3309-1-35 Health care.

 

 

 

3309-1-35                    Health care and medicare "B".

 

 

 

(A)  As used in this rule:

 

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

 

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

 

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

 

(4)"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.

 

(5)"Disability benefit recipient" means a member who is receiving a benefit or allowance pursuant to section 3309.35, 3309.40 or 3309.41 of the Revised Code.

 

(6)"Child" means an unmarried, biological, adopted or step-child of the retirant, member, deceased retirant or deceased member or other child who lives or lived with the retirant, member, deceased retirant or deceased member in a parent-child relationship in which the retirant, member, deceased retirant or deceased member has or had custody of the child.

 

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

 

(a)

 

(i) Is under age eighteen or under age twenty-two if attending an institution of learning or training pursuant to a program designed to complete in each school year the equivalent of at least two-thirds of the full-time curriculum requirements of such institution, or

 

(ii) Regardless of age is physically or mentally incompetent, provided that the incompetency existed prior to the retirant's or member's death and prior to the dependent child reaching age eighteen or age twenty-two if attending an institution of learning or training pursuant to a program designed to complete in each school year the equivalent of at least two-thirds of the full-time curriculum requirements of such institution, and

 

 

(b) During the twelve-month period preceding the application for health care coverage or the member or retirant's death, lived with the member or retirant in a parent-child relationship or received at least one-half of his/her support from the member, retirant, deceased member or deceased retirant.

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

(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.

(4) "Disability benefit recipient" means a member who is receiving a benefit or allowance pursuant to section 3309.35, 3309.40 or 3309.41 of the Revised Code.

(5) "Child" means an unmarried, biological, adopted or step-child of the retirant, member, deceased retirant or deceased member or other child who lives or lived with the retirant, member, deceased retirant or deceased member in a parent-child relationship in which the retirant, member, deceased retirant or deceased member has or had custody of the child.

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

(a)

(i) Is under age eighteen or under age twenty-two if attending an institution of learning or training pursuant to a program designed to complete in each school year the equivalent of at least two-thirds of the full-time curriculum requirements of such institution, or

(ii) Regardless of age is physically or mentally incompetent, provided that the incompetency existed prior to the retirant's or member's death and prior to the dependent child reaching age eighteen or age twenty-two if attending an institution of learning or training pursuant to a program designed to complete in each school year the equivalent of at least two-thirds of the full-time curriculum requirement of such institution, and

(b) During the twelve-month period preceding the application for health care coverage or the member or retirant's death, lived with the member or retirant in a parent-child relationship or received at least one-half of his/her support from the member, retirant, deceased member or deceased retirant.

(7) "Health care coverage" means the plan offered by the system including, but not limited to, the medical plan, the prescription drug program, and the medicare part "B" premium reimbursement.

(B)    Any person who is not an "ineligible person" as defined in section 3309.69 of the Revised Code, is eligible for health care coverage under the system's health care plan so long as eligibility has not been terminated as provided in paragraph (D) of this rule and the person qualifies as one of the following:

(1)   An age and service retirant or his/her the retirant's spouse or dependent child,

(2)     A disability benefit recipient or his/her the recipient's spouse or dependent child,

(3)     The spouse or dependent child of a deceased age and service retirant or 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,

(4)    The dependent child of a deceased member or deceased 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.

(C)

(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, for:

(a) A disability benefit recipient, spouse 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) An age and service retirant, spouse 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 school employees retirement system or the benefit effective date, whichever is later.

(c) For an eligible spouse or dependent child of a deceased member or deceased 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.

(2) Eligibility for health care shall terminate when:

(a) The person ceases to qualify as one of the persons listed in paragraph (B) of this rule;

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

(c) The person's coverage is waived as provided in paragraph (E) of this rule.

(D)

(1) Payment of premiums for health care coverage shall be by deduction from the benefit recipient's monthly benefit provided the monthly benefit is sufficient. If the monthly premium exceeds the monthly benefit, the benefit recipient shall be billed for the monthly premium.

(2) Premium payments billed to a benefit recipient shall be deemed in default after two 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 terminated on the first day of the month after the date of the notice unless payment for all months in default is received prior to the termination date.

(3) After termination for default, eligibility for health care coverage can be reestablished and coverage reinstated as provided in paragraph (E)(1)(a) or (b) 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, and payment of all premium amounts in default. "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 and all payments in default received.

(E)

(1) Except as otherwise provided in rule 3309-1-55 of the Administrative Code, a benefit recipient may waive health care coverage. Such waiver is effective beginning the first of the month following the later of the retirement system's receipt of the waiver or the effective date of a monthly benefit. The waiver is effective as to both the benefit recipient and the recipient's dependents. A benefit recipient may revoke the waiver by filing a health care enrollment

application as follows.

(a) The application is received no later than thirty-one days after reaching age 65. Health care coverage shall be effective the later of the first day of the month after reaching 65 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 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) A benefit recipient retaining health care coverage may remove a spouse or dependent child from health care coverage at any time. An eligible spouse or dependent child may subsequently be enrolled for health care coverage only as provided in paragraph (E)(1)(a) or (b) of this rule.

(C) 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:

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

(2) Age and service retirant, spouse or dependent child of an age and service retirant - health care coverage shall begin on the first of the month following the date that the retirement application is filed with the school employees retirement system or the benefit effective date, whichever is later.

(3) Eligible spouse or dependent child of a deceased member or deceased retirant - health care coverage shall begin 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.

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

(5) After waiver of coverage - health care coverage approved after waiver as provided in paragraph (D) of this rule or rule 3309-1-55 of the Administrative Code shall begin on the first of the month following the date that the application for health care is approved.

(D) An age and service retirant or disability benefit recipient may waive health care coverage  and  such  waiver  is  effective  during  the  age  and  service  retirant's  or

disability benefit recipient's lifetime as to both the retirant or benefit recipient and his/her dependents. The waiver is irrevocable except as follows:

(1) Within thirty-one days of reaching age sixty-five, an age and service retirant or disability benefit recipient may apply for health care coverage; or

(2) Within thirty-one days of termination of coverage under another group plan, and with proof of such termination, an age and service retirant or disability benefit recipient may apply for health care coverage.

Upon the death of an age and service retirant or disability benefit recipient, the recipient of a benefit has the same option as to waiving the health care coverage.

(E)(F) The effective date of the medicare "B" premium to be paid by the board shall be the later of:

(1)   January 1, 1977; or

(2)    The first of the month following the date that the retirant or benefit recipient first began payment of the premium as documented by proof satisfactory to the school employees retirement system; received satisfactory proof of coverage; or

(3)   The effective date of SERS health care coverage, whichever is later.

(F)(G)

(1)   The board shall not pay more than one monthly medicare "B" premium when a retirant or benefit recipient is receiving more than one monthly benefit from this system.

(2)     The board shall not pay a medicare "B" premium to a retirant or benefit recipient who is receiving reimbursement for this premium from the highway patrol retirement system, the police and firemen's disability and pension fund, the public employees retirement system and/or the state teachers retirement system the highway patrol retirement system, the police and fire pension fund, the public employees retirement system and/or the state teachers retirement system.

Effective:                                06/13/2003

R.C. 119.032 review dates:    01/22/2003 and 02/01/2007

CERTIFIED ELECTRONICALLY

Certification

06/03/2003

Date

Promulgated Under:   111.15

Statutory Authority:   3309.04

Rule Amplifies:           3309.69

Prior Effective Dates: 11/9/98, 8/10/98, 1/2/93,

7/20/89, 3/20/80, 1/1/77