3309-1-35 Health care.

 

 

 

3309-1-35                    Health care.

 

 

 

(A)  Definitions

 

As used in this rule:

 

(1)"Ineligible person" has the same meaning as in section 3309.69 of the Revised Code.

 

(2)(1) "Benefit recipient" means an age and service retirant, disability benefit recipient, or a beneficiary as defined in section 3309.01 of the Revised Code, who is receiving monthly benefits due to the death of a member, age and service retirant or disability benefit recipient.

 

(3)(2) "Member" has the same meaning as in section 3309.01 of the Revised Code.

 

(4)(3)  "Age  and  service  retirant"  means  a  former  member  who  is  receiving  a retirement  allowance  pursuant  to  section  3309.34,  3309.35,  3309.36  or

3309.381 of the Revised Code. A former member with an effective retirement date after June 13, 1986 must have accrued ten years of service credit, exclusive of credit obtained after January 29, 1981 pursuant to sections 3309.021, 3309.301, 3309.31, and 3309.33 of the Revised Code.

 

(5)(4) "Disability benefit recipient" means a member who is receiving a benefit or allowance pursuant to section 3309.35, 3309.39, 3309.40 or 3309.401 of the Revised Code.

 

(6)(5) "Child" means a biological, "Dependent" means an individual who is either of the following:adopted or step-child of the retirant, member, deceased retirant or deceased member or other child in a parent-child relationship in which the retirant, member, deceased retirant or deceased member has or had custody of the child.

 

(a) A spouse of an age and service retirant, disability benefit recipient, or member,

 

(b) A biological, adopted or step-child of an age and service retirant, disability benefit recipient, member, deceased age and service retirant, deceased disability benefit recipient, or deceased member or other child in a parent-child relationship in which the age and service retirant, disability benefit recipient, member, deceased age and service retirant, deceased disability benefit recipient, or deceased member has or had custody of the child, so long as the child:

 

(i) Is under age twenty-six, or

 

 

(ii) Regardless of age is permanently and totally disabled, provided that the disability existed prior to the age and service retirant's, disability benefit recipient's, or member's death and prior to the child reaching age twenty-six. For purposes of this paragraph "permanently and totally disabled" means the individual is unable to engage in any substantial gainful activity by reason of any medically determinable physical or mental impairment which can be expected to result in death, or which has lasted or can be expected to last for a continuous period of not less than twelve months.

(7) "Dependent child" means a child who:

(a)

(i) Is under age twenty-six, or

(ii) Regardless of age is permanently and totally disabled, provided that the disability existed prior to the retirant's or member's death and prior to the dependent child reaching age twenty-six. For purposes of this paragraph "permanently and totally disabled" means the individual is unable to engage in any substantial gainful activity by reason of any medically determinable physical or mental impairment which can be expected to result in death, or which has lasted or can be expected to last for a continuous period of not less than twelve months.

(8)(6) "Health care coverage" means any plan offered by the system including, but not limited to, the medical plan, and the prescription drug programplan.

(9)(7) "Premium" means a monthly amount that may be required to be paid by a benefit recipient to continue enrollment for health care coverage for the recipient or the recipient's eligible dependents.

(10)(8) "Employer" and "public employer" have the same meaning as in section

3309.01 of the Revised Code.

(B)  Eligibility

(1)    Any person who is not an "ineligible person" as defined in section 3309.69 of the Revised Code,A person is eligible for health care coverage under the school employees retirement system's health care plan so long as the person qualifies as one of the following:

(a)   An age and service retirant or the retirant's spouse or dependent child,

(b)   A disability benefit recipient or the recipient's spouse or dependent child,

(c)    The spouse or dependent child of a deceased member, deceased age and service retirant, or deceased disability benefit recipient, if the spouse or dependent child is receiving a benefit pursuant to section 3309.45 or

3309.46 of the Revised Code,

(d)   The dependent child of a deceased member, deceased disability benefit recipient, or deceased age and service retirant who is living with the primary recipient of a benefit under section 3309.45 or 3309.46 of the Revised Code in a parent-child relationship in which the primary recipient has custody of the dependent child.if the spouse is receiving a benefit pursuant to section 3309.45 or 3309.46 of the Revised Code and the spouse elects to be covered.

(2)    Eligibility for health care coverage shall terminate when the person ceases to qualify as one of the persons listed in paragraph (B)(1) of this rule.

(C)  Enrollment

(1)    Except as otherwise provided in this rule, an eligible benefit recipient may enroll in school employees retirement system's health care coverage only at the time the benefit recipient applies for an age and service retirement, disability benefit, or monthly benefits pursuant to section 3309.45 of the Revised Code.

(2)    An eligible spouse of an age and service retirant or disability benefit recipient may only be enrolled in the system's health care coverage as follows:

(a)    At the time the retirant or disability benefit recipient enrolls in school employees retirement system's health care coverage; or,

(b)   Within thirty-one days of the eligible spouse's:

(i)   Marriage to the retirant or disability benefit recipient;

(ii)   Attaining age sixty-five; or

(iii)      Involuntary termination of health care coverage under another group plan, medicare advantage plan, or medicare part D plan.

(3)    An eligible dependent child of an age and service retirant, disability benefit recipient, or deceased member may be enrolled in the system's health care coverage as follows:

(a)    At the time the retirant, disability benefit recipient, or surviving spouse enrolls in school employees retirement system's health care coverage; or,

(b)   Within thirty-one days of the eligible dependent child's:

(i)   Birth, or adoption, or custody order; or

(ii)   Involuntary termination of health care coverage under another group plan, medicaid, medicare advantage plan, or medicare part  D plan.

(D)  Cancellation of health care coverage

(1)   Health care coverage of a person shall be cancelled when:

(a)   The person's eligibility terminates as provided in paragraph (B)(2) of this rule;

(b)   The person's health care coverage is cancelled for default as provided in paragraph (F) of this rule;

(c)   The person's health care coverage is waived as provided in paragraph (G) of this rule;

(d)     The person's health care coverage is cancelled due to the person's enrollment in a medicare advantage plan or medicare part D plan as provided in paragraph (H) of this rule;

(e)   The health care coverage of a spouse or dependent child is cancelled when the health care coverage of a benefit recipient is cancelled; or

(f)     The  person's  benefit  payments  are  suspended  for  failure  to  submit

documentation required to establish continued benefit eligibility under division (B)(2)(b)(i) of section 3309.45 of the Revised Code, division

(F) of section 3309.39 of the Revised Code, or division (D) of section

3309.41 of the Revised Code.

(E)  Effective date of coverage

(1)    The effective date of health care coverage for persons eligible for health care coverage as set forth in paragraph (B) of this rule shall be as follows:

(a)     For a disability benefit recipient, spouse or or dependent child of a disability benefit recipient, health care coverage shall be effective on the first of the month following approval of the benefit or the benefit effective date, whichever is later.

(b)   For an age and service retirant, spouse or or dependent child of an age and service retirant, health care coverage shall be effective on the first of the month following the date that the retirement application is filed with the retirement system or the benefit effective date, whichever is later.

(c)   For an eligible spouse or dependent child of a deceased member, deceased disability benefit recipient, or deceased age and service retirant, health care coverage shall be effective on the effective date of the benefit if the appropriate application is received within three months of the date of the member's or retirant's death, or the first of the month following the date that the appropriate application is received if not received within three months of the date of the member's or retirant's death.

(F)   Premiums

(1)    The school employees retirement board may establish premiums for a benefit recipient's health care coverage, including dependent coverage with the system.

(a)   Payment of premiums for health care coverage shall be by deduction from the benefit recipient's monthly benefit. If the full amount of the monthly premium cannot be deducted from the benefit recipient's monthly benefit, the benefit recipient shall be billed for the portion of the monthly premium due after any deduction from the monthly benefit.

(b)   Premium payments billed to a benefit recipient shall be deemed in default after three consecutive months of nonpayment. A benefit recipient who

is in default shall be sent notice by certified U.S. mail informing the benefit recipient that payments are in default and that coverage will be cancelled on the first day of the month after the date of the notice unless payment is received. If coverage is cancelled due to a recipient's failure to pay premium amounts in default, the recipient shall remain liable for such amounts due for the period prior to cancellation of coverage.

(c)    After cancellation for default, health care coverage can be reestablished and coverage reinstated as provided in paragraph (I) of this rule, or upon submission of an application for reinstatement supported by medical evidence acceptable to SERS that demonstrates that the default was caused by the benefit recipient's physical or mental incapacity. "Medical evidence" means documentation provided by a licensed physician of the existence of the mental or physical incapacity causing the default. Health care coverage reinstated after termination for default shall be effective on the first of the month following the date that the application for reinstatement is approved.

(2)   A person enrolled in SERS' health care plan cannot receive a premium subsidy unless that person is:

(a)   A dependent child.

(b)   An age and service retirant:

(i) An age and service retirant with an effective retirement date before August 1, 1989; or

(i)(ii) An age and service retirant with an effective retirement date on or after August 1, 1989 and before August 1, 2008 who had earned fifteen years of service credit; or

(ii)(iii) An age and service retirant with an effective retirement date on or after August 1, 2008 who had earned twenty years of service credit, exclusive of credit obtained after January 29, 1981, pursuant to sections 3309.021, 3309.301, 3309.31, and 3309.33 of the Revised Code, and who;

(a)   Was eligible to participate in the health care plan of his or her employer at the time of retirement or separation from SERS service; or

(b)   Was eligible to participate in the health care plan of his or her

employer  at  least  three  of  the  last  five  years  of  service preceding retirement or separation from SERS service.

(c)   A disability benefit recipient:

(i)    A disability benefit recipient with an effective benefit date before August 1, 2008; or

(ii)    A disability benefit recipient with an effective benefit date on or after August 1, 2008 who:

(a)   Was eligible to participate in the health care plan of his or her employer at the time of separation from SERS service; or

(b)   Was eligible to participate in the health care plan of his or her employer at least three of the last five years of service preceding separation from SERS service.

(d)  A spouse:

(i)     A spouse or surviving spouse of an age and service retirant or disability benefit recipient with an effective retirement date or benefit date before August 1, 2008 who had earned twenty-five years of service credit, exclusive of credit obtained after January 29, 1981, pursuant to sections 3309.021, 3309.301, 3309.31, and

3309.33 of the Revised Code;

(ii)     A spouse or surviving spouse of an age and service retirant or disability benefit recipient with an effective retirement date or benefit date on or after August 1, 2008 who had earned twenty-five years of service credit, exclusive of credit obtained after January 29, 1981, pursuant to sections 3309.021, 3309.301, 3309.31, and 3309.33 of the Revised Code, and who:

(a)   Was eligible to participate in the health care plan of his or her employer at the time of retirement or separation from SERS service; or

(b)   Was eligible to participate in the health care plan of his or her employer at least three of the last five years of service preceding retirement or separation from SERS service.

(iii)      A surviving spouse of a deceased member who had earned twenty-five years of service credit, exclusive of credit obtained after January 29, 1981, pursuant to sections 3309.021, 3309.301, 3309.31, and 3309.33 of the Revised Code, with an effective benefit date before August 1, 2008; or

(iv)      A surviving spouse of a deceased member who had earned twenty-five years of service credit, exclusive of credit obtained after January 29, 1981, pursuant to sections 3309.021, 3309.301, 3309.31, and 3309.33 of the Revised Code, with an effective benefit date on or after August 1, 2008, and the member;

(a)   Was eligible to participate in the health care plan of his or her employer at the time of death or separation from SERS service; or

(b)   Was eligible to participate in the health care plan of his or her employer at least three of the last five years of service preceding the member's death or separation from SERS service.

(e)     For purposes of determining eligibility for a subsidy under paragraph (F)(2) of this rule, when the last contributing service of an age and service retirant, disability benefit recipient, or member was as an employee as defined by division (B)(2) of section 3309.01 of the Revised Code, the health care plan participation requirement shall be if the individual would have been eligible for the public employer's health care plan if the individual were an employee as defined by division (B)(1) of section 3309.01 of the Revised Code.

(f)    Any other individual covered under a SERS health care plan shall be eligible for a premium subsidy under the standard set forth for spouses.

(g)    In all cases of doubt, the retirement board shall determine whether a person enrolled in a SERS health care plan is eligible for a premium subsidy, and its decision shall be final.

(G)  Waiver

(1)      A  benefit  recipient  may  waive  health  care  coverage  by  completing  and submitting a SERS waiver form to SERS.

(2)   The health care coverage of a benefit recipient's spouse or dependent child may be waived as follows:

(a)    For non-medicare eligible spouses and dependents children, the benefit recipient may waive their coverage by completing and submitting a signed written request to SERS on their behalf.

(b)    For medicare eligible spouses and dependents children, the spouse and dependent child may waive their coverage by completing and submitting a signed written request to SERS.

(H)  Medicare advantage or medicare part D

(1)    SERS shall cancel the health care coverage of a benefit recipient, spouse, or dependent child who enrolls in a medicare advantage or medicare part D plan that is not offered by the system unless SERS receives proof of cancellation within fourteen days of receipt of notice of enrollment. The cancellation shall be effective on the first day of the month after SERS notifies the benefit recipient that the coverage has been cancelled.

(I)  Reinstatement to SERS health care coverage

(1)   An eligible benefit recipient, or spouse or dependent child of a benefit recipient with health care coverage, whose coverage has been previously cancelled may be reinstated to SERS health care coverage by filing a health care enrollment application as follows.

(a)   The application is received no later than thirty-one days after reaching age sixty-five. Health care coverage shall be effective the later of the first day of the month after reaching sixty-five or receipt of the enrollment application by the system;

(b)   The application is received no later than thirty-one days after involuntary termination of coverage under another group plan, medicaid, medicare advantage plan, or medicare part D plan with proof of such termination. Health care coverage shall be effective the later of the first day of the month after termination of the other group plan or receipt of proof of termination and the enrollment application by the system.

(2)      An eligible person whose coverage was cancelled pursuant to paragraph (D)(1)(f)  of  this  rule  shall  be  reinstated  to  SERS  health  care  plan  when

benefit payments are reinstated.

(3)   An eligible benefit recipient, or spouse or dependent child of a benefit recipient with health care coverage, whose coverage has been previously cancelled and who is enrolled in medicare A and B or medicare B only on December 31, 2007 may be reinstated to SERS health care coverage by filing a healthcare enrollment application during the period of time beginning October 1, 2007 and ending November 30, 2007. Health care coverage shall be effective January 1, 2008.

(4)   An eligible benefit recipient, or spouse or dependent child of a benefit recipient with health care coverage, whose coverage has been previously cancelled pursuant to paragraph (H) of this rule and who is enrolled in medicare A and B or medicare B only on June 30, 2009 may be reinstated to SERS health care coverage by filing a health care enrollment application during the period of time beginning May 21, 2009 and ending July 15, 2009.

(5)   An eligible benefit recipient who had an effective retirement or benefit date on or after August 1, 2008, who qualifies for a premium subsidy under paragraph (F)(2) of this rule, and whose coverage has previously been waived as provided in paragraph (G) of this rule, may be reinstated to school employees retirement system health care coverage by submitting a complete health care enrollment application on or before December 14, 2012. Health care coverage shall be effective January 1, 2013.

(J)   Medicare part "B"

(1)    A benefit recipient person who is enrolled in SERS' health care shall enroll in medicare part B at the recipientperson's first eligibility date for medicare part B.

(2)

(a) The board shall determine the monthly amount paid to reimburse an eligible benefit recipient for medicare part B coverage. The amount paid shall be no less than forty-five dollars and fifty cents, except that the board shall make no payment that exceeds the amount paid by the recipient for the coverage.

(b) As used in paragraph (J) of this rule, an "eligible benefit recipient" means:

(i) An eligible person who was a benefit recipient and was eligible for medicare B coverage before January 7, 2013, or

(ii) An  eligible  person  who  is  a  benefit  recipient,  is  eligible  for medicare B coverage, and is enrolled in SERS' health care.

(2)(3) The effective date of the medicare "B" premium to be paid by the board shall be the later ofas follows:

(a) For eligible benefit recipients who were a benefit recipient and were eligible for medicare B coverage before January 7, 2013 the later of:

(a)(i) January 1, 1977; or

(b)(ii) The first of the month following the date that the school employees retirement system received satisfactory proof of coverage.

(b) For eligible benefit recipients not covered under paragraph (J)(3)(a) of this rule, the later of:

(i) The  first  month  following  the  date  that  the  school  employees retirement system received satisfactory proof of coverage, or

(ii) The effective date of SERS health care.

(3)(4) The board shall not:

(a)    Pay more than one monthly medicare "B" premium when a retirant or benefit recipient is receiving more than one monthly benefit from this system; nor

(b)    Pay a medicare "B" premium to a retirant or benefit recipient who is receiving reimbursement for this premium from any other source.

Effective:                                                     03/08/2013

R.C. 119.032 review dates:                         02/01/2015

CERTIFIED ELECTRONICALLY

Certification

02/26/2013

Date

Promulgated Under:                           111.15

Statutory Authority:                           3309.04

Rule Amplifies:                                  3309.69

Prior Effective Dates:                         1/1/77, 3/20/80, 7/20/89, 1/2/93, 8/10/98, 11/9/98,

6/13/03, 1/2/04, 3/1/07, 9/28/07 (Emer.), 12/24/07,

8/8/08, 1/8/09, 5/22/09 (Emer.), 8/10/09, 6/11/10,

7/1/10 (Emer.), 9/26/10, 8/14/11, 9/30/12