Kan. Admin. Regs. § 108-1-1 - Eligibility
(a) Definitions. Each of the following terms,
as used in this regulation, shall have the meaning specified in this
subsection:
(1) "Active participant" means any
person enrolled in the health care benefits program.
(2) "Child" means any of the following:
(A) A natural son or daughter of a primary
participant;
(B) a lawfully adopted
son or daughter of a primary participant. The term "lawfully adopted" shall
include those instances in which a primary participant has filed the petition
for adoption with the court, has a placement agreement for adoption, or has
been granted legal custody;
(C) a
stepchild of a primary participant. However, if the natural or adoptive parent
of the stepchild is divorced from the primary participant, the stepchild shall
no longer qualify;
(D) a child of
whom the primary participant has legal custody; or
(E) a grandchild, if at least one of the
following conditions is met:
(i) The primary
participant has legal custody of the grandchild or has lawfully adopted the
grandchild;
(ii) the grandchild
lives in the home of the primary participant and is the child of a covered
eligible dependent child, and the primary participant provides more than 50
percent of the support for the grandchild; or
(iii) the grandchild is the child of a
covered eligible dependent child and is considered to reside with the primary
participant even when the grandchild or eligible dependent child is temporarily
absent due to special circumstances including education of the covered eligible
dependent child, and the primary participant provides more than 50 percent of
the support for the grandchild.
(3) "COBRA" means the consolidated omnibus
budget reconciliation act, public law 99-272 , as amended.
(4) "Commission" means the Kansas state
employees health care commission.
(5) "Direct bill participant" means any
person enrolled in the health care benefits program pursuant to subsections
(d), (e), and (h).
(6) "Eligible
dependent child" means any dependent child who meets one of the following
criteria:
(A) The child is under 26 years of
age.
(B) The child is aged 26 or
older, has a permanent and total disability, and has continuously maintained
group coverage as an eligible dependent child of the primary participant before
attaining the age of 26. The child shall be chiefly dependent on the primary
participant for support.
(7) "Health care benefits program" means the
state of Kansas health care benefits program established by the
commission.
(8) "Permanent and
total disability" means that an individual is unable to engage in any
substantial gainful activity by reason of any medically determinable physical
or mental impairment that can be expected to result in death or has lasted or
can be expected to last for a continuous period of at least 12 months. An
individual shall not be considered to have a permanent and total disability
unless that person furnishes proof of the permanent and total disability in the
form and manner, and at the times, that the health care benefits program may
require.
(9) "Primary participant"
means any person enrolled in the health care benefits program under subsection
(b), a direct bill participant under subsection (d), or a COBRA
participant.
(10) "Variable-hour
employee" means any officer or employee of a state agency for whom, at the date
of hire, it cannot be determined that the employee is reasonably expected to
work at least 1,000 hours per year.
(b) Primary participants. Subject to the
provisions of subsection (c), the classes of persons eligible to participate as
primary participants in the health care benefits program shall be the following
classes of persons:
(1) Any elected official
of the state;
(2) any other officer
or employee of a state agency who meets both of the following conditions:
(A) Is working in one or more positions that
together require at least 1,000 hours of work per year; and
(B) is not a variable-hour
employee;
(3) any person
engaged in a postgraduate residency training program in medicine at the
university of Kansas medical center or in a postgraduate residency or
internship training program in veterinary medicine at Kansas state
university;
(4) any person serving
with the foster grandparent program;
(5) any person participating under a phased
retirement agreement outlined in K.S.A. 76-746, and amendments
thereto;
(6) any student employee
and any adjunct professor at a state institution of higher learning if the
individual works in one or more positions that together require at least 1,560
hours of work per year; and
(7) any
other class of individuals approved by the Kansas state employees health care
commission, within the limitations specified in K.S.A. 75-6501 et seq., and
amendments thereto.
(c)
Eligibility upon beginning employment.
Each person who is within a class listed in paragraph (b)(1), (b)(2), (b)(3), (b)(4), (b)(6), or (b)(7) shall become eligible for enrollment in the health care benefits program on the first day of work for the state of Kansas. Each person shall have 31 days after becoming eligible to elect coverage.
(d) Classes of
direct bill participants. Subject to the provisions of subsection (e), the
classes of persons eligible to participate as members of the health care
benefits program on a direct bill basis shall be the following:
(1) Any former elected state
official;
(2) any retired state
officer or employee who is eligible to receive retirement benefits under K.S.A.
74-4925, and amendments thereto, or retirement benefits administered by the
Kansas public employees retirement system;
(3) any totally disabled former state officer
or employee who is receiving disability benefits administered by the Kansas
public employees retirement system;
(4) any surviving spouse or dependent of a
qualifying participant in the health care benefits program;
(5) any person who is in a class listed in
paragraph (b) (1), (b)(2), (b)(3), (b)(4), or (b)(6) and who is lawfully on
leave without pay;
(6) any blind
person licensed to operate a vending facility as defined in K.S.A. 75-3338, and
amendments thereto;
(7) any former
"state officer," as that term is defined in K.S.A. 74-4911f and amendments
thereto, who elected not to be a member of the Kansas public employees
retirement system as provided in K.S.A. 74-4911f and amendments thereto;
and
(8) any former state officer or
employee who separated from state service when eligible to receive a retirement
benefit but, in lieu of that, withdrew that individual's employee contributions
from the retirement system.
(e) Conditions for direct bill participants.
Each person who is within a class listed in paragraph (d)(1), (d)(2), (d) (3),
(d)(4), (d)(5), (d)(7), or (d)(8) shall be eligible to participate on a direct
bill basis only if the conditions of both paragraphs (e)(1) and (e)(2) are met:
(1) The person was covered by the health care
benefits program on one of the following bases:
(A) The person was covered as an active
participant, as a COBRA participant, or as a spouse under paragraph (g) (1)
immediately before the date that person ceased to be eligible for that type of
coverage or the date the individual became newly eligible for a class listed in
subsection (d).
(B) The person is
the surviving spouse or eligible dependent child of a person who was enrolled
as a primary participant or a direct bill participant when the primary
participant died, and the surviving spouse or eligible dependent child was
covered by the health care benefits program as a dependent pursuant to
subsection (g) when the primary participant died.
(2) The person completes an enrollment form
requesting transfer to the direct bill program and submits the form to the
health care benefits program. The form shall be submitted no more than 30 days
after the person ceased to be eligible for coverage.
(f) COBRA participants. Any individual with
rights to extend coverage under COBRA may continue to participate in the health
care benefits program, subject to the provisions of that federal law.
(g) Eligible dependent participants.
(1) Any person enrolled in the health care
benefits program as a primary participant may enroll the following dependents,
subject to the same conditions and limitations that apply to the primary
participant:
(A) The primary participant's
lawful wife or husband, as recognized by Kansas law and subject to the
documentation requirements of the commission or its designee; and
(B) any of the primary participant's eligible
dependent children, subject to the documentation requirements of the commission
or its designee.
(2) An
eligible dependent child who is enrolled by one primary participant shall not
be eligible to be enrolled by another primary participant.
(3) An individual who is eligible to enroll
as a primary participant in the health care benefits program shall be eligible
to be enrolled under this subsection as a dependent in the health care benefits
program, subject to the following requirements:
(A) The individual who enrolls as a dependent
of a primary participant shall be the lawful spouse, as defined in paragraph
(g)(1)(A).
(B) An individual who
enrolls as a dependent of a primary participant shall not be eligible to be
enrolled as a primary participant during that plan year.
(C) Each individual who enrolls as a
dependent of a primary participant shall be subject to the copays, deductibles,
coinsurance, and employer contribution levels as a dependent and not as a
primary participant.
(4)
The term "dependent" shall exclude any individual who is not a citizen or
national of the United States, unless the individual is a resident of the
United States or a country contiguous to the United States, is a member of a
primary participant's household, and resides with the primary participant for
more than six months of the calendar year. The dependent shall be considered to
reside with the primary participant even when the dependent is temporarily
absent due to special circumstances, including illness, education, business,
vacation, and military service.
(h) Direct bill participants; continuous
coverage provisions.
(1) Except as otherwise
provided in this subsection, each direct bill participant enrolled in the state
health care benefits program on or after January 21, 2001 shall maintain
continuous coverage in the program or shall lose eligibility to be in the state
health care benefits program as a direct bill participant.
(2) Any person who discontinued direct bill
coverage in the state health care benefits program before January 21, 2001 and
who is not a direct bill participant on that date may return one time to the
state health care benefits program if the person meets the criteria specified
in subsections (d) and (e) and if that person has not previously discontinued
and returned to direct bill coverage before January 21, 2001.
Notes
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