Or. Admin. Code § 101-020-0002

Current through Register Vol. 63, No. 11, November 1, 2024

Section 101-020-0002 - Plan Effective Dates, Employee Eligibility Continuation, and Plan Termination Dates

(1) Irrevocability Rule. Except as otherwise provided in OAR chapter 101, all eligible employee benefit plan elections or mid-year plan changes are irrevocable for the plan year and must have a prospective effective date.

(2) PEBB's eligible employee benefits are in whole month increments for coverage and premium cost. PEBB's core benefits are part of an Internal Revenue Service Code 125 Cafeteria plan, requiring an employee's monthly pay deduction for premium contribution is in advance of the coverage.

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

(a) The employee must be actively at work as specified in OAR 101-010-0005(2) 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 medical underwriting prior to coverage approval, coverage will be effective the first of the month following plan approval.

(4) Employee Continuation of Coverage. An enrolled benefit eligible employee continuing employment:

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

(b) Not within a current stability period, must accrue a minimum of 80 paid regular status hours in a month to qualify for benefit coverage in the following month. If the employee accrues less than 80 paid regular status hours in a given month, the employee's benefits will end the last day of that month. The agency must send the employee a self-pay COBRA Enrollment Notice. Employees within an approved FMLA, CBIW or other protected leave are not required to accrue 80 paid regular hours for benefits in the following month, see division 30.

(5) Open enrollment elections are effective on the first day of the new plan year. When an optional plan requires a medical underwriting prior to coverage approval, coverage will be effective the first of the month following plan approval in the new plan year.

(6) Coverage effective date for Special Enrollment Rights. An eligible employee or family member losing other group medical coverage is eligible to enroll in PEBB plans within 30 days of the date of the loss of other group coverage. When enrolled within 30 days of the loss, PEBB coverage will be effective the first day of the month that coverage is lost. When notified after 30 days from the loss of coverage, if approved, the effective date will be prospective only to the first day of the month following submission of forms.

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.

Example 3: Joe loses coverage under his spouse's plan October 15. Joe submits the enrollment update forms November 23 (after 30 days from loss of coverage). If approved, Joe's coverage effective date is December 1.

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

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

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

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

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

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

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

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

(B) When the employee has received the 15 day notice and payment is not received by the due date, coverage is terminated retroactively to the last day of the last month that employee premium was received. The agency and PEBB may adjust premiums for one month when the termination is caused by an employee's premium non-payment, this is not rescission

(C) When coverage is terminated because of the employee's failure to pay the premium share timely and the employee returns from the leave within 12 months from the loss of coverage, the agency must reinstate employee to the benefits equivalent to those the employee would have if the leave had not been taken and premium payments missed. See OAR 101-20-0045 Returning to Work.

Example: John is in a benefit eligible current stability period. His August premium share was paid by his agency with his August 1 pay (July pays August). John starts a leave without pay on August 1. His current stability period status allows John to continue enrollment in his health benefits for September, but only if he pays his September premium share to his agency as designated. His agency requires the premium share payments by the 15th of each month. John's agency does not receive his August 15 payment for September coverage. The agency sends John a notice of nonpayment by August 17. The notice provides a 15 day notice that payment must be made to the agency by September 15 or his enrollment will retroactively terminate to August 31 (the last day, of the last month that premium was paid). The agency pays full premium for the September coverage. John's payment is not received by September15. John's enrollment is terminated back to August 31 and he is sent a COBRA Election Notice. If the agency paid the premiums for September, reconciliation adjustments are made by PEBB and the agency. John later returns to work in the middle of September, his previous benefits will reinstate for an October 1 effective date. He does not need to work 80 hours in the month of return for benefits in the following month, because he returned within his current stability period status. (If John was not in a current benefit eligible stability status, or was not in a leave without pay connected to a FMLA, CBIW, or other protected leave, he would need to work 80 hours in the month of return.)

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

(9) Optional plan coverages end according to the individual optional plan's policy or certificate directives. Refer to OAR 101-020-0060 and 101-020-0065 for FSA termination dates.

Or. Admin. Code § 101-020-0002

PEBB 2-2007, f. 9-28-07, cert. ef. 10-1-07; PEBB 2-2008, f. & cert. ef. 8-1-08; PEBB 7-2010, f. 12-10-10, cert. ef. 1-1-11; PEBB 1-2015, f. & cert. ef. 5/12/2015; PEBB 2-2017, f. & cert. ef. 8/17/2017

Stat. Auth.: ORS 243.061 - 302

Stats. Implemented: ORS 243.061-302, 659A.060-069, 743.600 - 602 & 743.707