Ohio Admin. Code 3307:1-11-03 - Health care services - medical plan

(A) Eligibility

The following individuals shall be eligible to participate in a medical plan offered by the retirement system:

(1) A service retiree with an effective benefit date:

(a) Before January 1, 2004; or

(b) Between January 1, 2004 and July 1, 2023 and the benefit is based on fifteen or more years of total service credit; or

(c) After July 1, 2023 and the benefit is based on twenty or more years of total service credit.

(2) A service retiree who began receiving service retirement benefits with no break in monthly benefits following the termination of disability benefits, with a disability effective benefit date:

(a) Before January 1, 2004; or

(b) Between January 1, 2004 and July 1, 2023 and the service retiree benefit is based on fifteen or more years of total service credit; or

(c) After July 1, 2023 and the service retiree benefit is based on twenty or more years of total service credit.

(3) A disability benefit recipient.

(4) A survivor annuitant who was eligible for health care coverage as a dependent at the time of the service retiree's death.

(5) A survivor benefit recipient under division (C)(1) of section 3307.66 of the Revised Code who was eligible for coverage as a dependent at the time of the member's or disability benefit recipient's death where the effective date of survivor benefits or the effective date of disability benefits of the deceased member is:

(a) Before January 1, 2004; or

(b) Between January 1, 2004 and July 1, 2023 provided that the deceased member or disability benefit recipient had fifteen or more years of total service credit at the time of death; or

(c) After July 1, 2023 provided the deceased member or disability benefit recipient had twenty or more years of total service credit at the time of death.

(6) A survivor benefit recipient under division (C)(2) of section 3307.66 of the Revised Code who was eligible for coverage as a dependent at the time of the member's or disability benefit recipient's death.

(7) Dependents, to the extent that a medical plan and/or ancillary plan allows for dependent coverage.

(8) Notwithstanding paragraphs (A)(1) to (A)(7) of this rule, an individual not eligible for medicare coverage is not eligible for primary coverage in a medical plan offered by the retirement system if the individual is employed and has access to an entity's medical plan or if similarly situated, non-retired employees have access to an entity's medical plan, provided the medical plan includes prescription coverage. The retirement board may require each enrollee to annually file a verification of employment statement disclosing the availability for enrollment as an employee in an entity's medical plan.

(a) When an individual is enrolled in an entity's medical plan and a medical plan offered by the retirement system, coverage in the retirement system's medical plan will be limited to secondary coverage applied only to those covered medical expenses not paid by the entity's medical plan.

(b) An employed individual not eligible for medicare who does not file a verification of employment statement with the retirement system when requested by the retirement system; does not enroll in the entity's medical plan when eligible to enroll, or is excluded from the entity's medical plan based upon being an enrollee in the retirement system's medical plan is not eligible to enroll or remain enrolled in a medical plan offered by the retirement system.

(9) An individual enrolled in a medical plan offered by the retirement system shall enroll in medicare part A, if the enrollee is able to enroll in medicare part A without being required to pay a premium, and part B upon first attaining eligibility for each.

(B) Effective date

The effective date of coverage for enrollees in a medical plan shall be determined as follows:

(1) Initial enrollment: When a monthly benefit payment begins, medical coverage shall begin for a:

(a) Service retiree:

(i) On the effective benefit date when the service retirement application is received on or before the effective benefit date, provided the service retiree enrolls by the end of the month of the effective benefit date; or

(ii) On the first day of the month following the date the service retirement application is received when the effective benefit date is prior to the date the service retirement application is received, provided the service retiree enrolls by the end of the month following the month the service retirement application is received.

(b) Disability benefit recipient:

(i) On the effective benefit date when the disability benefit recipient is granted disability benefits on or before the effective benefit date, provided the disability benefit recipient enrolls by the end of the month of the effective benefit date.

(ii) On the first day of the month following the date the disability benefit is granted when the effective benefit date is prior to the date the disability benefit is granted, provided the disability benefit recipient enrolls by the end of the month following the month the disability benefit is granted.

(c) Survivor benefit recipient:

(i) On the effective benefit date when a survivor benefit recipient enrolls by the end of the third month following the month of the member's or disability benefit recipient's death.

(ii) On the first of the month following the receipt of a survivor benefit application submitted after the third month following the month of the member's or disability benefit recipient's death provided the survivor benefit recipient enrolls by the end of the month following the month the survivor benefit application is received.

(d) Survivor annuitant:

(i) On the first of the month following the month of the service retiree's death, provided a survivor annuitant enrolls by the end of the third month following the month of the service retiree's death.

(ii) On the first of the month following the month of the service retiree's death when a survivor annuitant was enrolled as a service retiree's dependent at the time of the service retiree's death.

(2) Subsequent enrollment: Coverage shall begin as follows if a benefit recipient does not enroll as permitted under paragraph (B)(1) of this rule and later applies to enroll:

(a) Open enrollment: The retirement system may offer an open enrollment period during which eligible benefit recipients may enroll or change medical plans for themselves and eligible dependents. Coverage will begin on the first day of the next plan year following an open enrollment period specified by the retirement system.

(b) Special enrollment: A person may enroll under the following circumstances when a benefit recipient submits his or her application to enroll within thirty-one days from the date of a qualifying event, provides any other required documentation, the application is approved by the retirement system, and the person meets all other eligibility requirements:

(i) Benefit recipients:

(a) A benefit recipient may enroll based upon his or her loss of health care coverage that provided minimum essential coverage as defined under the federal Patient Protection and Affordable Care Act of 2010, 124 Stat. 119 (2010), as amended, for coverage beginning the first of the month in which coverage is lost.

(b) A benefit recipient may enroll based upon his or her enrolling in medicare parts A and B or only medicare part B for coverage beginning the first of the month medicare coverage begins.

(ii) Provided the benefit recipient is enrolled, dependents may be enrolled as follows:

(a) A primary recipient may enroll his or her new spouse for coverage beginning the first of the month following the date of marriage or the first day of the month of marriage when the date of marriage is on the first day of the month.

(b) A benefit recipient may enroll a child for coverage beginning the day of birth, legal adoption, or the date the benefit recipient was legally appointed as guardian of that child.

(c) A benefit recipient may enroll a dependent who lost health care coverage that provided minimum essential coverage as defined under the federal Patient Protection and Affordable Care Act of 2010 for coverage beginning the first of the month in which coverage is lost.

(d) A benefit recipient may enroll a dependent based upon the dependent enrolling in medicare parts A and B or only medicare part B for coverage beginning the first of the month medicare coverage begins.

(C) Premium

(1) The premium for an enrollee in a medical plan shall be based upon the total service credit used in the calculation of the primary recipient's benefit, the effective benefit date, and such other factors as the retirement board may find relevant in its sole discretion.

(2) The premium for an enrollee in a medical plan shall be pre-paid through a monthly deduction from the monthly benefit unless the amount of the monthly benefit will not cover the total premium. In that case, the benefit recipient will be billed directly by the retirement system for any premium balance owed for an initial period not to exceed three months and authorizes the retirement system to electronically debit the premium balance owed each month from the benefit recipient's bank account. It will be the sole responsibility of the benefit recipient to provide and maintain the information and available funds required for the retirement system to complete the monthly electronic debit. Should the retirement system be unable to debit the payment electronically after the initial three month period, enrollment in the health care program may be terminated. If for any reason payment is not received on or before the first business day of the month the premium is due, enrollment in the health care program may be terminated.

(3) The following benefit recipients are eligible to receive a subsidy:

(a) A service retiree either with an effective benefit date prior to August 1, 2023 and fifteen or more years of total service credit, or with an effective benefit date on or after August 1, 2023 and twenty or more years of total service credit.

(b) A disability benefit recipient either with five or more years total service credit with an effective benefit date prior to August 1, 2023, or with six or more years of total service credit with an effective benefit date on or after August 1, 2023.

(D) Open enrollment and plan changes

(1) The retirement system may offer an open-enrollment period during which benefit recipients may enroll in or change medical plans for themselves and eligible dependents.

(2) Once coverage under a medical plan begins, a benefit recipient can request a change of medical plans during the plan year as follows:

(a) A change to any other available medical plan may occur when an enrolled benefit recipient provides required documentation and requests a change:

(i) Within thirty-one days of: receipt of the first regular monthly benefit payment; marriage, divorce, legal separation or dissolution; birth, adoption, or legal appointment as guardian of a child; death; or full loss of subsidy; or enrolling a dependent with a qualifying event as described in paragraph (B)(2)(b) of this rule.

(ii) Within three months of benefit recipient or enrolled dependent enrolling in medicare parts A and B or only medicare part B.

(b) A change to another medical plan may occur at any time when an enrolled benefit recipient requests a change and provides documentation that evidences one of the following events:

(i) Loss of a key provider from a medical plan's provider network.

(ii) Relocation of permanent residence to another service area not covered by the enrollee's current medical plan.

(iii) Benefit recipient enrolled in a medicare fully insured medical plan.

Notes

Ohio Admin. Code 3307:1-11-03

Effective: 5/4/2023
Five Year Review (FYR) Dates: 6/3/2026
Promulgated Under: 111.15
Statutory Authority: 3307.04
Rule Amplifies: 3307.39, 3307.391
Prior Effective Dates: 12/23/1976, 11/28/1977, 03/17/1989 (Emer.), 06/01/1989, 09/23/1991 (Emer.), 05/28/1992, 06/22/1992 (Emer.), 09/10/1992, 02/13/1993, 09/01/1996, 07/03/1997, 09/16/1998 (Emer.), 11/27/1998, 05/25/2000, 07/01/2001 (Emer.), 09/17/2001, 09/27/2001, 09/17/2002, 01/01/2004 (Emer.), 03/22/2004, 07/01/2006, 10/27/2006, 01/08/2007, 12/06/2007, 01/06/2008, 05/14/2009, 08/12/2010 (Emer.), 10/28/2010, 06/06/2011, 01/01/2013, 01/01/2014 (Emer.), 02/10/2014, 06/12/2014, 09/04/2014, 12/10/2015, 06/10/2016, 06/03/2021