Ga. Comp. R. & Regs. R. 111-4-1-.04 - Eligibility for Coverage
(1) Active Employees. Employees who are
actively at work or on approved leave of absence and have not terminated their
employment may participate in the SHBP if classified as the following:
(a)
Full-Time.
1. State Employees who work a minimum of
thirty (30) hours per weeks are considered full-time.
2. A regular full-time Employee who receives
a salary or wage payment from a state department, board, agency, commission,
the general assembly, a community service board, or a local government or other
organization to which the Department of Community Health provides SHBP coverage
through a contract authorized by the Board of Community Health; except
contingent workers of the Labor Department, specially classified Employees of
the Jekyll Island State Park Authority, Employees working as an independent
contractor or on a temporary, seasonal, or intermittent basis and Employees
whose duties are expected to require less than nine (9) months of
service.
3. A regular full-time
Employee who receives a salary or wage payment from a state authority that
participates in the Employees' Retirement System;
4. Part-time Employees of the General
Assembly who had coverage prior to January 1981, and Administrative and
clerical personnel of the General Assembly;
5. A full-time district attorney, assistant
district attorney who was appointed pursuant to O.C.G.A. §
15-18-14, or district attorneys'
investigators appointed pursuant to O.C.G.A. §
15-18-14.1 of the superior courts
of this state;
6. A full-time
Employee who receives a salary or wage payment from a county board of health or
a county board of family and children services that receives financial
assistance from the Department of Human Resources; except for sheltered
workshop Employees;
7. Full-time
secretaries and law clerks who are employed by district attorneys and judges
and are employed under O.C.G.A. §§
15-6-25 through
15-6-28 and O.C.G.A. §§
15-18-17 through
15-18-19.
(b) Teachers who are employed not less than
half time, which must be at least seventeen and a half (171/2) hours per week,
in the public school systems of Georgia are eligible to participate under these
regulations. An eligible teacher shall not include any independent contractor,
emergency or temporary person and is further defined as:
1. A person employed in a professionally
Certificated Capacity or Position in the public school systems of
Georgia;
2. A person employed by a
regional or county library of Georgia;
3. A person employed in a professionally
Certificated Capacity or Position in the public vocational and technical
schools operated by a local school system;
4. A person employed in a professionally
Certificated Capacity or Position in the Regional Educational Service Areas of
Georgia;
5. A person employed in a
professionally Certificated Capacity or Position in the high school program of
the Georgia Military College.
(c) Public School Employees who are employed
by a local school system that have elected to participate in the Plan, and are
not considered independent contractors, are eligible to enroll under the
conditions of these regulations.
1. An
Employee who is eligible to participate in the Public School Employees
Retirement System as defined by Paragraph (20) of O.C.G.A. §
47-4-2 may enroll, provided the
Employee works the greater of at least 60 percent of the time required to carry
out the duties of such position or a minimum of fifteen (15) hours per week and
is not employed on an emergency or temporary basis.
2. An Employee who holds a non-certificated
public school position and who is eligible to participate in the Teachers
Retirement System (or other independent local school retirement system),
provided the Employee is not employed on an emergency or temporary basis and
the Employee works at least 60 percent of the time required to carry out the
duties of such position or a minimum of twenty (20) hours per week, whichever
is greater may enroll.
(d)
Local Boards of Education
that elect to provide group medical insurance for members of the local
board of education, their spouses, and dependents in accordance with O.C.G.A. §
45-18-5 are eligible to enroll
under the conditions of these regulations. Collection and remittance of
Enrolled Member premium and employer contribution amounts shall be in
accordance with O.C.G.A. §
20-2-55 and these
regulations.
(2)
Retired Employees. Any Employee who was eligible to participate
under 111-4-1-.04(1)(a),
111-4-1-.04(1)(b),
or 111-4-1-.04(1)(c)
and who was enrolled in the Plan at the time of retirement shall be eligible to
continue coverage if:
(a) The Retired
Employee is eligible to immediately receive an annuity from the Employees'
Retirement System, Georgia Legislative Retirement System, Judicial Retirement
System, Superior Court Judges or District Attorneys' Retirement System,
Teachers Retirement System, Public School Employees Retirement System, any
local school system teachers retirement system, or other retirement system with
which the Board is authorized to contract; or
(b) The Retired Employee as an Employee of a
county department of family and children services or a county department of
health is eligible to receive an annuity from the Fulton County Retirement
System.
(3)
Eligibility for Coverage as an Enrolled Member and a Dependent. In
the situation where both husband and wife are eligible to be covered under the
SHBP as an Enrolled Member, each may enroll as a Member and enroll the eligible
dependents. The benefits provided under the SHBP will
be coordinated in accordance with the Coordination of Benefits or the Medicare
Coordination of Benefits provisions of the Summary Plan Description. In no case
shall the sum of the total benefits provided by the SHBP exceed the reasonable
charges for covered services.
(4)
Eligibility for Coverage as an Enrolled Member Limited. In the
situation where the Enrolled Member is entitled to Coverage under the SHBP as
an Active Employee under a health insurance act and Retired Employee under a
different health insurance act, or any combination of provisions, the Member
may choose among the Active Employee provisions under which the Member will be
covered, but may not choose Coverage as a Retiree or Beneficiary of a Retiree
as long as the Member is eligible for Coverage under one of the Active Employee
provisions. In no circumstance shall the individual be an Enrolled Member under
more than one provision of these regulations.
(5)
Eligibility for Coverage as an
Active Employee with Two (2) Employing Entities. Dual eligibility and
overlapping Coverage shall be handled as follows:
(a)
Dual Eligibility. In the
situation where the Enrolled Member is eligible for Coverage under the SHBP as
an Active Employee of two (2) separate Employing Entities, the Employee may,
during the annual Open Enrollment period, elect which Employing Entity shall
deduct the Employee Premium in the upcoming Plan Year. Each Employing Entity is
responsible for remitting Employer Contribution amounts in accordance with
111-4-1-.02(3)(d)
of these regulations.
(b)
Overlapping Coverage. In the situation where the Enrolled Member
experiences a period of overlapping Coverage as a result of transferring
employment between two (2) separate Employing Entities, the Coverage effective
date with the second Employer shall determine the Coverage termination date
with the first Employer. The Employing Entities shall be responsible under this
provision for deducting or refunding Employee Premiums as
appropriate.
(6)
Employees on Leave Without Pay. Active Employees who are Enrolled
Members of the SHBP may continue the Coverage in which enrolled during a period
of "Approved Leave of Absence Without Pay", subject to the conditions in these
regulations. Enrolled Employees who are on suspension or Approved Leave of
Absence Without Pay who did not continue Coverage shall not be eligible to
enroll or re-enroll for Coverage while on Approved Leave of Absence Without Pay
under any provision of these regulations except during the annual Open
Enrollment period. Except for military leave Coverage shall not be extended for
an Employee who is self employed or gainfully employed by another party during
a period of Approved Leave of Absence Without Pay. A request to continue
Coverage while on Approved Leave Without Pay must be received by the Employing
Entity within thirty-one (31) calendar days of the termination of paid Coverage
through payroll Deductions. Employees who qualify for continued Coverage under
multiple leave types may continue Coverage under a combination of leave types;
however, the total period of Coverage on Approved Leave of Absence Without Pay
shall not exceed twelve (12) calendar months, unless otherwise noted in these
provisions. Premium payments must be in an amount sufficient to provide
continuous Coverage between termination of paid Coverage through payroll
Deductions and the beginning of Approved Leave of Absence Without Pay Coverage.
When an Employee on Approved Leave of Absence Without Pay enrolls during the
annual Open Enrollment, Period the twelve (12) calendar month Coverage period
shall be reduced by the number of prior months of Approved Leave of Absence
Without Pay during which the Employee did not elect to participate in the SHBP.
Employees on Leave Without Pay must timely submit required Premiums to the
Employing Entity, and the Employing Entity must timely pay required Employer
Contributions associated with such Employees. An Employee's failure to timely
submit a required Premium to the Employing Entity causes a loss of eligibility
for Coverage, and the Employing Entity must timely notify the Administrator of
loss of eligibility in accordance with these regulations.
(a)
Disability Leave. A
disability leave is the period of time an Approved Leave of Absence Without Pay
has been granted to the Employee due to personal illness, accident or
disability. Coverage may be continued under this paragraph for the period of
disability, but not longer than twelve (12) consecutive calendar months.
Certification of the disability period by a licensed physician shall be
required to continue coverage under this provision.
(b)
Reduced Working Hours Due to
Partial Disability. A Partial Disability leave is the period of time
during which an Employer approves an Employee's return to work on a part-time
basis from a period of disability leave or paid leave if the part-time work is
part of a process to gradually return the Employee to full-time work. Coverage
may be continued under this provision for the period of disability approved by
a licensed physician, but not longer than twelve (12) consecutive calendar
months, inclusive of any time from a period of disability leave without pay.
Certification of the Partial Disability period shall be required to continue
coverage under this provision.
(c)
Leave of Absence for the Employer's Convenience. Employer's
convenience leave is a period of time during which an Approved Leave of Absence
Without Pay has been granted by the appropriate organizational official due to
a regular programmatic plan for Employee absence and pursuant to appropriate
regulation. The Employee may continue the Coverage such leave of absence, but
not longer than twelve (12) consecutive calendar months.
(d)
Educational Leave.
Educational leave is the period of time during which an Approved Leave
of Absence Without Pay has been granted by the appropriate organizational
official for educational or training purposes. The Employee may continue the
Coverage under such leave for the period of absence, but not longer than twelve
(12) consecutive calendar months.
(e)
Family Medical Leave. Family
medical leave is the period of time during which an Approved Leave of Absence
Without Pay has been granted to the Employee by the appropriate organizational
official for personal illness, the care of the Employee's child after birth or
placement for adoption or the care of an Employee's seriously ill Spouse,
child, or parent. An Employee's personal illness, if properly certified and
approved may be granted under the disability leave provisions. Coverage while
on Approved Leave of Absence Without Pay for family medical leave may be
continued for the period of approved leave, but not longer than twelve (12)
weeks in any twelve (12) consecutive month period.
(f)
Military Leave. Military
leave is the period of time during which an Approved Leave of Absence Without
Pay has been granted by the appropriate organization official when an Employee
is ordered to military duty or the period, as provided by law, during which an
Employee is attending military training. Military leave also applies to an
Employee who qualifies for an exigency leave or service member care leave, as
defined under Federal law. The Employee may continue the Coverage under such
leave for the period of absence.
(g)
Suspension or Other Leave of
Absence. Suspension or other leave of absence is the period of time
during which suspension is in effect or an Approved Leave of Absence Without
Pay has been granted by the appropriate organization official for the
Employee's convenience. The Employee may continue the Coverage for the period
of suspension or approved leave, but not to exceed twelve (12) calendar
consecutive months, provided the Employee is not self employed or gainfully
employed by another party during such leave of absence.
(h)
Extensions of Leave of Absence.
If the Employee is unable to return to work at the expiration of the
approved leave and the maximum period has not been exhausted, a request to
extend the leave of absence may be filed. The Administrator must receive the
Employee's request for extension no later than thirty-one (31) calendar days
following expiration of Coverage under the leave of absence. The Employing
Entity must certify approval of the extension. The attending physician must
complete a new disability certification for an extension of a disability
leave.
(i)
Sequential Periods
of Leave. Health benefits may be continued during sequential types of
leave, provided that continuation of health benefits during continuous,
sequential periods of time shall not exceed the time limitation of the most
recently approved type of leave.
(j)
Premiums. Premiums for
continued Coverage during a period of Approved Leave of Absence Without Pay
shall be paid monthly to the Employing Entity. When establishing the monthly
Premium amount to be paid by the Employee, the Board may add a processing fee.
The Premium Rate, excluding the processing fee, shall be based on the type of
approved leave. The Premium Rate for disability, family leave or military leave
of absence shall be the same as the Employee Deduction; the Premium Rate for
all other types of leave shall be the total cost of coverage as set forth in
Board resolution. Failure to pay the full Premium to the Employing Entity
within the allotted time shall result in loss of eligibility for
Coverage.
(7)
Spouse. An Active Employee shall be entitled to enroll the
Employee's Spouse upon employment, during Open Enrollment, or under conditions
specified in Section
111-4-1-.06 of these regulations. A
Retiree shall be entitled to continue Coverage for the Spouse upon retirement
or may enroll the Spouse in accordance with Section
111-4-1-.06(5) or
111-4-1-.06(6). The
Administrator shall require the Social Security Number for the Spouse as well
as appropriate documentation from an Enrolled Member in order to verify a
Spouse's eligibility for Coverage.
(8)
Dependent Child. An Active
Employee shall be entitled to enroll eligible Dependent children upon
employment, during Open Enrollment, or under conditions specified in Section
111-4-1-.06 of these regulations. A
Retiree shall be entitled to continue Coverage for eligible Dependent children
upon retirement or may enroll eligible Dependent children in accordance with
Section 111-4-1-.06(5). The
Administrator shall require the Social Security Number for every child,
starting at age two, as well as appropriate documentation from an Enrolled
Member in order to verify a Dependent child's eligibility for Coverage. An
eligible Dependent child must meet one of the following definitions;
(a) A natural child, for which the natural
guardian has not relinquished all guardianship rights through a judicial
decree. Eligibility begins at birth and ends at the end of the month in which
the child reaches age twenty-six (26);
(b) An adopted child. Eligibility begins on
the date of legal placement for adoption and ends at the end of the month in
which the child reaches age twenty-six (26);
(c) A stepchild. Eligibility begins on the
date of marriage to the natural parent and ends at the end of the month in
which the child reaches age twenty-six (26), or at the end of the month in
which he or she loses status as the stepchild of the Enrolled Member, whichever
date is earlier; or
(d)
Guardianship. A child for whom the Enrolled Member is the legal guardian.
Eligibility begins on the date the legal guardianship is established and ends
at the end of the month in which the child reaches age twenty-six (26), or at
the end of the month in which the legal guardianship terminates, whichever is
earlier. Certification documentation requirements are at the discretion of the
Administrator. However, a judicial decree from a court of competent
jurisdiction is required unless the Administrator concludes that documentation
is satisfactory to establish legal guardianship and financial dependence and
that other legal papers present undue hardship on the Member or living natural
parent(s).
(9)
Totally Disabled Child. An Enrolled Member shall be entitled to
apply for Coverage of a natural child, legally adopted child or stepchild age
twenty-six (26) or older if the child was physically or mentally disabled
before age twenty-six (26), continues to be physically or mentally disabled,
lives with the Enrolled Member or is institutionalized and depends primarily on
the Enrolled Member for support and maintenance.
(a)
Application Period. The
Enrolled Member may apply for Coverage during Open Enrollment, as a New Hire,
or as the result of a Qualifying Event. At all other times, an Enrolled Member
whose Totally Disabled Child was a covered dependent on the Member's Family
Plan prior to turning age twenty-six (26) must apply for continuation of
Coverage and include all supporting documentation no later than thirty-one (31)
calendar days following the end of the month in which the child reaches age
twenty-six (26). If the Enrolled Member fails to complete the request within
the allotted time, eligibility for Coverage until the next Open Enrollment is
limited to the conditions outlined for Extended Beneficiaries.
(b)
Documentation and Approval.
The Administrator shall require documentation as necessary to provide
certification that the child was physically or mentally incapable of
sustaining, self-supporting employment because of the physical or mental
disability before age twenty-six (26), continues to be physically or mentally
incapable of sustaining, self-supporting employment because of the physical or
mental disability, and lives at the Enrolled Member's home or is
institutionalized. The documentation may include but is not limited to
certification from a qualified medical practitioner that outlines the physical
and psychological history, diagnosis, and provides an estimate of length of
time for disability, and an estimate of the child's earning capacity. If the
documentation is satisfactory to substantiate the physical or mental disability
as required in these regulations, the Administrator may approve Coverage for
the period of incapacitation. The Administrator may require periodic
recertification of the disabling condition and circumstances, provided the
recertification is not more frequent than each twelve (12) calendar months or
at the end of the projected disability period if that date is less than twelve
(12) calendar months.
(10)
Surviving Beneficiary. An
Enrolled Member's Surviving Spouse and eligible Dependent children, who were
included in the Coverage by the Enrolled Member immediately before death, may
continue Coverage provided an application for continuing Coverage is received
by the Administrator within ninety (90) calendar days following Coverage
termination as a result of the death of the Enrolled Member in the situations
set forth below. In the application, the Surviving Spouse shall be required to
list all eligible Covered Dependents who will continue Coverage and shall not
be allowed to add any future spouse or children not listed. Surviving Covered
Spouses and Dependent children are entitled by federal law to continue Coverage
under the Extended Beneficiary provisions set forth in Section
111-4-1-.08. By electing to continue
coverage under any of these Surviving Beneficiary provisions, the Surviving
beneficiary waives rights to continuation coverage under the Extended
Beneficiary provisions of Section
111-4-1-.08.
(a) The Surviving Spouse of an Active
Employee may continue Coverage for him or herself and surviving eligible
Covered Dependent children if the Spouse is eligible to immediately receive a
monthly benefit payment from a state supported retirement system in an amount
sufficient to pay the Premium established by the Board. The Spouse must elect
to continue Coverage as a Surviving Spouse under this provision or as an
Employee as a result of the Spouse's own employment, and cannot elect double or
dual Coverage under separate provisions of the SHBP. Eligibility of Dependent
children shall terminate in accordance with provisions for Dependent children
of these regulations. An election to take a lump sum distribution rather than
the monthly Annuity negates eligibility to continue Coverage as a Surviving
Spouse
(b) The Surviving Spouse of
an Annuitant may continue Coverage for him or herself and surviving eligible
Covered Dependent children if the Spouse is eligible to immediately receive a
monthly benefit payment from a state supported retirement system in amount
sufficient to pay the Premium established by the Board. The Surviving Spouse
must elect to continue Coverage as a Surviving Spouse under this provision or
as an Employee as a result of the Spouse's own employment, and cannot elect
double or dual Coverage under separate provisions of the SHBP Eligibility of
Dependent children shall terminate in accordance with provisions for Dependent
children. An election to take a lump sum distribution rather than the monthly
Annuity negates eligibility to continue Coverage as a Surviving
Spouse.
(c) Upon the death of an
Active Employee, an eligible Covered Dependent child who is the principal
Beneficiary under one of the state supported retirement systems may continue
Coverage, provided the Dependent child is not covered as a Dependent child
under another contract under the SHBP, and provided the monthly benefit payment
from a state supported retirement system is in an amount sufficient to pay the
Premium established by the Board. Eligibility to continue Coverage shall
terminate in accordance with provisions for Dependent children. An election to
take a lump sum distribution rather than the monthly Annuity negates
eligibility to continue Coverage under this provision.
(d) Upon the death of a Retired Employee, an
eligible Covered Dependent child who is the principal beneficiary under one of
the state supported retirement systems may continue Coverage, provided the
Dependent child is not covered as a Dependent child under another contract
under the SHBP, and provided the monthly benefit payment from a state supported
retirement system is in an amount sufficient to pay the Premium established by
the Board. Eligibility to continue coverage shall terminate in accordance with
provisions for Dependent children. An election to take a lump sum distribution
rather than the monthly Annuity negates eligibility to continue Coverage under
this provision.
(e) The Surviving
Spouse of a Retired Employee who is included in Coverage at the time of death
of the enrolled Retiree and who will not receive a monthly annuity payment from
one of the state supported retirement systems shall be eligible to continue
Coverage for him or herself and any of the Retiree's Dependent children who
were Covered at the time of the Retiree's death, if the following conditions
are met:
1. The Surviving Spouse must make
written application no later than ninety (90) calendar days following Coverage
termination as a result of the death of the Retired Employee; and
2. The parties must have been married at
least one full year prior to the death of the Retired Employee; and
3. The Surviving Spouse agrees to pay the
monthly premium payment established by the Board in accordance with the
established requirements; and
4.
Coverage under this provision shall terminate for the Surviving Spouse and any
enrolled Dependent children in the event the Surviving Spouse
remarries.
(f) The
eligible Covered Spouse and Dependent children of a Covered Active State
Employee who is killed or receives injury that results in death while acting in
the scope of his or her employment may continue Coverage provided the deceased
Enrolled Member's Coverage was continuous during the period between injury and
death. The eligible Covered Dependents may elect Coverage as a surviving
Dependent or as an Employee as a result of the person's own employment, but
cannot elect double or dual Coverage under separate provisions of the SHBP.
Surviving Covered Dependents must agree to pay the monthly Premium payment
established by the Board for Active State Employees. The Surviving Spouse may
elect to continue Coverage for eligible Covered Dependent children. Eligibility
of Dependent children shall terminate in accordance with provisions for
Dependent children.
(11)
Dependent Eligibility Unverified. The Administrator shall define
the supporting documentation requirements for verifying Dependent eligibility.
Coverage for Dependents whose eligibility is unverified will pend awaiting
receipt and review of the documentation. When the Administrator has verified
eligibility of the Dependent, the Coverage will be activated in accordance with
the provisions of this Section. If the Administrator cannot verify Dependent
eligibility within the allotted time, the Dependent will be ineligible for
Coverage. The next opportunity to enroll the Dependent and verify the
Dependent's eligibility will be the annual Open Enrollment period or subsequent
Qualifying Event. Changes to a different coverage tier will not be allowed
based on unverified dependent eligibility.
(12)
Retired Employees Having
Intermittent Periods of Active Employment. Retired Employees who are
eligible to continue Coverage under these regulations may elect to return to or
continue Active employment with any of the Employing Entities. In such case,
the retirement benefit may be suspended or continued; however, the federal
Social Security Act requires the health benefit Coverage must be purchased as
an Active Employee whenever the eligibility requirements of Section
111-4-1-.04 of these regulations are
met. At the point the Employee discontinues Active employment, continuous
health benefit Coverage shall be reinstated with the state supported retirement
system which previously collected the Premium. In no case, however is an
individual who retired prior to the initial legislated funding for that Group
of Employees to be entitled to enroll as a Retiree, unless the final Active
service period qualifies the Employee for a retirement benefit by one of the
state supported retirement systems.
(13)
Judicial Reinstatement of State
Employees. State Employees who are reinstated to employment by the State
Personnel Board or the judiciary shall have Coverage reinstated for themselves
and any eligible Dependents. If employment reinstatement occurs within twelve
(12) calendar months of discharge and back-pay for continuous employment is
awarded, all retroactive Premiums must be collected and remitted to the Plan
before and Claims incurred during the period may be filed for reimbursement. If
back-pay to provide for continuous employment is not awarded, Coverage may be
reinstated with the Employee's return to work. If reinstatement occurs
following a period longer than twelve (12) calendar months after the discharge,
Coverage for the Employee and previously Covered Dependents will be reinstated
when the Employee returns to work or in accordance with the judicial review. In
any case where the reinstatement overlaps an Open Enrollment period, the
Employee will be given fifteen (15) calendar days after reinstatement to modify
Coverage in compliance with Open Enrollment guidelines. Pre-existing condition
limitations will be waived for the reinstated Employee and all previously
enrolled Dependents. Employing Entities shall be responsible for collecting and
remitting any Premiums due for the selected Coverage.
(14)
Contract Employees.
Employees who are on approved leave of absence and/or have not
terminated their employment may participate in the Plan if their Employer has
contracted with the Board to provide inclusion in the SHBP. The Employee will
be eligible to participate in accordance with the provisions of the
contract.
Notes
State regulations are updated quarterly; we currently have two versions available. Below is a comparison between our most recent version and the prior quarterly release. More comparison features will be added as we have more versions to compare.
No prior version found.