Or. Admin. Code § 111-040-0040 - Qualified Status Changes (QSCs)
(1) An eligible
employee experiencing a change in family or work status as noted below after an
annual open enrollment, or anytime during the plan year, has 31 calendar days
beginning on the date of the event to make allowable changes. If the event is
gaining a child, as defined by 111-040-0040(4)(c), or results in a loss of
eligibility, the eligible employee has 60 calendar days after the event to make
allowable changes.
(2) An eligible
employee may only make changes that are consistent with the event for
themselves and/or dependents.
(3)
An eligible employee must report the Qualified Status Change (QSC) to their
entity within the specified timeframe. Failure to report a QSC that results in
removal of a spouse, domestic partner, or child within the timeframe stated in
111-040-0040(1) may be considered intentional misrepresentation, and OEBB may
rescind the individual's coverage back to the last day of the month in which
the individual lost eligibility. Please refer to the Qualified Status Change
(QSC) matrix below for details on what changes may occur with each
event.
(4) Qualified Status Changes
which allow an employee to make changes to his or her coverage are:
(a) Gaining a spouse by marriage or domestic
partner by meeting domestic partner eligibility;
(b) Loss of spouse or domestic partner by
divorce, annulment, death or termination of domestic partnership,
(c) Gaining a child by birth, placement
for/or adoption, or Domestic Partner's children (by affidavit of domestic
partnership),
(d) Change in
employee group which affects plan option availability;
(e) Spouse, domestic partner or child starts
new employment or other change in employment status which affects eligibility
for benefits;
(f) Spouse, domestic
partner's or child's employment ends or other change in employment status
resulting in a loss of eligibility for benefits under their employer's
plan;
(g) Event by which a child
satisfies eligibility requirements under OEBB plans;
(h) Event by which a child ceases to satisfy
eligibility requirements under OEBB plans;
(i) Changes in the residence of the active
eligible employee, spouse, domestic partner, or child (i.e., moving out of the
service area of an HMO or limited network service area plan);
(j) Significant changes in cost of the
eligible employee's or early retiree's current plan and tier level that result
in a negative or positive impact of 10 percent or more to:
(A) The amount an eligible employee or early
retiree must contribute toward benefits.
(B) The amount a spouse or domestic partner
must contribute toward his or her group health insurance plan cost.
(k) Different Open Enrollment/Plan
Year under a spouse/domestic partner's employer plan.
(l) Related laws or court orders. For
example: Qualified Medical Child Support Order (QMSCO), Entitlement to Medicare
or Medicaid, HIPAA, or Children's Health Insurance Program (CHIP) Changes are
determined by the applicable law or court order.
(5) Changes in coverage do not constitute a
Qualified Status Change.
(6) The
following applies to the Long Term Care benefit plans only:
(a) Cancel the plan at any time without a QSC
event.
(b) Plan additions or
changes require a QSC event as defined 111-040-0040(2). The addition of a plan
or change in plans with a QSC is subject to a medical evidence review by the
LTC carrier.
(7) If
optional life insurance is requested beyond the guarantee issued amount,
Evidence of Insurability must be submitted to the OEBB life insurance
carrier(s) within 90 calendar days of the QSC event.
Notes
To view attachments referenced in rule text, click here to view rule.
Statutory/Other Authority: ORS 243.860 - 243.886
Statutes/Other Implemented: ORS 243.864(1)(a)
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