the death of an Active Employee, an eligible Covered Dependent child who is the principal Beneficiary under one of the state supported retirement systems may continue Coverage, provided the Dependent child is not covered as a Dependent child under another contract under the SHBP, and provided the monthly benefit payment from a state supported retirement system is in an amount sufficient to pay the Premium established by the Board. Eligibility to continue Coverage shall terminate in accordance with provisions for Dependent children. An election to take a lump sum distribution rather than the monthly Annuity negates eligibility to continue Coverage under this provision.(d) Upon the death of a Retired Employee, an eligible Covered Dependent child who is the principal beneficiary under one of the state supported retirement systems may continue Coverage, provided the Dependent child is not covered as a Dependent child under another contract under the SHBP, and provided the monthly benefit payment from a state supported retirement system is in an amount sufficient to pay the Premium established by the Board. Eligibility to continue coverage shall terminate in accordance with provisions for Dependent children. An election to take a lump sum distribution rather than the monthly Annuity negates eligibility to continue Coverage under this provision.(e) The Surviving Spouse of a Retired Employee who is included in Coverage at the time of death of the enrolled Retiree and who will not receive a monthly annuity payment from one of the state supported retirement systems shall be eligible to continue Coverage for him or herself and any of the Retiree's Dependent children who were Covered at the time of the Retiree's death, if the following conditions are met: 1. The Surviving Spouse must make written application no later than ninety (90) calendar days following Coverage termination as a result of the death of the Retired Employee; and2. The parties must have been married at least one full year prior to the death of the Retired Employee; and3. The Surviving Spouse agrees to pay the monthly premium payment established by the Board in accordance with the established requirements; and4. Coverage under this provision shall terminate for the Surviving Spouse and any enrolled Dependent children in the event the Surviving Spouse remarries.(f) The eligible Covered Spouse and Dependent children of a Covered Active State Employee who is killed or receives injury that results in death while acting in the scope of his or her employment may continue Coverage provided the deceased Enrolled Member's Coverage was continuous during the period between injury and death. The eligible Covered Dependents may elect Coverage as a surviving Dependent or as an Employee as a result of the person's own employment, but cannot elect double or dual Coverage under separate provisions of the SHBP. Surviving Covered Dependents must agree to pay the monthly Premium payment established by the Board for Active State Employees. The Surviving Spouse may elect to continue Coverage for eligible Covered Dependent children. Eligibility of Dependent children shall terminate in accordance with provisions for Dependent children.(11)Dependent Eligibility Unverified. The Administrator shall define the supporting documentation requirements for verifying Dependent eligibility. Coverage for Dependents whose eligibility is unverified will pend awaiting receipt and review of the documentation. When the Administrator has verified eligibility of the Dependent, the Coverage will be activated in accordance with the provisions of this Section. If the Administrator cannot verify Dependent eligibility within the allotted time, the Dependent will be ineligible for Coverage. The next opportunity to enroll the Dependent and verify the Dependent's eligibility will be the annual Open Enrollment period or subsequent Qualifying Event. Changes to a different coverage tier will not be allowed based on unverified dependent eligibility.(12)Retired Employees Having Intermittent Periods of Active Employment. Retired Employees who are eligible to continue Coverage under these regulations may elect to return to or continue Active employment with any of the Employing Entities. In such case, the retirement benefit may be suspended or continued; however, the federal Social Security Act requires the health benefit Coverage must be purchased as an Active Employee whenever the eligibility requirements of Section 111-4-1-.04 of these regulations are met. At the point the Employee discontinues Active employment, continuous health benefit Coverage shall be reinstated with the state supported retirement system which previously collected the Premium. In no case, however is an individual who retired prior to the initial legislated funding for that Group of Employees to be entitled to enroll as a Retiree, unless the final Active service period qualifies the Employee for a retirement benefit by one of the state supported retirement systems.(13)Judicial Reinstatement of State Employees. State Employees who are reinstated to employment by the State Personnel Board or the judiciary shall have Coverage reinstated for themselves and any eligible Dependents. If employment reinstatement occurs within twelve (12) calendar months of discharge and back-pay for continuous employment is awarded, all retroactive Premiums must be collected and remitted to the Plan before and Claims incurred during the period may be filed for reimbursement. If back-pay to provide for continuous employment is not awarded, Coverage may be reinstated with the Employee's return to work. If reinstatement occurs following a period longer than twelve (12) calendar months after the discharge, Coverage for the Employee and previously Covered Dependents will be reinstated when the Employee returns to work or in accordance with the judicial review. In any case where the reinstatement overlaps an Open Enrollment period, the Employee will be given fifteen (15) calendar days after reinstatement to modify Coverage in compliance with Open Enrollment guidelines. Pre-existing condition limitations will be waived for the reinstated Employee and all previously enrolled Dependents. Employing Entities shall be responsible for collecting and remitting any Premiums due for the selected Coverage.(14)Contract Employees. Employees who are on approved leave of absence and/or have not terminated their employment may participate in the Plan if their Employer has contracted with the Board to provide inclusion in the SHBP. The Employee will be eligible to participate in accordance with the provisions of the contract.Ga. Comp. R. & Regs. R. 111-4-1-.04
O.C.G.A. Secs. 20-2-55, 20-2-880, 20-2-881, 20-2-885 to 20-2-887, 20-2-895, 20-2-910 to 20-2-912, 20-2-915, 20-2-916, 20-2-923, 31-3-2.1, 45-18-1et seq., 45-20-2, 47-2-313, 47-6-41, Family and Medical Leave Act of 1993 (FMLA), Social Security Act, Uniformed Services Employment & Reemployment Act, Americans With Disabilities Act (ADA). Patient Protection and Affordable Care Act (PPACA).
Original Rule entitled "Eligibility for Coverage" 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. May 25, 2007; eff. June 14, 2007.Amended: F. Aug. 20, 2008; eff. Sept. 9, 2008.Amended: F. Jan. 26, 2011; eff. Feb. 16, 2011.Amended: F. Jan. 17, 2012; eff. Feb. 6, 2012.