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Employee Insurance Education Part #1

Employee Insurance Education Part #1. Introduction and Eligibility. Important Information for Employees. The information in this overview is not meant to serve as a comprehensive description of the benefits offered by the Employee Insurance Program.

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Employee Insurance Education Part #1

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  1. Employee • Insurance Education Part #1

  2. Introduction and Eligibility

  3. Important Information for Employees 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.

  4. Eligibility • 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

  5. 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

  6. 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)

  7. 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

  8. 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

  9. 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

  10. Insurance Education Part #1 Survivors

  11. Survivors • Eligibility • Dependent must be covered at time of death to be classified as survivor • If coverage terminated, survivor cannot return to survivor coverage

  12. 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*

  13. 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

  14. Insurance Education Part #1 Eligibility and Coordination of Benefits

  15. Eligibility and Coordination of Benefits Enrollment: Employees and Dependents • 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)

  16. 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

  17. Insurance Education Part #1 Terminations and COBRA Continuation Of Coverage

  18. Terminations and COBRA • Ineligible Spouse • Spouse may remain on coverage until he/she becomes ineligible (with divorce) • Divorce (unless coverage court-ordered) • Death • Gains state insurance coverage

  19. Terminations and COBRA Ineligible Dependent Children • Child marries • Child becomes employed with benefits • Child turns 19, unless full-time student or approved for incapacitation

  20. Terminations and COBRA • 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

  21. Terminations and COBRA • (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

  22. Terminations and COBRA • (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

  23. Terminations and COBRA • (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

  24. Terminations and COBRA (cont.) • Dependents who become ineligible may continue coverage for 36 months if ineligibility is reported within 60 days of date of qualifying event

  25. Insurance Education Part #1 Pre-existing Condition Period

  26. Does not apply to: • State Dental Plan • Life Insurance plan • Health plan carrier change (if pre-existing previously satisfied) • Long Term Care plan 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

  27. Pre-existing Condition Period • 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)

  28. Pre-existing Condition Period Creditable Coverage • May reduce pre-existing period for health insurance by providing certificate of creditable coverage from subscriber’s previous insurance plan

  29. Pre-existing Condition Period (cont.) • 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

  30. Insurance Education Part #1 Benefits Enrollment Periods

  31. 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)

  32. Benefits Enrollment Periods • Open Enrollment Period • October: odd-numbered years (2009, 2011, etc.) • May enroll as late entrant • May add or drop coverage • May add or dropdependents • May make health and dental plan changes • MoneyPlu$ changes • Life Insurance changes (with medical underwriting)

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