Ga. Comp. R. & Regs. R. 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.
Notes
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