Employee Insurance Education Part #1. Introduction and Eligibility.

EmployeeInsurance Education

Part #1

Introduction and

Eligibility

The information in this overview is not meant to serve as a comprehensive description of the benefits offered by the Employee Insurance Program.

Have your Insurance Benefits Guide and literature from the various HMOs handy as you read through this presentation for additional information.

Important Information for Employees

Employee•Classified as permanent and full-time

•Works at least 30 hours per week•Works at least 20 hours per week

Employer has option to request to enroll this type of employee

Decision irrevocable after EIP approval

Eligibility

Retiring Employee•Must meet SCRS, GARS, JSRS or PORS eligibility criteria for retirement

•Last five years of service must be full-time, permanent and consecutive, with employer participating in state’s insurance benefits programs

Eligibility

Dependent Spouse•Wedded spouse or common-law spouse (cannot be employed by state insurance participating employer)

•Ex-spouse if coverage is court-ordered (by divorce decree)

Eligibility

Children• Under 19, or until age 25, if a full-time student

• Unmarried children Natural child Stepchild Adopted or foster child Child for which subscriber has

legal custody

Eligibility

(cont.)

•Children not employed with benefits

•Child that resides with employee or employee’s child by court order

•Child who is principally dependent on subscriber for more than 50 percent of time

•Child approved for incapacitation

Eligibility

Additional Documentation• Incapacitated child•Adopted child•Student certification, age 19 to 25•Employee’s child who resides outside home (under court-order to cover child)

•Common-law spouse or ex-spouse by court order

Eligibility

Survivors

Insurance Education Part #1

Eligibility•Dependent must be covered at time of death to be classified as survivor

• If coverage terminated, survivor cannot return to survivor coverage

Survivors

Premiums Can continue coverage after one-year waiver but must pay full cost of health premium

Following one-year premium waiver, survivors of employees killed in line of duty may continue health and dental insurance coverage at employer-funded rate*

Survivors

Health Insurance• Premium waived for one year*

• Spouse eligible until remarried

• Children eligible if classified as eligible dependents

Dental Insurance• No premium waiver

• Spouse eligible until remarried

• Children eligible if classified as eligible dependents

Survivors

Eligibilityand

Coordination ofBenefits


•Within 31 days of hire date•Within 31 days of special eligibility situation Marriage, birth, adoption or placement of child for adoption

Involuntary loss of coverage•During open enrollment period (will be enrolled as late entrant)

Enrollment: Employees and Dependents

Eligibility and Coordination of Benefits

Enrollment Guidelines: Employees and Dependents•State-offered health and dental insurance plans coordinate benefits with other coverage

•Parent whose birthday occurs earliest in year (for both parents) is primary for dependents covered by both parents

Eligibility and Coordination of Benefits

Terminations andCOBRA

Continuation OfCoverage


Ineligible Spouse•Spouse may remain on coverage until he/she becomes ineligible (with divorce)

•Divorce (unless coverage court-ordered)

•Death•Gains state insurance coverage

Terminations and COBRA

Ineligible Dependent Children• Child marries• Child becomes employed with benefits

• Child turns 19, unless full-time student or approved for incapacitation


When to Offer COBRA•Employee must meet group plan’s definition of eligibility to participate in group health plan

•Child turns 25, unless approved for incapacitation


(cont.)

•When qualifying event occurs, COBRA offered to eligible participants enrolled in a group health plan State health plans HMOs State dental plans MoneyPlu$ Medical Spending Account


(cont.)

•Employee may continue coverage for 18 months if he/she: Leaves employment, terminated or terminated as a result of RIF (reduction in force)

Has hours reduced


(cont.)

• If approved for Social Security disability within first 18 months of COBRA continuation coverage, Employee may extend coverage up to 29 months, provided COBRA notification rules are followed


•Dependents who become ineligible may continue coverage for 36 months if ineligibility is reported within 60 days of date of qualifying event

(cont.)


Pre-existing Condition Period


Applies to:• State Health Plan• HMOs and Point

of Service plans• Basic Long Term

Disability plan• Supplemental

Long Term Disability plan

Does not apply to:• State Dental Plan• Life Insurance plan• Health plan carrier

change (if pre-existing previously satisfied)

• Long Term Care plan


Definition•Condition for which medical advice, diagnosis, care or treatment was recommended or received during six months preceding subscriber’s enrollment date on plan

•Benefits not payable until 12 months after enrollment date (18 months for late entrant)


•May reduce pre-existing period for health insurance by providing certificate of creditable coverage from subscriber’s previous insurance plan

Creditable Coverage


•Pre-existing period can be reduced by number of months subscriber was insured as long as: Prior coverage was continuous and Any break in coverage did not exceed 62 days

(cont.)


Benefits Enrollment Periods


Annual Enrollment Period•October: even-numbered years (2008, 2010, etc.)

•May make: Health plan carrier changes MoneyPlu$ changes Life Insurance changes (with medical underwriting)


•May make health and dental plan changes

•MoneyPlu$ changes•Life Insurance changes (with medical underwriting)

Open Enrollment Period•October: odd-numbered years (2009, 2011, etc.) May enroll as late entrant May add or drop coverage May add or drop dependents


Employee Insurance Education Part #1. Introduction and Eligibility.

Documents

benefits child

dependents eligibility

employees child

court order eligibility

foster child child

eligibility dependent

eip approval eligibility

parents eligibility