Ga. Comp. R. & Regs. R. 111-4-1-.03 - General Provisions

(1) Applicability. All Members who become eligible for Coverage under the SHBP shall be enrolled or permitted to change Coverage election only in accordance with these regulations. All Employing Entities covered by the Acts shall administer the SHBP in accordance with these regulations_. All Annuitants or Extended Beneficiaries shall be enrolled or permitted to change Coverage election only in accordance with these regulations.

(2) Extension of SHBP to Eligible Groups. The Board shall review and approve provisions for extending Coverage to eligible Groups as required by law. The special provisions may include allowing Members or Beneficiaries to reenroll in the SHBP.

(3) Conformity with Federal Requirements. When federal law is enacted requiring public employers to comply with certain requirements for continued receipt of public health or other grant funds, the Commissioner shall submit proposed regulations to the Board for approval.

(4) Records. The Plan records shall be maintained in accordance with applicable State and federal law and regulations, including, but not limited to, Chapter 33 of Title 31 of the Georgia Code and the privacy regulations promulgated under the Health Insurance Portability and Accountability Act of 1996 (HIPAA). Records which are not private, confidential or otherwise excluded from disclosure shall be available for public inspection and copying, in accordance with the Georgia Open Records Act. Any medical records and other individually identifying health information presented to the Administrator or to any of the Third Party Administrators in the Claim adjudication process or medical review process shall be confidential and shall be accessible only in accordance with applicable State and federal law and regulations.

(5) Member Responsibility. The Member has responsibility for notifying the Employer and the Plan of discrepancies in the Member's Coverage records. Notwithstanding the foregoing, the requirements of this provision do not negate the Employer's responsibility. The Employing Entity must still fulfill notification and all other requirements set forth under these regulations.

(a) The Enrolled Member is responsible for assuring that the proper Premium payments are deducted or reduced from the Enrolled Member's salary or retirement benefit for the Coverage that the Enrolled Member selected. Premiums of Enrolled Members that are paid through direct pay are to be paid in accordance with their Coverage selection.

(b) The Enrolled Member is responsible for submitting such documentation as the Plan requires to verify the eligibility of Dependents to be added to Coverage within the timeframe allotted by the Plan. Any Dependents not verified within the Plan's allotted time shall not be eligible for Coverage until the next annual Open Enrollment period or subsequent Qualifying Event as described in these regulations.

(c) The Enrolled Member is responsible for updating Spouse and Dependent information and requesting appropriate changes in Coverage as the circumstances may warrant. The Enrolled Member shall reimburse the Plan in full for Claim liability and expenditures incurred by the Plan on behalf of a Dependent who does not meet the definition of an eligible Dependent under these regulations. Any refunds of Premiums (for reasons other than administrative error) will be limited to twelve (12) calendar months from the date that the Administrator receives evidence from the Enrolled Member that the Plan had no liability for additional covered persons.

(d) When the Enrolled Member desires to reduce the period under the insurance Options of limited Coverage for Pre-existing conditions which may apply to himself/herself or any Covered Dependent, the Enrolled Member shall provide the Administrator certification of prior Creditable Coverage from the appropriate health plan administrator.

(6) Gender and Number. Except when otherwise indicated by the context, any masculine terminology herein shall also include the feminine and the definition of any terms herein of the singular may also include the plural.

Notes

Ga. Comp. R. & Regs. R. 111-4-1-.03

O.C.G.A. Secs. 20-2-881, 20-2-894, 20-2-897, 20-2-911, 20-2-922, 20-2-925, 45-18-1et seq., 50-18-72, 50-18-94, Health Insurance Portability and Accountability Act (HIPAA).

Original Rule entitled "General Provisions" adopted. F. Apr. 18, 2005; eff. May 8, 2005. Amended: ER. 111-4-1-0.1-.03 adopted. F. June 13, 2005; eff. June 16, 2005, as specified by the Agency. Amended: Permanent Rule adopted. F. Sept. 15, 2005; eff. Oct. 5, 2005. Repealed: New Rule of same title adopted. F. Jan. 22, 2007; eff. Feb. 11, 2007.