OAR Chapter 101 — Oregon Health Authority, Public Employees' Benefit Board

Division 1 PROCEDURAL RULES

Or. Admin. R. 101-001-0000 Notice of Proposed Rule Changes

Prior to adoption, amendment, or repeal of any rule, the Public Employees' Benefit Board (PEBB), will give notice of the intended action to the following:

(1) The Secretary of State's Bulletin, referred to in ORS 183.360, at least 21 days prior to the effective date.

(2) To persons on the PEBB mailing list established pursuant to ORS 183.335(8) at least 28 days before the effective date of the rule.

(3) To the Legislative Counsel Committee and Legislators specified in ORS 183.335(15), at least 49 days before rule takes effect.

(4) Employee organizations certified by the Employment Relations Board.

(5) State agency and university personnel and payroll representatives.

(6) Insurance carriers.

History

Statutory/Other Authority: ORS 243.061 - 243.302
Statutes/Other Implemented: ORS 183.310 - 183.550, 192.660, 243.061 - 243.302 & 292.05
PEBB 2-2009, f. 7-29-09, cert. ef. 8-1-09
PEBB 1-2009(Temp), f. & cert. ef. 2-24-09 thru 8-22-09
PEBB 1-2004, f. & cert. ef. 7-2-04
PEBB 1-1999, f. 12-8-99, cert. ef. 1-1-00

Or. Admin. R. 101-001-0005 Uniform and Model Rules of Procedure

The Attorney General’s Uniform and Model Rules of Procedure under the Administrative Procedure Act, dated 2024, are adopted as rules of procedure of the Public Employees’ Benefit Board and are made a part of OAR chapter 101.

[ED. NOTE: The full text of the Attorney General’s Model Rules of Procedures is available from the office of the Attorney General or the Oregon Health Authority, Public Employees’ Benefit Board.]

History

Statutory/Other Authority: ORS 243.061 - 243.302
Statutes/Other Implemented: ORS 183.310 - 183.750
PEBB 1-2025, amend filed 10/06/2025, effective 10/06/2025
PEBB 1-2004, f. & cert. ef. 7-2-04
PEBB 1-1999, f. 12-8-99, cert. ef. 1-1-00

Or. Admin. R. 101-001-0015 Disbursement of PEBB Fund Monies

The Public Employees’ Benefit Board Fund was created for the purpose of maintaining insurance program stabilization reserves. PEBB may disburse any or all monies in the fund for any of the following purposes:

(1) To reimburse insurers for monies due under the applicable contract (For example, when benefit plan expenses exceed premium revenues);

(2) To minimize premium increases resulting from random experience flux, inflationary variations or any other cause;

(3) To minimize impact on contributions to premiums due to benefit plan design changes;

(4) To pay for expenses critical to administration of PEBB programs (For example, data processing, benefit plan communications, etc.); and

(5) To pay for services, programs, or studies that will reduce benefit plan costs.

History

Statutory/Other Authority: ORS 243.061 - 243.302
Statutes/Other Implemented: ORS 243.135
PEBB 1-2004, f. & cert. ef. 7-2-04
PEBB 1-1999, f. 12-8-99, cert. ef. 1-1-00

Division 2 POWERS OF THE BOARD

Or. Admin. R. 101-002-0005 Powers and Duties of the Board

(1) Pursuant to ORS 243.125, it will be within the powers and duties of the Board to study all matters connected with providing adequate benefit plan coverage for Eligible Employees on the best basis possible with relation both to the welfare of the employees and to the state.

(2) The Board will design benefit plans, devise specifications, invite proposals, analyze responses to requests for proposals, decide on the award of contracts for benefit plan coverage of Eligible Employees.

(3) The Board seeks optimal health for PEBB’s members through a system of care that is patient-centered, focused on wellness, coordinated, efficient, effective, accessible, and affordable. The Board will place emphasis on:

(a) Employee choice among high quality benefit plans;

(b) A competitive marketplace;

(d) Employer flexibility in benefit plan design and contracting;

(e) Quality customer services;

(f) Creativity and innovation;

(g) Benefit plans as part of total employee compensation;

(h) The improvement of employee health;

(i) An innovative delivery system;

(j) A focus on improving quality and outcomes;

(k) Promotion of health and wellness;

(l) Appropriate provider, health plan, and consumer incentives;

(m) Accessible and understandable information about costs, outcomes, and other health data, and;

(n) Benefits that are affordable to the state and employees.

(4) The Board may retain consultants, brokers, or other advisory personnel as it determines necessary; and subject to the State Personnel Relations Law, will employ such personnel as are required to perform the functions of the Board.

(5) The Board may delegate authority to the Administrator and Staff to complete duties described in (2)–(4) above.

History

Statutory/Other Authority: ORS 243.061 - 243.302
Statutes/Other Implemented: ORS 183.310 - 550, 192.660, 243.061 - 302 & 292.051
PEBB 3-2010, f. 9-23-10, cert. ef. 10-1-10
PEBB 1-2004, f. & cert. ef. 7-2-04
PEBB 1-1999, f. 12-8-99, cert. ef. 1-1-00

Or. Admin. R. 101-002-0010 Conduct of Meetings of the Board

(1) The Board will select one of its appointed voting members as chairperson and another voting member as vice chairperson.

(2) Meetings will be conducted by and will be under the control of the chairperson of the Board. In the absence of the chairperson, the vice chairperson or other Board member designated by the chairperson in the absence of the vice chairperson will preside. All meetings of the Board will be conducted in the matter prescribed by and in accordance with the Oregon Public Meetings Law, ORS 192.610 to 192.690.

History

Statutory/Other Authority: ORS 243.061 - 243.302
Statutes/Other Implemented: ORS 183.310 - 550, 192.660, 243.061 - 302 & 292.051
PEBB 3-2010, f. 9-23-10, cert. ef. 10-1-10
PEBB 1-2004, f. & cert. ef. 7-2-04
PEBB 1-1999, f. 12-8-99, cert. ef. 1-1-00

Division 5 RENEWAL, SCREENING AND SELECTION FOR BENEFITS AND VENDOR CONTRACTS

Or. Admin. R. 101-005-0010 Renewal, Screening and Selection for Benefit, Vendor and Consultant Contracts

(1) The Board is charged with the obligation of obtaining Benefit Plans to provide Benefits to Eligible Employees. OARs 101-005-0040 through 101-005-0140 set forth the screening, selection and renewal process to be used for all such Benefit Plan contracts. The Board has sole authority for procuring all benefits and services contemplated by ORS 243.061 through 243.302.

(2) Except as provided in OAR 101-005-0040 through 101-005-0140, the Board adopts the DOJ model public contract rules in OAR 137, division 46 (General Provisions Related to Public Contracting) and division 47 (Public Procurements for Goods or Services), effective January 1, 2010, as the contracting rules that shall apply to its procurements for Benefit Plan contracts.

(3) The Board adopts the DOJ model public contract rules in OAR 137, division 46 (General Provisions Related to Public Contracting) and division 47 (Public Procurements for Goods or Services), effective January 1, 2010, as the contracting rules that shall apply to its procurements for Vendor and consultant contracts within the Board’s contracting authority.

History

Statutory/Other Authority: ORS 243.061 - 243.302
Statutes/Other Implemented: ORS 243.125
PEBB 3-2010, f. 9-23-10, cert. ef. 10-1-10
PEBB 2-2005, f. 7-26-05, cert. ef. 7-29-05
PEBB 1-2004, f. & cert. ef. 7-2-04
PEBB 1-2003, f. & cert. ef. 12-4-03

Or. Admin. R. 101-005-0020 Policy

The policy of the Board is to select Contractors in an expeditious and efficient a manner that is consistent with the goal of delivering high quality Benefits and other services at a cost that is affordable to both the employees and the state, consistent with the requirements of ORS 242.135 and OAR 101-002-0005. The Board may enter into more than one contract for each type of Benefit Plan or other service sought.

History

Statutory/Other Authority: ORS 243.061 - 243.302
Statutes/Other Implemented: ORS 243.125 & 243.135(2)
PEBB 3-2010, f. 9-23-10, cert. ef. 10-1-10
PEBB 2-2005, f. 7-26-05, cert. ef. 7-29-05
PEBB 1-2004, f. & cert. ef. 7-2-04
PEBB 1-2003, f. & cert. ef. 12-4-03

Or. Admin. R. 101-005-0030 Definitions

For the purposes of OARs 101-005-0010 through 101-005-0140 the following terms have the meanings indicated below.

(1) "Benefit Plan" includes, but is not limited to:

(a) Contracts for insurance or other benefit based on life; supplemental medical, supplemental dental, optical, accidental death or disability insurance; group medical, surgical, hospital, flexible spending account, or any other remedial care recognized by state law; and related services and supplies.

(b) Comparable benefits for employees who rely on spiritual means of healing;

(d) Employee assistance programs.

(2) "Benefits" means those goods and services provided under Benefit Plans.

(3) "Board" means the ten-member Public Employees' Benefit Board. created by ORS 243.061.

(4) "Consultant" means consultants, brokers or other advisory personnel hired by the Board pursuant to ORS 243.125(5) to assist in acquiring adequate Benefit Plan coverage for eligible state employees; assist in the study of all matters connected with the provision of adequate Benefit Plan coverage for eligible state employees; assist in the development and implementation of decision-making processes; design and implement additional programs to review, monitor and assist in the improvement of Eligible Employees and their dependents' health; and provide other services as required by the Board.

(5) "Contractor" means an individual or firm selected to provide Benefits Plan services and other services with whom the Board contracts;

(6) "Eligible Employee" shall have the same definition as is described in ORS 243.105(4).

(7) "Emergency" means circumstances that:

(a) Could not have been reasonably foreseen;

(b) Create a substantial risk of loss, damage or interruption of Benefits or other services or a substantial threat to property, public health, welfare or safety; and

(8) “PEBB” means the agency, overseen by the Board, that is within the Department of Administrative Services until the operational transfer to the Oregon Health Authority described in OAR 943-001-0015(2).

(9) “Person” means a natural person capable of being legally bound, a sole proprietorship, a corporation, a partnership, a limited liability company or partnership, a limited partnership, a for-profit or nonprofit unincorporated association, a business trust, two or more persons having a joint or common economic interest, any other person with legal capacity to contract or a public body.

(10) "Proposal" means a competitive Proposal, binding on the Proposer and submitted in response to a Request for Proposals.

(11) "Proposer" means a Person who submits a Proposal in response to a Request for Proposals.

(12) "Renewal Contractors" means those Contractors who provided the same or similar employee Benefit Plan or other services under a contract with the Board in the year immediately prior. An employee Benefit Plan or other services contract is similar if it is reasonably related to the scope of work described in the procurement under which such a contract was awarded.

(13) "Request for Proposals" or "RFP" means all documents, whether attached or incorporated by reference, used for soliciting Proposals.

(14) "Responsible Proposer" means a person who meets the standards of responsibility described in OAR 101-005-0130.

(15) "Responsive Proposal" means a Proposal that substantially complies with the request for proposals and all prescribed procurement procedures and requirements.

(16) "Single Source" means the only vendor of a particular product or service reasonably available. If the Board chooses to procure a particular Benefit or service that is only available from one vendor, documentation must be maintained to support the determination that the product or service is available only from that one seller.

(17) "Formal Selection Procedure” means the process described in OAR 101-005-0040(1).

(18) "Informal Selection Procedure” means the process described in OAR 101-005-0040(2).

(19) "ORPIN" means the Oregon Procurement Information Network, an online service operated by the Department of Administrative Services that displays procurements and contracts issued by the State of Oregon's agencies.

(20) "Selection Committee" means the group of individuals comprised of PEBB staff, Board members, constituents, or consultants associated with PEBB who review, score, and recommend an Apparent Successful Proposer (ASP selected as a result of a RFP issued by PEBB) to the Board for approval.

(21) "Small Procurement" means the process described in OAR 101-005-0040(4).

(22) "Vendor" means the contractors from which PEBB will secure services other than Benefits.

History

Statutory/Other Authority: ORS 243.125
Statutes/Other Implemented: ORS 243.125(1)
PEBB 2-2019, amend filed 03/19/2019, effective 03/19/2019
PEBB 10-2018, temporary amend filed 09/11/2018, effective 09/11/2018 through 03/09/2019
PEBB 3-2010, f. 9-23-10, cert. ef. 10-1-10
PEBB 2-2009, f. 7-29-09, cert. ef. 8-1-09
PEBB 1-2009(Temp), f. & cert. ef. 2-24-09 thru 8-22-09
PEBB 2-2005, f. 7-26-05, cert. ef. 7-29-05
PEBB 1-2004, f. & cert. ef. 7-2-04
PEBB 1-2003, f. & cert. ef. 12-4-03

Or. Admin. R. 101-005-0040 Procurement and Renewal Processes

(1) Formal Selection Procedure: This procedure will be used for the procurement of Benefits Exceptions to this procedure are specified in sections (2), (3), (4) and (5).

(a) Announcement: The Board will give notice of intent to contract for Benefits via the Oregon Procurement Information Network (ORPIN). The notice shall include a description of the Benefits or services sought the scope of the services required, and a description of special requirements, if any. The notice will invite qualified prospective contractors to apply. The notice will specify when and where the application may be obtained, to whom it must be returned, and the closing date.

(b) Proposal: The Proposal from the prospective contractors will consist of a statement that describes the prospective contractor's credentials, performance data and other information sufficient to establish contractor's qualifications for providing the Benefits or services sought, as well as any other information requested in the announcement.

(c) Evaluation: The Board or its designees will evaluate the qualifications of all applicants and select prospective contractors as set forth in OAR 101-005-0110.

(d) Award of Contracts: The Board will make final selections based on the criteria included in OAR 101-002-005(3) in addition to criteria included in the Request for Proposal (RFP).

(2)(a) Informal Selection Procedure: This procedure may be used at the Board's discretion, when the informal selection procedure will not interfere with competition among prospective contractors, reduce the quality of services, is an amount less than $150,000 in contract costs, or will not increase costs. The Board will contact a minimum of three prospective contractors known to the Board to be qualified to propose the sought-after services. The selection will be made by the Board based upon the factors described in paragraph (1) (d) of this rule. If three quotes are not received, the Board will make a written record of its efforts to obtain quotes.

(b) When informal selection procedure has been used, the cumulative amendment(s) to the contract shall not increase the total contract cost to sum that is greater than twenty-five percent (25%) of the original contract cost.

(3)(a) Sole Source Procedure: PEBB may award a contract for Benefits without competition when the Administrator of PEBB determines in writing that the services are available from only one source, or the contractor is defined as a Qualified Rehabilitation Facility as defined in Oregon’s public contracting code.

(b) The determination of a sole source must be based on written findings that may include:

(A) That the efficient utilization of existing services requires the acquisition of compatible services;

(B) That the services required for the exchange of software or data with other public or private agencies are available from only one source;

(D) Other findings that support the conclusion that the goods or services are available from only one source.

(c) To the extent reasonably practical, PEBB shall negotiate with the sole source to obtain contract terms advantageous to PEBB.

(4) Small Procurement Procedure: PEBB may procure Contractor services in an amount less than $10,000 in any manner it deems practical, including by direct selection, negotiation and award.

(a) Award of Contracts. PEBB will base selections on evaluation criteria which may include, but is not limited to, contractor availability; capability; experience; approach; compensation requirements; previous litigation and remedy applied; customer service history with PEBB, members and clients; debarment status; and references. Emphasis will be placed on quality customer service, creativity, affordability, and innovation and the improvement of employee health.

(b) Contract. The selected Contractor must promptly execute the Contract. PEBB will execute the Contract only after obtaining all applicable required documents and approvals.

(c) An amendement for additional services shall not increase the total contract cost to a sum that is greater than twenty-five percent of the original contract cost.

(5) Renewal Procedure: If the Board does not issue an RFP or Single Source procurements to solicit formal proposals from qualified potential Contractors or Vendors, the Board may directly negotiate and enter into renewal contracts each plan year with Renewal Contractors to provide Benefits and other services without following the procedures set forth in sections (1) and (2) above. The Board may renew contracts with Renewal Contractors for as many years as the Board determines is in the best interest of the state and employees. The Board may invite renewal Proposals from those Contractors or Vendors who provided the same or similar employee Benefit Plan or other services in the year immediately prior. An employee Benefit Plan or other services contract is similar if it is reasonable related to the scope of work described in the procurement under which such a contract was awarded. The Board will negotiate with Renewal Contractors and enter into contracts with them after giving full consideration to the factors listed in paragraph (1)(d) or to such of those factors as the Board determines shall be evaluated for the renewal.

(6) Emergency Appointment Procedure: The Board may select a Benefit Plan or other service Contractor without following any of the above procedures when Emergency conditions require. In such instance, the recommended appointment and a written description of the conditions requiring the use of this appointment procedure shall be submitted to the Board. The Board will determine if an Emergency exists, declare the Emergency and negotiate a contract with the Contractor after giving full consideration to the factors listed in paragraph (1)(d).

History

Statutory/Other Authority: ORS 243.061 - 243.302
Statutes/Other Implemented: ORS 243.135
PEBB 2-2019, amend filed 03/19/2019, effective 03/19/2019
PEBB 10-2018, temporary amend filed 09/11/2018, effective 09/11/2018 through 03/09/2019
Reverted to PEBB 3-2010, f. 9-23-10, cert. ef. 10-1-10
PEBB 2-2013(Temp), f. & cert. ef. 10-2-13 thru 3-28-14
PEBB 3-2010, f. 9-23-10, cert. ef. 10-1-10
PEBB 2-2009, f. 7-29-09, cert. ef. 8-1-09
PEBB 1-2009(Temp), f. & cert. ef. 2-24-09 thru 8-22-09
PEBB 2-2005, f. 7-26-05, cert. ef. 7-29-05
PEBB 1-2004, f. & cert. ef. 7-2-04
PEBB 1-2003, f. & cert. ef. 12-4-03

Or. Admin. R. 101-005-0050 Mistakes

(1) Treatment of Mistakes. If the Board discovers certain mistakes in a Proposal before award of the Contract, and the mistakes are not identified as those qualifying as non-responsive to the specifications of the procurement, the Board may take the following action unless otherwise allowed under the procurement:

(a) The Board may waive a minor formaility, or permit a Proposer to correct a minor informality. A minor informality is a matter of form(s) rather than substance that is evident on the face of the Proposal, or an insignificant mistake that can be waived or corrected without prejudice to other Proposers. Mistakes including, but not limited to, signatures not affixed to the proposal document, proposals sent to the incorrect address, insufficient number of proposals submitted, incorrect format, etc., will not be considered minor.

(b) The Board may correct a clerical error if the intended Proposal and the error are evident on the face of the Proposal, or other documents submitted with the Proposal, and the Proposer confirms the Board's correction in writing. A clerical error is a Proposer's error in transcribing its Proposal.

(2) Rejection for Mistakes. Unless otherwise allowed under the procurement, the Board may reject any Proposal in which a mistake is evident on the face of the Proposal and the intended correct Proposal is not evident or cannot be substantiated from documents accompanying the Proposal; i.e., documents submitted with the Proposal. In order to insure integrity of the competitive procurement process and to assure fair treatment of Proposers, mistakes discovered that are contrary to the specifications of the procurement will be carefully reviewed and will be determined, under the sole authority of the Board, to be waived or not be waived.

(3) If the Board discovers mistakes in the proposal after award, and the mistakes are not considered minor, the Board reserves the right to determine if the award will be revoked and then will re-evaluate proposals deemed to be in second, third, fourth, etc., in the standings.

History

Statutory/Other Authority: ORS 243.061 - 243.302
Statutes/Other Implemented: ORS 243.125(1)
PEBB 2-2019, amend filed 03/19/2019, effective 03/19/2019
PEBB 10-2018, temporary amend filed 09/11/2018, effective 09/11/2018 through 03/09/2019
PEBB 3-2010, f. 9-23-10, cert. ef. 10-1-10
PEBB 2-2005, f. 7-26-05, cert. ef. 7-29-05
PEBB 1-2004, f. & cert. ef. 7-2-04
PEBB 1-2003, f. & cert. ef. 12-4-03

Or. Admin. R. 101-005-0070 Contract Amendments

PEBB may amend a contract without additional competition in any of the following circumstances:

(1) The amendment is within the scope of the procurement as described in RFP, the sole source determination, or special procurement (the “Procurement Document”). An amendment is not within the scope of the procurement if the Agency determines that if it had described the changes to be made by the amendment in the Procurement Document, it would likely have increased competition or affected award of the contract.

(2) These rules otherwise permit PEBB to award a contract without competition for the goods or services to be procured under the amendment.

(3) The amendment is necessary to comply with a change in law that affects performance of the contract.

(4) The amendment results from renegotiation of the terms and conditions, including the contract price, of a contract and the amendment is advantageous to PEBB, subject to all of the following conditions:

(a) The Services to be provided under the amended contract are the same as the Services to be provided under the unamended contract.

(b) PEBB determines that, with all things considered, the amended contract is at least as favorable to PEBB as the unamended contract.

(c) The amended contract does not have a total term greater than allowed in the Procurement Document after combining the initial and extended terms.

History

Statutory/Other Authority: ORS 243.061 - 243.302
Statutes/Other Implemented: ORS 243.135 & 243.125
PEBB 3-2010, f. 9-23-10, cert. ef. 10-1-10
PEBB 2-2009, f. 7-29-09, cert. ef. 8-1-09
PEBB 1-2009(Temp), f. & cert. ef. 2-24-09 thru 8-22-09
PEBB 2-2005, f. 7-26-05, cert. ef. 7-29-05
PEBB 1-2004, f. & cert. ef. 7-2-04
PEBB 1-2003, f. & cert. ef. 12-4-03

Or. Admin. R. 101-005-0075 Pre-Proposal Conference

(1) Unless identified in the procurement as required, the Pre-Proposal Conference will:

(a) Include voluntary attendance;

(b) Will be held in Salem, Oregon or will be conducted via conference call or by other electronic means; and

(2) If the Pre-Proposal Conference requires mandatory attendance by prospective proposers, no remuneration will be offered to prospective proposers for attendance, travel, document preparation, etc.

History

Statutory/Other Authority: ORS 243.061 - 243.302
Statutes/Other Implemented: ORS 243.135 & 243.125
PEBB 2-2019, amend filed 03/19/2019, effective 03/19/2019
PEBB 10-2018, temporary amend filed 09/11/2018, effective 09/11/2018 through 03/09/2019
PEBB 2-2005, f. 7-26-05, cert. ef. 7-29-05

Or. Admin. R. 101-005-0080 RFP Protest; Request for Change; Request for Clarification

(1) Protest.

(a) Unless otherwise specified in the procurement, a Proposer must deliver a written protest to the Board not less than 10 (ten) calendar days prior to closing;

(b) Content of Protest. A Proposer's written protest shall include:

(A) A detailed statement of the legal and factual grounds for the protest;

(B) A description of the resulting prejudice to the Proposer; and

(2) Request for Change.

(a) Unless otherwise specified in the procurement, a Proposer may request in writing a change to the Contract terms and conditions. If the RFP allows for a Proposer to make a request for changes, and unless otherwise specified in the RFP, a Proposer must deliver the written request for change to the Board not less than 10 (ten) calendar days prior to closing;

(b) A Proposer's written request for change shall include a statement of the requested changes to the Contract terms and conditions, including specifications together with the reason for the requested change.

(3) Board Response. The Board shall not consider a Proposer's request for change or protest after the deadline established for submitting such request or protest. The Board shall provide notice to the applicable entity if it entirely rejects a protest. If the Board agrees with the entity's request or protest, in whole or in part, the Board shall either issue an addendum reflecting its determination under OAR 137-047-0430 or cancel the solicitation under 137-047-0660.

(4) Extension of Closing. If the Board receives a written request for change or protest from a Proposer in accordance with this rule, the Board may extend closing if the Board determines an extension is necessary to consider the request or protest and to issue an addendum, if any, to the RFP.

(5) Clarification. Unless otherwise specified in the procurement, and prior to the deadline for submitting a written request for change or protest, a Proposer may request that the Board clarify any provision of the RFP. The Board's clarification to a Proposer, whether orally or in writing, does not change the RFP and is not binding on the Board unless the Board amends the RFP by addendum.

History

Statutory/Other Authority: ORS 243.061 - 243.302
Statutes/Other Implemented: ORS 243.135 & 243.125
PEBB 2-2019, amend filed 03/19/2019, effective 03/19/2019
PEBB 10-2018, temporary amend filed 09/11/2018, effective 09/11/2018 through 03/09/2019
PEBB 2-2009, f. 7-29-09, cert. ef. 8-1-09
PEBB 1-2009(Temp), f. & cert. ef. 2-24-09 thru 8-22-09
PEBB 2-2005, f. 7-26-05, cert. ef. 7-29-05
PEBB 1-2004, f. & cert. ef. 7-2-04
PEBB 1-2003, f. & cert. ef. 12-4-03

Or. Admin. R. 101-005-0090 Addenda to an RFP

(1) Issuance; Receipt. The Board may change an RFP only by written addenda.

(2) Notice and Distribution. The RFP shall specify how the Board will provide notice of addenda and how the Board will make the addenda available.

(3) Timelines; Extensions. The Board shall issue addenda within a reasonable time to allow prospective Proposers to consider the addenda in preparing their Proposals. The Board may extend the Closing if the Board determines prospective Proposers need additional time to review and respond to addenda. Unless otherwise specified in the procurement, and except to the extent required by public interest, the Board shall not issue addenda less than 72 hours before the closing unless an addendum also extends the Closing.

(4) Request for Change or Protest. Unless a different deadline is set forth in an addendum, a Proposer may submit a written request for change or protest to the addendum by the close of the Board's next business day after issuance of the addendum.

History

Statutory/Other Authority: ORS 243.061 - 243.302
Statutes/Other Implemented: ORS 243.135 & 243.125
PEBB 2-2019, amend filed 03/19/2019, effective 03/19/2019
PEBB 10-2018, temporary amend filed 09/11/2018, effective 09/11/2018 through 03/09/2019
PEBB 3-2010, f. 9-23-10, cert. ef. 10-1-10
PEBB 2-2005, f. 7-26-05, cert. ef. 7-29-05
PEBB 1-2004, f. & cert. ef. 7-2-04
PEBB 1-2003, f. & cert. ef. 12-4-03

Or. Admin. R. 101-005-0100 Extension of Time for Acceptance of Proposal

The Board may request, orally or in writing that Proposers extend, in writing, the time during which the Board may consider their Proposal. If a Proposer agrees to such extension, the Proposal shall continue as irrevocable, valid and binding on the Proposer for the agreed-upon extension period.

History

Statutory/Other Authority: ORS 243.061 - 243.302
Statutes/Other Implemented: ORS.243.125(1)
PEBB 2-2005, f. 7-26-05, cert. ef. 7-29-05
PEBB 1-2004, f. & cert. ef. 7-2-04
PEBB 1-2003, f. & cert. ef. 12-4-03

Or. Admin. R. 101-005-0105 Submission of Proposals; Format; Timing

(1) All Proposals submitted as a result of a Formal Solicitation, Informal Solicitation, or Single Source Solicitation shall comply with the procurement's specifications. If portions of the Proposal to any solicitation are deemed unacceptable or non-responsive to the specifications of the solicitation, the Proposal will be deemed non-responsive and will not be given further evaluation or consideration. If a Proposal to any solicitation is delivered late, it will be deemed non-responsive to the specification of the solicitation and will be returned to the Proposer unopened.

(2) Submission of Proposals shall be in writing and shall be delivered in the written format, as required by the specifications of the solicitation. Proposals may be submitted entirely electronically in any reasonable format if required under the procurement.

History

Statutory/Other Authority: ORS 243.061 - 243.302
Statutes/Other Implemented: ORS 243.125(1)
PEBB 2-2019, amend filed 03/19/2019, effective 03/19/2019
PEBB 10-2018, temporary amend filed 09/11/2018, effective 09/11/2018 through 03/09/2019
Reverted to PEBB 3-2010, f. 9-23-10, cert. ef. 10-1-10
PEBB 2-2013(Temp), f. & cert. ef. 10-2-13 thru 3-28-14
PEBB 3-2010, f. 9-23-10, cert. ef. 10-1-10
PEBB 2-2005, f. 7-26-05, cert. ef. 7-29-05

Or. Admin. R. 101-005-0110 Evaluation of Proposals

(1) Evaluation. The evaluation process described in this rule applies to the Formal Selection Procedure set forth in OAR 101-005-0040(1). The Board and any assigned representatives, including but not limited to, PEBB stakeholders staff, or Consultants, hereinafter identified as the Selection Committee, shall evaluate Proposals only in accordance with criteria set forth in the RFP and applicable law. The Board shall evaluate Proposals to determine the Responsible Proposer or Proposers submitting the best responsive Proposal or Proposals.

(2) Competitive Range; Protest; Award.

(a) Determining Competitive Range. If the Board does not cancel the solicitation, and to the extent the solicitation includes a competitive range determination, the Board will evaluate all Proposals in accordance with the evaluation criteria set forth in the RFP. After evaluation of all Proposals in accordance with the criteria set forth in the RFP, the Board will determine the Proposers in the competitive range.

(b) Protesting Competitive Range. The Board shall provide written notice to all Proposers identifying Proposers in the competitive range. A Proposer that is not within the competitive range may protest the Board's evaluation and determination of the competitive range in not more than two (2) business days after the Board has sent written e-mail notice of the competitive range to all Proposers.

(c) Intent to Award; Discuss or Negotiate. After the protest period provided in accordance with paragraph (2)(b) expires, or after the Board has provided a final response to any protest, whichever date is later, the Board may engage in discussions and negotiations with Proposers in the competitive range.

(3) Discussions and Negotiations. If the Board chooses to enter into discussions and negotiations with the Proposers in the competitive range, the Board shall proceed as follows:

(a) Initiating Discussions. The Board shall initiate oral or written discussions and negotiations with all of the Proposers in the competitive range regarding their Proposals.

(b) Conducting Discussions. The Board may conduct discussions and negotiations with each Proposer in the competitive range necessary to fulfill the purposes of this section, but need not conduct the same amount of discussions or negotiations with each Proposer. The Board may terminate discussions and negotiations with any Proposer in the competitive range at any time. However, the Board shall offer all Proposers in the competitive range the opportunity to discuss their Proposals with the Board before the Board notifies Proposers of the award decisions. The Proposers' opportunities to discuss their Proposals with the Board before Proposers are notified of the award decisions may be satisfied by interviewing Proposers in the competitive range, as specified in the procurement.

(A) In conducting discussions, the Board and any designated representatives:

(i) Shall treat all Proposers fairly and shall not favor any Proposer over another.

(ii) Shall determine whether other factors, including but not limited to, Oregon residency of the primary business office and Proposer demonstration of services and products, will be used to determine the apparent successful Proposer, should a tie between Proposers occur.

(B) At any time during the time allowed for discussions and negotiations, the Board may:

(i) Continue discussions and negotiations with a particular Proposer or Proposers, or;

(ii) Terminate discussions with a particular Proposer and continue discussions with other Proposers in the competitive range;

(C) The Board may continue discussions and negotiations with Proposers until the Board has determined which Proposer or Proposers shall be awarded contracts.

(c) Intent to Award; Protest. The Board shall provide written notice to all Proposers in the competitive range of the Board's intent to award the contracts. An unsuccessful Proposer may protest the Board's intent to award in accordance with OAR 101-005-0140. After the protest period provided in accordance with 101-005-0140 expires, or after the Board has provided a final response to any protest, whichever date is later, the Board may commence final Contract execution with the successful Proposer or Proposers.

History

Statutory/Other Authority: ORS 243.061 - 243.302
Statutes/Other Implemented: ORS 243.135 & 243.125
PEBB 2-2019, amend filed 03/19/2019, effective 03/19/2019
PEBB 10-2018, temporary amend filed 09/11/2018, effective 09/11/2018 through 03/09/2019
Reverted to PEBB 3-2010, f. 9-23-10, cert. ef. 10-1-10
PEBB 2-2013(Temp), f. & cert. ef. 10-2-13 thru 3-28-14
PEBB 3-2010, f. 9-23-10, cert. ef. 10-1-10
PEBB 2-2005, f. 7-26-05, cert. ef. 7-29-05
PEBB 1-2004, f. & cert. ef. 7-2-04
PEBB 1-2003, f. & cert. ef. 12-4-03

Or. Admin. R. 101-005-0120 Rejection of a Proposal

Rejection of Proposals.

(1) The Board may reject any Proposal upon PEBB's finding that the Proposal:

(a) Is contingent upon PEBB's acceptance of terms and conditions (including Specifications) that differ from the RFP;

(b) Takes exception to terms and conditions set forth in the RFP;

(c) Attempts to prevent public disclosure of matters in contravention of the terms and conditions of the RFP or in contravention of applicable law;

(d) Offers services that fail to meet the specifications of the RFP;

(e) Is late;

(f) Is not in substantial compliance with the RFP;

(g) Is not in substantial compliance with all prescribed procurement procedures;

(h) Has been debarred as set forth in ORS 279 B.130;

(i) Has failed to provide the certification of non-discrimination required under ORS 279A.110(4), or;

(j) Is from a Proposer found non-responsible as described in OAR 101-005-0130.

(2) The Board may for good cause reject all Proposals in whole or in part or may cancel, delay or suspend the RFP upon the Board's written finding it is in the state's or employees' interest to do so. The Board shall notify all Proposers of the rejection of all Proposals, along with the good cause justification and finding. PEBB is not liable to any Proposer for any loss or expense caused by or resulting from the rejection, cancellation, delay or suspension.

History

Statutory/Other Authority: ORS 243.061 - 243.302
Statutes/Other Implemented: ORS 243.135 & 243.125
PEBB 3-2010, f. 9-23-10, cert. ef. 10-1-10
PEBB 2-2005, f. 7-26-05, cert. ef. 7-29-05
PEBB 1-2004, f. & cert. ef. 7-2-04
PEBB 1-2003, f. & cert. ef. 12-4-03

Or. Admin. R. 101-005-0130 Responsible Proposer

(1) Before awarding a Contract, the Board must have information that indicates the Proposer meets the applicable standards of responsibility. PEBB shall prepare a written determination of non responsibility for a Proposer if PEBB determines that the Proposer does not meet the standards of responsibility.

(2) In determining whether a Proposer has met the standards of responsibility, PEBB shall consider whether a Proposer:

(a) Has available the appropriate financial, material, equipment, facility and personnel resources and expertise, or has the ability to obtain the resources and expertise, necessary to meet all contractual responsibilities.

(b) Completed previous contracts of a similar nature with a satisfactory record of performance. For purposes of this paragraph, a satisfactory record of performance means that to the extent that the costs associated with and time available to perform a previous contract remained within the Proposer’s control, the Proposer stayed within the time and budget allotted for the procurement and otherwise performed the contract in a satisfactory manner. PEBB shall document the Proposer’s record of performance if PEBB finds under this paragraph that the Proposer is not responsible.

(c) Has a satisfactory record of integrity. PEBB in evaluating the Proposer’s record of integrity may consider, among other things, whether the Proposer has previous criminal convictions for offenses related to obtaining or attempting to obtain a contract or subcontract or in connection with the Proposer’s performance of a contract or subcontract. PEBB shall document the Proposer’s record of integrity if PEBB finds under this paragraph that the Proposer is not responsible.

(d) Is legally qualified to contract with PEBB.

(e) Supplied all necessary information in connection with the inquiry concerning responsibility. If a Proposer fails to promptly supply information concerning responsibility that PEBB requests, PEBB shall determine the Proposer’s responsibility based on available information or may find that the Proposer is not responsible.

(f) Was not debarred by PEBB in accordance with ORS 279B.130.

(3) PEBB may refuse to disclose outside of PEBB confidential information furnished by a Proposer under this section when the Proposer has clearly identified in writing the information the Proposer seeks to have treated as confidential and PEBB has authority under ORS 192.410 to 192.505 to withhold the identified information from disclosure.

History

Statutory/Other Authority: ORS 243.061 - 243.302
Statutes/Other Implemented: ORS 243.135 & 243.125
PEBB 3-2010, f. 9-23-10, cert. ef. 10-1-10
PEBB 2-2005, f. 7-26-05, cert. ef. 7-29-05
PEBB 1-2004, f. & cert. ef. 7-2-04
PEBB 1-2003, f. & cert. ef. 12-4-03

Or. Admin. R. 101-005-0140 Protest of Contractor Selection, Contract Award

(1) Purpose. An adversely affected or aggrieved Proposer must exhaust all avenues of administrative review and relief before seeking judicial review of the Board's Contractor selection or contract award decision.

(2) Notice of Intent to Award. Unless otherwise provided in the RFP, the Board shall provide written notice to all Proposers of the Board's intent to award the contract(s). The Board's award(s) shall not be final until the later of the following:

(a) Seven (7) days after the date of the notice, unless the RFP provided a different period for protest, or;

(b) The Board provides a written response to all timely filed protests that denies the protests and affirms the award.

(3) Right to Protest Award. An adversely affected or aggrieved Proposer may submit to the Board a written protest of the Board's intent to award within seven (7) days after issuance of the notice of intent to award the contract, unless a different protest period is provided under the RFP.

(a) The Proposer's protest shall be in writing and must specify the grounds upon which the protest is based.

(b) A Proposer is adversely affected or aggrieved only if the Proposer would be eligible to be awarded the contract in the event that the protest were successful, and the reason for the protest is that:

(A) All higher ranked Proposals are nonresponsive;

(B) PEBB has failed to conduct the evaluation of Proposals in accordance with the criteria or processes described in the RFP;

(D) PEBB’s evaluation of Proposals or PEBB’s subsequent determination of award is otherwise in violation of PEBB’s rules or ORS 243.105 to 243.285.

(c) The Board shall not consider a protest submitted after the time period established in this rule or such different period as may be provided in the RFP.

(4) Authority to Resolve Protests. The chairperson of the Board, or his or her designee, has the authority to settle or resolve a written protest submitted in accordance with the requirements of this rule.

(5) Decision. If a protest is not settled, the chairperson of the Board, or his or her designee, shall promptly issue a written decision on the protest. Judicial review of this decision will be available if provided by statute.

(6) Award. The successful Proposer shall promptly execute the contract after the award is final and all contractual terms and conditions have been negotiated and agreed upon. The Board shall execute the contract only after it has obtained all applicable required documents and approvals.

History

Statutory/Other Authority: ORS 243.061 - 243.302
Statutes/Other Implemented: ORS 243.135 & 243.125
PEBB 3-2010, f. 9-23-10, cert. ef. 10-1-10
PEBB 2-2005, f. 7-26-05, cert. ef. 7-29-05
PEBB 1-2004, f. & cert. ef. 7-2-04
PEBB 1-2003, f. & cert. ef. 12-4-03

Division 10 DEFINITIONS

Or. Admin. R. 101-010-0005 Definitions

Unless the context indicates otherwise, as used in OAR chapter 101, divisions 1 through 60, the following definitions will apply:

(1) “ACA” means the Patient Protection and Affordable Care Act and regulations promulgated under the Act by any federal agencies as of the effective date of the amended rule, including but not limited to Shared Responsibility for Employers Regarding Health Coverage, 79 Fed. Reg. 8544 (Feb. 12, 2014).

(2) “Actively at work” for medical and dental insurance coverage means an active eligible employee at work, in paid status and scheduled for work during the month. Optional plan policies or plan certificates contain “actively at work” criteria specific to the individual plan.

(3) “Active Participation” in reference to a Flexible Spending Account (FSA) means an eligible employee currently enrolled in the plan and who each month deposits the required dollar contribution in the account.

(4) “Administrative Period” means ACA period of no longer than 90 days beginning immediately following the end of a Standard Measurement Period and no longer than 90 days beginning immediately following the end of an Initial Measurement Period and ending immediately before the start of the associated Stability Period. During this time period the employer completes administrative tasks, for example but not limited to, calculating measurement period hours, eligibility determination, providing the employee with enrollment materials.

(5) “Affidavit of Dependency” means a notarized document that attests a dependent child meets the criteria for a dependent child under OAR 101-015-0011.

(6) “Affidavit of Domestic Partnership” means a notarized document that attests the eligible employee and one other individual meet the criteria in OAR 101-015-0026(2).

(7) “Agency” means a PEBB participating organization such as an individual state of Oregon public agency, semi-independent agency, and individual OUS University.

(8) “Benefit amount” means the amount of money paid by a PEBB participating organization for the purchase of core benefit plans on behalf of active eligible employees. PEBB does not determine the benefit amount.

(9) “Benefit eligible” means an employee who has met the eligibility requirements of (18) of this rule and is eligible to enroll in PEBB core benefits and optional plans.

(10) “CBIW” means Continuation of Benefits for Injured Workers.

(11) “Certificate of Registered Domestic Partnership” means the certificate issued by an Oregon county clerk to two individuals of the same sex after they file a Declaration of Domestic Partnership with the county clerk.

(12) “COBRA” means the federal Consolidated Omnibus Reconciliation Act of 1985.

(13) “Core Benefits” means specific benefit plans that a PEBB employer may contribute a benefit amount towards the cost of the premiums for active eligible employees (e.g., medical, dental, vision, and employee basic term life coverage).

(14) “Commuter Accounts” means either a Transportation or Parking account as permitted under Commuter Benefits 26 CFR 1.132-9. This benefit allows benefit enrolled employees to contribute to one or both accounts on a pretax basis to pay for work-related commuting expenses.

(15) “Court Ordered” means it is an official proclamation by a judge (or panel of judges) that defines the legal relationship between the parties to a hearing, a trial, an appeal or other court proceedings.

(16) “Dependent Care Flexible Spending Account” or “Dependent Care FSA” means the Dependent Care Assistance Program (DCAP) that PEBB has adopted in accordance with section 129 of the Internal Revenue Code.

(17) “Dependent child” means a child that satisfies the conditions of OAR 101-015-0011, as applicable.

(18) “Domestic partner” means an eligible employee’s partner in a registered domestic partnership under Chapter 99 Oregon Laws 2007 or unmarried partner of the same or opposite sex that meets the requirements as outlined in OAR 101-015-0026(2).

(19) “Eligible employee” means an individual eligible to enroll in PEBB plan benefits by reason of his or her employment with a PEBB-participating employer, and includes:

(a) “Active eligible employee” means an employee of a PEBB participating employer, including a state official, in an exempt, unclassified, classified, or management service position who works at least half-time or in a position classified as job share and is expected to work at least 90 days. The term active eligible employee can apply to an employee in an initial or standard measurement period, or in a stability period, and includes:

(A) A permanent employee who is appointed to a permanent position (as defined by OAR 105-010-0000(40)) that is a benefit eligible position, including but not limited to a full time, half-time, job share, or seasonal position; or

(B) A temporary or impermanent worker who is not appointed to a permanent position, but by following the ACA regulations and policy for full time employees, becomes benefit eligible on a specific date after appointment due to work expectations or becomes benefit eligible following an initial measurement period.

(b) “Retired eligible employee” means a previously active eligible employee, who meets retiree eligibility as defined in OAR 101-050-0005. A retired eligible employee can enroll in PEBB retiree benefit plans as established in Division 50 of this chapter, and must self-pay the premiums.

(c) “Other eligible employee” means an individual of a specific self-pay group as established by ORS 243.140 and 243.200. These groups are eligible only for medical or dental benefits as approved by PEBB.

(20) “Family member” means a spouse, domestic partner, or a qualifying child.

(21) “FMLA” means the federal Family Medical Leave Act.

(22) “FTE” means full time equivalent job position.

(23) “Grandchild Affidavit” means a notarized document that attests a grandchild of an eligible employee, spouse, or domestic partner meets the eligibility criteria for PEBB grandchild coverage as defined in OAR 101-015-0011(1)(C).

(24) “Half-time” means an eligible employee who works less than full time but at least:

(a) Eighty paid regular hours per month; or

(b) 0.5 FTE for unclassified OUS employees; or

(d) As defined by collective bargaining.

(25) “Health Flexible Spending Account” or “Health FSA” means the health flexible spending arrangement that PEBB has adopted in accordance with the Internal Revenue Code.

(26) “Imputed value” means a dollar amount established yearly for an insurance premium at fair market value. The IRS or the Oregon Department of Revenue may view the imputed value as taxable income. The imputed value dollar amount is added to the eligible employee’s taxable wages.

(27) “Ineligible individual” means an individual who does not meet the definition of an eligible employee, spouse, domestic partner, or dependent child as defined in PEBB administrative rules.

(28) “Job share” means two eligible employees sharing one full time equivalent position. Each eligible employee’s percentage of the total position determines the benefit amount the employee receives. The monthly benefit percentage amount remains the same regardless of each individual’s hours worked per month. Job share employees may not donate their portion of the benefit amount to the job share co-worker.

"Example: John and Jill share one full time equivalent position. When they were hired into the position in July, John's percentage of the total position was 40 percent. Jill's percentage was 60 percent. John worked 70 percent of the available hours in September. John's benefit amount percentage for September remains at 40 percent. Jill's benefit amount percentage remains at 60 percent."

(29) “Local Government” means cities, counties and special districts in Oregon.

(30) “Measurement Period” means the required ACA look-back period during which hours are calculated to determine if an employee has averaged at least 30 hours per week. There are two types of measurement periods:

(a) “Standard Measurement Period” means the twelve (12) consecutive month period starting November 1 and ending October 31.

(b) “Initial Measurement Period” means the twelve (12) consecutive month period starting with the first day of the employee’s employment.

(31) “Members” means and includes the following:

(a) “Eligible employee as defined by OAR 101-010-0005 (19)

(b) “Dependent child” as defined by OAR 101-010-0005 (17)

(d) “Spouse” as defined by OAR 101-010-0005 (46)

(32) “Midyear plan change event” means an event that provides an eligible employee an exception to the general plan year irrevocability rule that applies to PEBB benefit plan elections. Not all events allow changes to all plans, only enrollment changes that are consistent with the event are allowed. Permissible midyear events fall into three broad groups with allowable subgroups. The broad groups are:

(a) Change in status,

(b) Cost or coverage changes; or

(33) “OFLA” means the Oregon Family Leave Act.

(34) “OSPS” means the Oregon State Payroll System.

(35) “OUS” means the Oregon University System.

(36) “Open enrollment period” means an annual period chosen by PEBB when both active and other eligible employees and COBRA participants can make benefit plan changes or elections for the next plan year.

(37) “Optional plans” means, but is not limited to:

(a) Dependent life insurance;

(b) Employee, spouse, or domestic partner optional life insurance;

(d) Short Term Disability insurance;

(e) Long Term Disability insurance;

(f) Flexible Spending Accounts (Health and Dependent Care);

(g) Long Term Care insurance; and

(h) Commuter Accounts (Transportation and Parking)

(38) “Paid regular status” means in current payroll status, and receiving payment for work time. Paid regular status includes the use of vacation, sick, holiday, personal leave accruals, compensatory time, or other employer approved status such as furlough.

(39) “PEBB benefits” means the electronic benefit management system sponsored by PEBB. The system allows electronic enrollment and termination of an eligible individual’s benefit plans, personal information updates, and the transmittal of data to plans, payroll centers, and third party administrators.

(40) “PEBB participating organization” means a state agency, board, commission, university, or other entity that receives approval to participate in PEBB benefit plans.

(41) “Plan change period” means a period chosen by PEBB when retirees can make limited benefit plan changes.

(42) “Plan year” means a period of twelve consecutive months. PEBB’s plan year is a calendar year.

(43) “Qualified status change” (QSC) means a midyear change event generally associated with a family change or a work status change that affects plan eligibility. Plan changes are allowed when consistent with the event.

(44) “Rescission” means a cancellation or discontinuance of coverage that has a retroactive effect. A cancellation or discontinuation of coverage that is prospective only, or one that is effective retroactively but is attributable to nonpayment of premiums or contributions, is not a rescission.

(45) “Reinstate” means to reactivate previous benefits and enrollments, if available, to an eligible employee returning to eligible status within a specific time frame. Reinstated enrollment does not include FSAs, Long Term Care or Commuter plans.

(46) “Spouse” means an individual who is legally married. A marriage or a relationship recognized as a legal marriage between two individuals in Oregon, or another state or foreign country, will be recognized in Oregon even though such a relationship would not be a marriage if the same facts had been relied upon to create the marriage in Oregon. The definition of spouse does not include a former spouse and a former spouse does not qualify as a dependent.

(47) “Stability Period” means the twelve (12) consecutive month period that immediately follows a Standard Measurement Period or an Initial Measurement Period, and, the Administrative Period associated with that Standard Measurement Period or Initial Measurement Period. An employee remains benefit eligible for the duration of a given stability period if the employee had an average of 30 hours of service per week, or 130 hours per month, for the duration of the measurement period immediately preceding the stability period.

(a) The stability period following a standard measurement period begins on January 1 of the year after the standard measurement period ends, and ends on December 31 of that year.

(b) The stability period following an initial measurement period begins on the first day of the second full calendar month after the date on which the initial measurement period ends.

History

Statutory/Other Authority: ORS 243.061 - 243.302
Statutes/Other Implemented: ORS 243.125
PEBB 3-2019, amend filed 07/10/2019, effective 07/10/2019
PEBB 1-2019, temporary amend filed 01/16/2019, effective 01/16/2019 through 07/14/2019
PEBB 5-2018, amend filed 08/15/2018, effective 08/15/2018
PEBB 2-2018, temporary amend filed 02/16/2018, effective 02/16/2018 through 08/14/2018
PEBB 2-2017, f. & cert. ef. 8-17-17
PEBB 1-2015, f. & cert. ef. 5-12-15
PEBB 3-2014(Temp), f. & cert. ef. 11-12-14 thru 5-10-15
PEBB 2-2014(Temp), f. & cert. ef. 6-9-14 thru 12-5-14
PEBB 1-2013, f. & cert. ef. 9-24-13
PEBB 7-2010, f. 12-10-10, cert. ef. 1-1-11
Reverted to PEBB 3-2009, f. 9-29-09 cert. ef. 10-1-09
PEBB 1-2010(Temp), f. & cert. ef. 6-1-10 thru 11-28-10
PEBB 3-2009, f. 9-29-09 cert. ef. 10-1-09
PEBB 2-2008, f. & cert. ef. 8-1-08
PEBB 1-2008(Temp), f. & cert. ef. 2-4-08 thru 8-1-08
PEBB 2-2007, f. 9-28-07, cert. ef. 10-1-07
PEBB 1-2007(Temp), f. & cert. ef. 6-11-07 thru 12-8-07
PEBB 2-2006(Temp), f. & cert. ef. 12-14-06 thru 6-12-07
PEBB 3-2005, f. 8-31-05, cert. ef. 9-1-05
PEBB 3-2004, f. & cert. ef. 10-7-04
PEBB 1-2004, f. & cert. ef. 7-2-04
PEBB 1-2003, f. & cert. ef. 12-4-03
PEBB 1-2002, f. 7-30-02, cert. ef. 8-1-02
PEBB 1-2001, f. & cert. ef. 9-6-01
PEBB 1-2000, f. 11-15-00, cert. ef. 1-1-01
PEBB 1-1999, f. 12-8-99, cert. ef. 1-1-00

Division 15 ELIGIBILITY

Or. Admin. R. 101-015-0005 Eligible Individuals

(1) The following individuals are eligible to participate in PEBB-sponsored benefit plans:

(a) An eligible employee as defined in OAR 101-010-0005(20).

(b) A permanent position seasonal or intermittent employee who meets the following requirements:

(A) An individual hired for the first time if expected to work a 90-calendar day continual period and works at least half-time or in a position classified as job share. The eligible employee must enroll within 30 days of the hire or eligibility date; or

(B) An individual hired for the first time working at least half-time or in a position classified as job share who was not expected to work a 90-day or more continual period, and works longer than a 90-calednar day continual period. The employee is eligible for enrollment retroactively effective to the first day of the month following the original hire or eligibility date; or

(C) A previously ineligible employee returning to work is eligible for benefit plans after 60 calendar days of employment within the current or immediately previous plan year. The 60 calendar days of employment need not be consecutive.

(c) An appointed temporary or impermanent employee who (i) as of the date of hire, is expected to work an average of 30 or more hours per week for a 90-day continual period, or (ii) has worked an average of 30 hours or more per week for a full initial measurement period (1,560 hours) and is in a subsequent benefit eligible stability period.

(d) A current spouse, domestic partner, or an eligible dependent child listed by the person who is eligible under subsection (1)(a), (b), (c), or (d) of this rule on the required enrollment form or the electronic equivalent.

(e) An appointed and elected official. Eligibility for benefit plans begins on the first day of the month following the date the official takes the oath of office.

(2) The eligible employee is responsible to maintain a valid PEBB enrollment for all eligible family members receiving coverage. Failure to maintain valid eligibility will result in the removal of coverage. See OAR 101-020-0025.

History

Statutory/Other Authority: ORS 243.061 to ORS 243.302
Statutes/Other Implemented: ORS 243.125(1)
PEBB 1-2022, amend filed 03/31/2022, effective 03/31/2022
PEBB 1-2015, f. & cert. ef. 5-12-15
PEBB 3-2014(Temp), f. & cert. ef. 11-12-14 thru 5-10-15
Reverted to PEBB 7-2010, f. 12-10-10, cert. ef. 1-1-11
PEBB 2-2011(Temp), f. & cert. ef. 8-5-11 thru 1-31-12
Suspended by PEBB 1-2011(Temp), f. & cert. ef. 3-9-11 thru 8-4-11
PEBB 7-2010, f. 12-10-10, cert. ef. 1-1-11
PEBB 2-2008, f. & cert. ef. 8-1-08
PEBB 2-2007, f. 9-28-07, cert. ef. 10-1-07
PEBB 3-2005, f. 8-31-05, cert. ef. 9-1-05
PEBB 3-2004, f. & cert. ef. 10-7-04
PEBB 1-2004, f. & cert. ef. 7-2-04
PEBB 1-2001, f. & cert. ef. 9-6-01
PEBB 1-2000, f. 11-15-00, cert. ef. 1-1-01
PEBB 1-1999, f. 12-8-99, cert. ef. 1-1-00

Or. Admin. R. 101-015-0011 Dependent Child

(1) A dependent child must meet the following eligibility conditions to receive PEBB health plan coverage:

(a) The child is:

(A) An eligible employee’s, spouse’s, or domestic partner’s son, daughter, stepson, stepdaughter, adopted child; or

(B) A Child by Affidavit which includes but is not limited to a foster child, grandchild, child placed for adoption, or court ordered placement of a child who lives in the household of the eligible employee, and is the eligible employee’s IRS dependent. The employee must provide court ordered documentation of guardianship and the notarized Affidavit of Child Dependency upon enrollment. The exception would be newborns or adopted children who are automatically covered as an eligible PEBB individual the first 31 days from birth or placement without documentation and Affidavit in place. The Affidavit and documentation must be on file the first of the month following the event date in order to meet eligibility and continue coverage under the PEBB plans. Coverage ends the last day of the month in which the court ordered guardianship ends or age 18, whichever comes first. An eligible employee may not add a child by affidavit age 18 or older to PEBB coverage unless they can provide court ordered documentation for responsibility of the child beyond the age of 18; or,

(C) The biological child of an eligible dependent child of an eligible employee, spouse, or domestic partner (a grandchild by affidavit) and meets all the following criteria:

(i) The child’s parent will not be older than age 26, is unmarried and without a domestic partner. Both the child’s parent and the child live in the household of the eligible employee, and both the child and grandchild are the eligible employee’s IRS dependent and must claim both child and grandchild on their most recent years tax return. The child’s parent has PEBB health coverage through the eligible employee. The grandchild is automatically covered as an eligible PEBB individual the first 31 days from birth without documentation and Affidavit in place. The Affidavit and any appropriate documentation must be on file the first of the month following the event date to meet eligibility and continue coverage under the PEBB rules. An eligible employee may not add a grandchild age 18 or older to their PEBB coverage unless they can provide court ordered documentation for responsibility of the child beyond the age of 18.

(ii) Once the child no longer meets the requirements of section (5) of this rule, the child and grandchild will no longer be eligible.

(D) Covered if the eligible employee loses their spouse or domestic partner by death, the dependents (i.e. child of domestic partner, stepchild, grandchild) may continue PEBB health plan coverage provided they are currently enrolled, and eligibility is still being met. For biological, stepchildren or children of domestic partners, coverage ends the last day of the month in which they turn 26. For Child by Affidavit of Dependency, coverage ends the last day of the month in which the court ordered guardianship ends or age 18. For Grandchild by Affidavit, eligibility ends when the grandchild no longer meets the definition of Grandchild by Affidavit.

(2) During Enrollment, as a new hire and during annual open enrollment, the employee may enroll a Child by Affidavit or Grandchild by Affidavit if the appropriate notarized affidavit and court ordered documentation is submitted within seven calendar days after enrollment closes. If the employee does not submit the court ordered documentation as required, the child’s enrollment will not activate. PEBB Coverage ends the last day of the month in which the court ordered guardianship ends or age 18, whichever comes first.

"Example: Jack's foster child Joe is receiving PEBB coverage. Jack's legal documentation used at the time of Joe's enrollment stated that Jack will no longer be responsible for Joe when Joe turns 18. Joe's birth date is November 11, if there is no change to the court ordered responsibility, Joe's PEBB coverage will terminate November 30 the year he turns 18."

(3) Employees with a midyear change requesting to enroll a Child by Affidavit or Grandchild by Affidavit must submit the appropriate court ordered documentation and the notarized Child by Affidavit or Grandchild by Affidavit to the agency within the allowable enrollment time. The agency will not process the employee’s enrollments until the employee submits all the following:

(a) Completed and signed appropriate forms;

(b) Completed and notarized affidavit; and

(4) There is no age limit for a dependent child who is incapable of self-sustaining employment because of a developmental disability, mental illness, or physical disability, when all the criteria in this section are met.

(a) The employee must submit to PEBB any appeal and enrollment forms to enroll a disabled child age 26 or older, or to indicate the child disabled in the PEBB benefit record when the child is already receiving coverage.

(b) The child’s attending physician must submit documentation of the child’s disability to the employee’s health plan. The health plan provides a medical review of the physician’s medical documentation and provides PEBB a disability determination based on the review.

(A)(i) The child must be the employee’s qualifying IRS dependent and must be claimed on the eligible employees' most recent years tax return, or

(ii) The child files a tax return and demonstrates that their adjusted gross income does not exceed 150 percent of the federal poverty level (FPL), or

(iii) The employee is the legal guardian of the disabled dependent child.

(B) The physician must verify to the health plan that the disability existed before the child attained age 26.

(C) The child must be unable to engage in substantial gainful activity because of a 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 12 months.

(D) The employee must provide evidence to PEBB that the child has had continuous health plan coverage, group or individual, prior to attaining age 26 and the coverage remains in effect. The other coverage must continue until the employee’s medical plan approves the child’s health status as disabled and the PEBB plan is effective. If the child has not had continuous coverage, the child is not eligible for PEBB coverage.

(d) When a disabled child is receiving coverage beyond the age of 26, the employee’s health plan can review the child’s health status at any time and determine if the child continues to meet the criteria for a disabled child.

(e) If a disabled dependent child’s PEBB health coverage terminates for any reason after the age of 26, the child is ineligible for future enrollment as a dependent child under that PEBB coverage. The exception is termination of the child’s coverage due to the employee’s termination of employment when the employee is rehired later into a PEBB benefit eligible position. In this situation, to enroll the child again as disabled all PEBB criteria for disabled child within (4) of this rule must be met.

(f) Imputed taxes may apply, per IRC provisions, when an employee enrolls and covers dependents on their PEBB coverage that are not claimed on their federal taxes, and thus are not tax dependents.

(5) Beginning January 1, 2019, PEBB will terminate all plan coverage for dependent children who reach age 26 during a calendar year at midnight on the last day of the month in which the dependent turned 26. PEBB will not terminate coverage for children age 26 or older when approved by the health plan as incapable of self-sustaining employment because of a developmental disability, mental illness, or physical disability pursuant to section (4) of this rule. The exception is Child and Grandchild by Affidavit, see section B.

History

Statutory/Other Authority: ORS 243.061 - ORS 243.302
Statutes/Other Implemented: ORS 243.125(1), Chapter 342, 2021 Laws
PEBB 1-2022, amend filed 03/31/2022, effective 03/31/2022
PEBB 3-2021, temporary amend filed 12/28/2021, effective 12/31/2021 through 06/28/2022
PEBB 9-2018, temporary amend filed 08/22/2018, effective 08/22/2018 through 02/17/2019
PEBB 8-2018, amend filed 08/17/2018, effective 08/18/2018
PEBB 5-2018, amend filed 08/15/2018, effective 08/15/2018
PEBB 2-2018, temporary amend filed 02/16/2018, effective 02/16/2018 through 08/14/2018
PEBB 1-2018, amend filed 01/09/2018, effective 01/09/2018
PEBB 3-2017, amend filed 12/11/2017, effective 12/11/2017
PEBB 1-2017(Temp), f. & cert. ef. 6-8-17 thru 12-4-17
PEBB 7-2010, f. 12-10-10, cert. ef. 1-1-11
Reverted to PEBB 3-2009, f. 9-29-09 cert. ef. 10-1-09
PEBB 1-2010(Temp), f. & cert. ef. 6-1-10 thru 11-28-10
PEBB 3-2009, f. 9-29-09 cert. ef. 10-1-09

Or. Admin. R. 101-015-0026 Domestic Partnership

(1) Certificate of Registered Domestic Partnership. When a Registered Domestic Partnership exists and the eligible employee wants to enroll the domestic partner or the domestic partner's eligible children in benefit plans, the employee may electronically enroll or submit enrollment update forms to the agency at the appropriate time as defined by PEBB enrollment rules.

(2) PEBB Affidavit of Domestic Partnership. An eligible employee and an individual of the opposite or same sex without a Certificate of Registered Domestic Partnership, who want enrollment in PEBB plans as Domestic Partners must meet all of the following criteria:

(a) Are both at least 18 years of age;

(b) Are responsible for each other's welfare and are each other's sole domestic partners;

(d) Share a close personal relationship and are not related by blood closer than would bar marriage in the State of Oregon;

(e) Currently share the same regular permanent residence;

(f) Are jointly financially responsible for basic living expenses defined as the cost of food, shelter, and any other expenses of maintaining a household. Financial information must be provided if requested, and;

(g) Eligible employees must submit enrollment forms and a notarized affidavit to enroll domestic partners and children. To enroll eligible dependent children of a domestic partnership by affidavit in benefit plans, whether or not the enrollment includes the domestic partner, the employee must submit an Affidavit of Domestic Partnership.

(A) For enrollment, the agency must receive the notarized affidavit within five business days following close date of the enrollment period.

(B) Employees with qualified mid-year changes may only enroll a domestic partner or partner’s children by submitting the correct enrollment forms and notarized affidavit within the allowable time for the enrollment type. Agencies will not process a domestic partner or a partner’s children’s enrollment until the enrollment documentation submission is complete.

(3) An imputed value for the fair market value of the domestic partner and domestic partner's dependent children's insurance premium will be added to the eligible employee's taxable wages.

(4) An eligible employee ending a domestic partnership established under the PEBB Affidavit of Domestic Partnership must complete and submit a Termination of Domestic Partnership form and enrollment update forms to the agency within 30 days of the event. Insurance coverage for the domestic partner and domestic partner's dependent children ends the last day of the month in which eligibility is lost.

History

Statutory/Other Authority: ORS 243.061 to ORS 243.302
Statutes/Other Implemented: ORS 243.125(1)
PEBB 1-2022, amend filed 03/31/2022, effective 03/31/2022
PEBB 4-2018, temporary amend filed 06/25/2018, effective 06/25/2018 through 12/21/2018
PEBB 7-2010, f. 12-10-10, cert. ef. 1-1-11
PEBB 5-2010(Temp), f. 9-23-10, cert. ef. 10-1-10 thru 3-29-11

Or. Admin. R. 101-015-0030 Eligibility and Policy Term Violations - Definitions

For the purposes of OAR 101-015-0035 and OAR 101-015-0040, the following definitions will apply:

(1) “Eligibility or Enrollment Violations” means and includes a violation of the PEBB's eligibility or enrollment rules or policies including fraud or material misrepresentation. Misstatements, misrepresentations, omissions or concealments on the part of the PEBB member are not fraudulent unless they are made with intent to knowingly defraud. PEBB has primary responsibly in investigating such violations. If an Eligibility Violation is considered a violation of the insurance carrier’s policy, then the violation may also be considered a Policy Term Violation, and OAR 101-015-0040 would also apply.

(a) “Intentional Violation” is a violation that has occurred in which PEBB has electronic or written documentation that the eligible employee took action resulting in a non-eligible member being enrolled in PEBB benefits.

(b) “Unintentional Violation” is a violation that has occurred in which the eligible employee was not aware that such violation had occurred and there is no evidence of the eligible employee completing a paper form or logging in and enrolling an ineligible member in PEBB benefits.

(2) “Policy Term Violations” means and includes a violation of the insurance carrier’s policy terms. The insurance carrier has primary responsibility in investigating such violations.

History

Statutory/Other Authority: ORS 243.125 & ORS 243.061-302, 659A.060-069, 743.600-602 and 743.707
Statutes/Other Implemented: ORS 243 & ORS 243.061-302, 292.501 and 2007 OL Chap. 99
PEBB 5-2018, adopt filed 08/15/2018, effective 08/15/2018
PEBB 3-2018, temporary adopt filed 02/23/2018, effective 02/23/2018 through 08/21/2018

Or. Admin. R. 101-015-0035 Eligibility Violations

(1) Unintentional Violation:

(a) PEBB will remove from coverage an ineligible PEBB member due to eligibility or enrollment violations. Removal from all benefit plans will be retroactive to the date the individual is determined to have no longer been eligible, or the effective date of coverage if eligibility criteria was never met unless in conflict with federal healthcare reform.

(b) When an eligibility or enrollment violation has been discovered and investigated, PEBB will notify the member and the Agency Human Resource Department with the outcome.

(2) Intentional Violation:

(a) The ineligible member shall be removed from coverage by PEBB. The ineligible member’s coverage will be retroactively terminated to the date the individual is determined to have no longer been eligible, or the effective date of coverage if eligibility criteria was never met.

(b) PEBB may terminate the eligible employee along with remaining dependents from all plans excluding basic and mandatory plans selected by the agency. This will be a prospective termination lasting for a period of 12 months. The prospective termination will be effective the first day of the following month that the Intentional Violation was discovered.

History

Statutory/Other Authority: ORS 243.125 & ORS 243.061-302, 659A.060-069, 743.600-602 and 743.707
Statutes/Other Implemented: ORS 243 & ORS 243.061-302, 292.501 and 2007 OL Chap. 99
PEBB 5-2018, adopt filed 08/15/2018, effective 08/15/2018
PEBB 3-2018, temporary adopt filed 02/23/2018, effective 02/23/2018 through 08/21/2018

Or. Admin. R. 101-015-0040 Policy Term Violations

(1) A PEBB-contracted insurance carrier may remove from coverage and/or deny the claims of a PEBB member due to policy term violations. Removal from coverage for policy term violations is at the discretion of the insurance carrier.

(a) If a policy term violation results in a termination from the plan or carrier that the violation was committed, it will not prevent the member from continuing enrollment in other PEBB types of coverages (e.g., medical, dental, vision, life, etc.), as long as they remain an employee and eligible for these benefits.

(b) If an eligible employee commits a policy term violation and loses coverage, PEBB will remove the entire family from the insurance plan since the benefits are extended to his or her dependents through the eligible employee. If the eligible employee chooses to, and it is offered, they can enroll in a different carrier plan (if applicable).

(c) If a dependent commits a policy term violation, PEBB will remove only the dependent from the insurance plan. If the eligible employee chooses to and it is offered, they can enroll in a different carrier plan (if applicable).

(d) The PEBB member who is removed from a PEBB sponsored insurance plan may appeal the decision through the carrier that terminated coverage.

(e) When a policy term violation has been discovered and investigated, the applicable insurance carrier will notify PEBB and the member with the outcome.

(2) The insurance carrier may do the following when a member has violated a provision of the policy the PEBB member has enrolled in, committed fraudulent activity or misrepresentation:

(a) The insurance carrier may retain the value of any expenditure it made related to the member who committed the fraudulent activity or misrepresentation.

(b) The insurance carrier may deny future enrollments of the individual in accordance with the carrier’s policies.

History

Statutory/Other Authority: ORS 243.125 & ORS 243.061-302, 659A.060-069, 743.600-602 and 743.707
Statutes/Other Implemented: ORS 243 & ORS 243.061-302, 292.501 and 2007 OL Chap. 99
PEBB 5-2018, adopt filed 08/15/2018, effective 08/15/2018
PEBB 3-2018, temporary adopt filed 02/23/2018, effective 02/23/2018 through 08/21/2018

Or. Admin. R. 101-015-0045 Eligibility Verifications and Reviews

(1) PEBB shall plan and conduct eligibility verifications and reviews to monitor compliance with PEBB administrative rules. Reviews shall include, but are not limited to the following:

(a) Dependent eligibility;

(b) Employee eligibility;

(d) Plan enrollment limitations.

(2) Employee eligibility, election change and plan enrollment reviews may occur on a random basis throughout the year, or if anomalies in data warrant a formal review. The Eligible Employee is responsible to submit documentation upon request.

(3) Dependent eligibility reviews shall be completed as needed. The Eligible Employee, Retiree, Self-Pay or COBRA participant is responsible to submit documentation upon request. In the event the required documentation is not provided to sufficiently prove the dependent meets eligibility requirements, or the documentation provided is insufficient, the dependent’s coverage will be terminated prospectively. Retroactive terminations may occur if the documentation provided shows the dependent was not eligible for coverage and the member misrepresented the dependent as being an eligible dependent as defined by OAR 101-010-0005.

(4) If an Eligible Employee does not complete the dependent eligibility review and moves to a different Agency under PEBB, their terminated dependent records may be locked in the PEBB benefit management system. The Eligible Employee must submit documentation to PEBB to be verified before the dependent records are unlocked.

(5) An Eligible Employee adding a new or previous dependent to enrollments after failing to verify dependent eligibility will be required to provide DEV documentation along with the enrollment form to PEBB. Enrollments will not take effect until the verification of eligibility. The effective date of coverage is the first of the month following receipt of the form and all appropriate verification documents by PEBB.

History

Statutory/Other Authority: ORS 243.061 to ORS 243.302
Statutes/Other Implemented: ORS 243.125(1)
PEBB 1-2022, amend filed 03/31/2022, effective 03/31/2022
PEBB 9-2018, temporary amend filed 08/22/2018, effective 08/22/2018 through 02/17/2019
PEBB 5-2018, adopt filed 08/15/2018, effective 08/15/2018
PEBB 3-2018, temporary adopt filed 02/23/2018, effective 02/23/2018 through 08/21/2018

Or. Admin. R. 101-015-0050 Dependent Eligibility Verification and Review Appeals

Dependent Eligibility Verifications and Review Appeals

(1) Following the termination of dependents due to a dependent eligibility review, Eligible Employees, Retirees, Self Pays or COBRA participants may file an appeal and submit requested documentation within 60 days from the date coverage ended.

(2) For Eligible Employees/Retirees/Self-Pay/COBRA, if the appeal and submitted requested documentation is received by PEBB prior to 60 days from the date coverage ended, and dependents are verified, PEBB will unlock the dependent records in the PEBB benefit management system and dependents will be added retrospectively.

(3) For Eligible Employees/Retirees/Self-Pay/COBRA, if the appeal and submitted requested documentation is received by PEBB after 60 days from the date the coverage ended then dependents will be added prospectively.

History

Statutory/Other Authority: ORS 243.125 & ORS 243.061-302, 659A.060-069, 743.600-602 and 743.707
Statutes/Other Implemented: ORS 243 & ORS 243.061-302, 292.501 and 2007 OL Chap. 99
PEBB 5-2018, adopt filed 08/15/2018, effective 08/15/2018
PEBB 3-2018, temporary adopt filed 02/23/2018, effective 02/23/2018 through 08/21/2018

Division 20 ENROLLMENT RULES

Or. Admin. R. 101-020-0002 Plan Effective Dates, Employee Eligibility Continuation, and Plan Termination Dates

(1) Irrevocability Rule. Except as otherwise provided in OAR chapter 101, all eligible employee benefit plan elections or mid-year plan changes are irrevocable for the plan year and must have a prospective effective date.

(2) PEBB’s eligible employee benefits are in whole month increments for coverage and premium cost. PEBB’s core benefits are part of an Internal Revenue Service Code 125 Cafeteria plan, requiring an employee’s monthly pay deduction for premium contribution is in advance of the coverage.

(3) The coverage effective date for newly eligible employees or for employees who receive approved qualified midyear changes is the first of the month following the later of the agency’s receipt of all required appropriate forms, electronic enrollment, or the actual event date.

(a) The employee must be actively at work as specified in OAR 101-010-0005(2) for medical and dental coverage to become effective and as specified by optional plans in optional plan policies or certificates.

(b) When an optional plan requires medical underwriting prior to coverage approval, coverage will be effective the first of the month following plan approval.

(4) Employee Continuation of Coverage. An enrolled benefit eligible employee continuing employment:

(a) Within a current stability period, remains benefit eligible for that stability period regardless of the number of paid regular status hours accrued in the month.

(b) Not within a current stability period, must accrue a minimum of 80 paid regular status hours in a month to qualify for benefit coverage in the following month. If the employee accrues less than 80 paid regular status hours in a given month, the employee’s benefits will end the last day of that month. The agency must send the employee a self-pay COBRA Enrollment Notice. Employees within an approved FMLA, CBIW or other protected leave are not required to accrue 80 paid regular hours for benefits in the following month, see division 30.

(5) Open enrollment elections are effective on the first day of the new plan year. When an optional plan requires a medical underwriting prior to coverage approval, coverage will be effective the first of the month following plan approval in the new plan year.

(6) Coverage effective date for Special Enrollment Rights. An eligible employee or family member losing other group medical coverage is eligible to enroll in PEBB plans within 30 days of the date of the loss of other group coverage. When enrolled within 30 days of the loss, PEBB coverage will be effective the first day of the month that coverage is lost. When notified after 30 days from the loss of coverage, if approved, the effective date will be prospective only to the first day of the month following submission of forms.

Example 1: Joe loses coverage under his spouse’s plan Oct. 15. Joe submits enrollment update forms Oct. 16. Joe’s coverage effective date is October 1.

Example 2: Joe loses coverage under his spouse’s plan October 31. Joe submits enrollment update forms November 16. Joe’s coverage effective date is November 1.

Example 3: Joe loses coverage under his spouse’s plan October 15. Joe submits the enrollment update forms November 23 (after 30 days from loss of coverage). If approved, Joe’s coverage effective date is December 1.

(7) Active benefit eligible employee core benefit termination dates:

(a) When any employee terminates employment, benefit coverage for the employee and covered family members will end regardless of whether the employee is within a current stability period as follows:

(A) On the last day of the month, when the employee accrues less than 80 paid regular status hours during the month the employment terminates.

(B) On the last day of the following month, when the employee accrues more than 80 paid regular status hours during the month the employment terminates.

(b) When the employee is a temporary or impermanent worker who is benefit eligible for the current stability period and has no paid regular status hours for at least 13 weeks, or for a period at least four weeks and longer than the prior period during which the employee was working, the employee’s benefits will end the last day of the month of that period. If the employee returns to work for the employer the employee must be considered a new employee.

(c) For employees of educational organizations, the time period applicable under this subsection is either 26 weeks or, if the employee’s prior period of employment was less than 26 weeks, a period that is at least four weeks long and one week longer than the prior period of employment.

(d) When an employee is in an employer approved period of leave without pay, (e.g., FMLA, CBIW), or is in a benefit eligible current stability period a termination of coverage occurs when the employee’s premium share is more than 30 days late from the designated payment due date. In order to terminate the coverage the agency:

(A) Must provide written notice to the employee that payment has not been received. The notice must be mailed to the employee at least 15 days before coverage terminates and the notice must advise the employee that coverage will be dropped on a specified date at least 15 days after the letter date, unless the payment is received by that specified date (30 days).

(B) When the employee has received the 15 day notice and payment is not received by the due date, coverage is terminated retroactively to the last day of the last month that employee premium was received. The agency and PEBB may adjust premiums for one month when the termination is caused by an employee’s premium non-payment, this is not rescission

(C) When coverage is terminated because of the employee’s failure to pay the premium share timely and the employee returns from the leave within 12 months from the loss of coverage, the agency must reinstate employee to the benefits equivalent to those the employee would have if the leave had not been taken and premium payments missed. See OAR 101-20-0045 Returning to Work.

Example: John is in a benefit eligible current stability period. His August premium share was paid by his agency with his August 1 pay (July pays August). John starts a leave without pay on August 1. His current stability period status allows John to continue enrollment in his health benefits for September, but only if he pays his September premium share to his agency as designated. His agency requires the premium share payments by the 15th of each month. John’s agency does not receive his August 15 payment for September coverage. The agency sends John a notice of non-payment by August 17. The notice provides a 15 day notice that payment must be made to the agency by September 15 or his enrollment will retroactively terminate to August 31 (the last day, of the last month that premium was paid). The agency pays full premium for the September coverage. John’s payment is not received by September15. John’s enrollment is terminated back to August 31 and he is sent a COBRA Election Notice. If the agency paid the premiums for September, reconciliation adjustments are made by PEBB and the agency. John later returns to work in the middle of September, his previous benefits will reinstate for an October 1 effective date. He does not need to work 80 hours in the month of return for benefits in the following month, because he returned within his current stability period status. (If John was not in a current benefit eligible stability status, or was not in a leave without pay connected to a FMLA, CBIW, or other protected leave, he would need to work 80 hours in the month of return.)

(8) Self-pay individuals and retired employees’ benefits terminate the last day of the last period for which the required premium contribution is paid.

(9) Optional plan coverages end according to the individual optional plan’s policy or certificate directives. Refer to OAR 101-020-0060 and 101-020-0065 for FSA termination dates.

History

Statutory/Other Authority: ORS 243.061 - 302
Statutes/Other Implemented: ORS 243.061-302, 659A.060-069, 743.600 - 602 & 743.707
PEBB 2-2017, f. & cert. ef. 8-17-17
PEBB 1-2015, f. & cert. ef. 5-12-15
PEBB 3-2014(Temp), f. & cert. ef. 11-12-14 thru 5-10-15
PEBB 7-2010, f. 12-10-10, cert. ef. 1-1-11
PEBB 2-2008, f. & cert. ef. 8-1-08
PEBB 2-2007, f. 9-28-07, cert. ef. 10-1-07

Or. Admin. R. 101-020-0005 Newly Hired and Newly Eligible Employee

(1) All newly hired or a newly eligible active employees have 30 days from the date of hire or date of eligibility to enroll in PEBB core and optional benefit plans. Benefit plan elections are irrevocable for the plan year except as specified in OAR 101-020-0050.

(a) Full time temporary or impermanent employees that will be benefit eligible by the fourth month of employment enroll for benefits during the third employment month for benefits to be effective by the first of the fourth month.

(b) Variable hour temporary or impermanent employees that become benefit eligible after an initial measurement period have 30 days from their benefit eligibility date to enroll.

(2) A newly hired benefit eligible employee or newly eligible employee can enroll in benefit plans for the following month regardless of the number of paid regular hours in the month of hire or eligibility. The employee must be actively at work, as specified in OAR 101-010-005(2) on the coverage effective date. In the months following initial eligibility and enrollment, to continue to receive coverage a benefit eligible employee:

(a) Not in a current benefit eligible stability period must meet the requirement of a minimum of 80 hours paid regular status each month to receive benefits the following month.

(b) In a current benefit eligible stability period is eligible for benefits the following month regardless of the number of paid regular status hours in the month.

Example: Sarah was a new hire and she enrolled in benefit plans on June 25. Sarah was in paid regular status on July 1; her coverage is effective July 1. Sarah will need to be in paid regular status for 80 hours in July in order to receive August coverage.

(c) Who enrolls in benefit plans and terminates employment before the effective date of insurance coverage will not receive active employee benefits or COBRA.

Example 1: Sarah was a new hire into a benefit eligible position, she enrolled in benefit plans on June 25. Sarah was in paid regular status on July 1; on July 2, she terminated employment. Sarah’s coverage was effective July 1 and will remain in place through July 31. Sarah will not receive PEBB coverage in August, but will receive a COBRA notice.

Example 2: Ron was a new hire into a benefit eligible position, he enrolled in benefit plans on June 25. He terminated employment on June 30. Ron is not eligible for insurance coverage because he was not in paid regular status on July 1. He will not receive a COBRA notice because he did not receive active coverage.

(3) Any employee that becomes eligible for benefits during or after the open enrollment period but before the start of the new plan year must receive the opportunity to complete open enrollment elections before the start of the plan year.

History

Statutory/Other Authority: ORS 243.061 - 302
Statutes/Other Implemented: ORS 243.061 - 302
PEBB 2-2017, f. & cert. ef. 8-17-17
PEBB 1-2015, f. & cert. ef. 5-12-15
PEBB 3-2014(Temp), f. & cert. ef. 11-12-14 thru 5-10-15
PEBB 7-2010, f. 12-10-10, cert. ef. 1-1-11
PEBB 3-2009, f. 9-29-09 cert. ef. 10-1-09
PEBB 2-2007, f. 9-28-07, cert. ef. 10-1-07
PEBB 3-2005, f. 8-31-05, cert. ef. 9-1-05
PEBB 3-2004, f. & cert. ef. 10-7-04
PEBB 1-2004, f. & cert. ef. 7-2-04
PEBB 1-2002, f. 7-30-02, cert. ef. 8-1-02
PEBB 1-2001, f. & cert. ef. 9-6-01
PEBB 1-2000, f. 11-15-00, cert. ef. 1-1-01
PEBB 1-1999, f. 12-8-99, cert. ef. 1-1-00

Or. Admin. R. 101-020-0012 Working in Two or More Positions or for Two or More PEBB Participating Organizations

(1) An individual working in two or more positions or for two or more PEBB participating organizations must work at least half-time or be in a current benefit eligible stability period to be eligible for PEBB-sponsored benefit plans. A benefit eligible employee in a job share position is not required to work at least half-time to meet benefit eligibility.

(2) An eligible employee cannot receive more benefits than what one full time employee is eligible for. An eligible employee working in two or more positions may enroll for benefits through only one position.

(3) The eligible employee’s enrollment will be completed with the PEBB participating organization with the highest percentage of FTE position.

(a) When the employee’s FTE percentages with more than one PEBB participating organization are equal, the employee enrolls through the organization with the earlier appointment date.

(b) When the employee has equal FTE percentages and simultaneous dates of employment with two or more PEBB participating organizations, the employee may choose the organization to enroll through.

History

Statutory/Other Authority: ORS 243.061-302
Statutes/Other Implemented: ORS 243.061-302
PEBB 2-2016, f. & cert. ef. 8-24-16
PEBB 1-2015, f. & cert. ef. 5-12-15
PEBB 3-2014(Temp), f. & cert. ef. 11-12-14 thru 5-10-15
Renumbered from 101-040-0015, PEBB 2-2007, f. 9-28-07, cert. ef. 10-1-07
PEBB 3-2004, f. & cert. ef. 10-7-04
PEBB 1-2004, f. & cert. ef. 7-2-04
PEBB 1-2001, f. & cert. ef. 9-6-01
PEBB 1-1999, f. 12-8-99, cert. ef. 1-1-00

Or. Admin. R. 101-020-0015 Opting Out of Medical Insurance Coverage

(1) A benefit eligible employee can Opt Out of medical coverage and receive cash in lieu of medical insurance coverage. PEBB determines the amount of cash paid to an employee who Opts Out of medical coverage. Opt Out cash is included in employee income and is subject to taxes.

(2) Opting Out of medical coverage is an enrollment choice, it is not an enrollment in a PEBB medical plan.

(3) PEBB can require eligible employees who enroll in Opt Out to also enroll in other core benefits, such as dental, vision, and employee basic life coverage. Opt out enrolled employees who enroll for a core benefit plan are responsible to pay any premium share required.

(4) Eligible employees choosing to enroll in medical Opt Out must have minimum essential medical coverage for themselves and all other individuals for whom the employee can reasonably expect to claim a personal tax exemption deduction for. The alternative medical coverage must be a group sponsored medical plan. The employee must attest to the coverage at enrollment and annually thereafter.

(5) The agency or PEBB will cancel an employee’s Opt Out enrollment when the attestation is not completed during initial enrolment or annually during the open enrollment period. If the Opt Out election is cancelled:

(a) The agency will enroll a new benefit eligible employee in the Employee Only tier of a PEBB medical plan that provides statewide coverage. All other employee plan elections will take effect as enrolled.

(b) When the Opt Out enrollment is to replace an enrolled employee’s PEBB medical plan, the employee and any eligible dependents will reinstate to the previous medical plan. All other employee plan elections will take effect as enrolled.

(6) An employee is not eligible for Opt Out if their alternative group medical coverage is one of the following Medicaid, Veterans' Administration Health Benefit Programs, Student Health Insurance, or individual market coverage.

(7) An employee enrolled in Opt Out will not receive money in lieu of a PEBB medical plan enrollment when he or she is in a leave without pay status, regardless if the leave is a protected leave; e.g., FMLA, CBIW, Military Duty, etc., or other administratively approved leave.

(8) Employees enrolled in Opt Out experiencing a federal HIPAA Special Enrollment Right event are eligible for a qualified midyear change medical plan enrollment, for example, a loss of group medical coverage, or a change in family status such as a birth, adoption, etc.

(9) A PEBB retiree enrolled in the PEBB retiree or COBRA plan receiving a premium subsidy, such as an early retirement premium subsidy, returning as an active benefit eligible employee, and choosing to continue coverage under the retiree or COBRA plan is not eligible to enroll for Opt Out as an active employee.

(10) Opt Out cash will not be paid if the agency or PEBB has knowledge or reason to know that the employee or any other member of the employee’s expected tax family does not have or will not have the required alternative coverage.

History

Statutory/Other Authority: ORS 243.061 - 243.302
Statutes/Other Implemented: ORS 243.061 - 243.302
PEBB 2-2017, f. & cert. ef. 8-17-17
PEBB 2-2016, f. & cert. ef. 8-24-16
PEBB 4-2014, f. & cert. ef. 12-31-14
PEBB 7-2010, f. 12-10-10, cert. ef. 1-1-11
PEBB 3-2010, f. 9-23-10, cert. ef. 10-1-10
PEBB 3-2009, f. 9-29-09 cert. ef. 10-1-09
PEBB 2-2007, f. 9-28-07, cert. ef. 10-1-07
PEBB 3-2004, f. & cert. ef. 10-7-04
PEBB 1-2004, f. & cert. ef. 7-2-04
PEBB 1-2003, f. & cert. ef 12-4-03
PEBB 1-2002, f. 7-30-02, cert. ef. 8-1-02
PEBB 1-2000, f. 11-15-00, cert. ef. 1-1-01
PEBB 1-1999, f. 12-8-99, cert. ef. 1-1-00

Or. Admin. R. 101-020-0018 Declining Benefits

(1) An active eligible employee who declines PEBB core benefits waives the employee’s right to the benefit amount and enrollment in any PEBB sponsored plans.

(2) An eligible employee may decline benefits at the time of hire or meeting eligibility, consistent with a qualifying midyear plan change event, or during the open enrollment period.

(3) An eligible employee who previously declined benefits may enroll in benefit plans consistent with a qualifying midyear plan change event or during the open enrollment period.

History

Statutory/Other Authority: ORS 243.061 - 243.302
Statutes/Other Implemented: ORS 243.061 - 302
PEBB 2-2017, f. & cert. ef. 8-17-17
PEBB 7-2010, f. 12-10-10, cert. ef. 1-1-11
PEBB 2-2007, f. 9-28-07, cert. ef. 10-1-07
PEBB 3-2004, f. & cert. ef. 10-7-04
PEBB 1-2004, f. & cert. ef. 7-2-04
PEBB 1-2003, f. & cert. ef 12-4-03
PEBB 1-2002, f. 7-30-02, cert. ef. 8-1-02

Or. Admin. R. 101-020-0020 Newborn and Adopted Child Enrollment

(1) An eligible employee's biological newborn child receives PEBB-sponsored medical and dental insurance coverage under the newborn's own coverage from the moment of birth through the first 31 days of life without completing PEBB forms. To continue coverage beyond the first 31 days of coverage the eligible employee must enroll the newborn child to their benefit plans within 30 days from the date of birth by submitting the correct enrollment update forms.

(2) An eligible employee's newly adopted child receives PEBB-sponsored medical and dental insurance coverage under the adopted child's own coverage from the date of the adoption decree or date of placement for adoption through the first 31 days without completing PEBB forms. To continue coverage beyond the first 31 days of coverage the eligible employee must enroll the adopted child to their benefit plans within 30 days from the date of the decree or placement by submitting the correct enrollment update forms.

(a) The eligible employee must submit the adoption agreement or placement agreement with the enrollment forms to the agency. Placement for adoption requires the submission of an Affidavit of Dependency with enrollment forms with legal documentation of the placement. Upon adoption completion, a copy of the finalized adoption document must be submitted to the employee’s agency.

(b) Claims payment will not occur prior to the adoption decree or placement for adoption date.

(3) A request to enroll a biological newborn or newly adopted child beyond 30 days of the date of birth, adoption decree, or placement for adoption is late enrollment as specified in OAR 101-020-0040.

History

Statutory/Other Authority: ORS 243.061 - 302
Statutes/Other Implemented: ORS 243.061-302, 659A.060-069, 743.600-602 & 743.707
PEBB 6-2018, amend filed 08/15/2018, effective 08/15/2018
PEBB 1-2013, f. & cert. ef. 9-24-13
PEBB 2-2008, f. & cert. ef. 8-1-08
PEBB 2-2007, f. 9-28-07, cert. ef. 10-1-07
PEBB 1-2005, f. & cert. ef. 4-14-05
PEBB 3-2004, f. & cert. ef. 10-7-04
PEBB 1-2004, f. & cert. ef. 7-2-04
PEBB 1-2003, f. & cert. ef 12-4-03
PEBB 1-2002, f. 7-30-02, cert. ef. 8-1-02
PEBB 1-2001, f. & cert. ef. 9-6-01
PEBB 1-2000, f. 11-15-00, cert. ef. 1-1-01
PEBB 1-1999, f. 12-8-99, cert. ef. 1-1-00

Or. Admin. R. 101-020-0025 Removing an Ineligible Individual from Benefit Plans

(1) All eligible employees have 30 days from the date a spouse, domestic partner, or dependent child loses eligibility to remove the individual from PEBB coverage. The individual will be removed from plans the last day of the month in which eligibility was lost.

(2) An employee’s failure to report a spouse, domestic partner, or dependent child’s loss of eligibility within 30 days of the event is an intentional misrepresentation of a material fact of enrollment by the employee. PEBB will rescind all coverage back to the last day of the month and plan year when eligibility was lost. Under COBRA regulations ineligible individuals removed more than 60 days from the eligibility loss date will receive a COBRA unavailability letter due to the employee’s late notification.

(a) At an agency’s discretion, an employee may become liable to repay the agency for premiums paid by the agency while the individual was ineligible.

(b) An employee may become liable for repayment of insurance claims incurred and paid by a plan for the ineligible individual according to contract agreements between PEBB and the plan.

Example: Ann’s divorce is final on June 6. Ann submits her update form to her agency October 10. The agency forwards the update forms to PEBB. PEBB terminates the ineligible individual’s coverage the last day of the month that the divorce was final. The ex-spouse will receive a COBRA unavailability letter.

(3) Premium refunds to agencies:

(a) Premium refunds for rescinded coverage may be available according to PEBB’s contract agreement with each plan.

(b) An agency will not receive a premium equivalent refund from a PEBB self-insured plan for an ineligible individual whose coverage is rescinded.

(3) A plan may remove from coverage or deny the claims of an eligible employee, a family member, domestic partner, or domestic partner’s dependent child because of fraud, intentional misrepresentation of a material fact, eligibility violations, or policy term violations. Violations include but are not limited to, fraud, material misrepresentation, or concealment. When a plan removes an employee from coverage for violations:

(a) The employee may choose, as a midyear plan change, an alternative plan to replace the terminated plan. If no alternative plan is available, there is no coverage.

(b) The plan may retain all premiums paid and has the right to recover from the employee, the benefits paid as a result of such wrongful activity that are in excess of the premiums.

(4) When discovered, PEBB may rescind coverage for individuals identified as ineligible to the end of the month that eligibility is lost, whether or not requested by the employee within the 30 day period.

History

Statutory/Other Authority: ORS 243.061 - 302
Statutes/Other Implemented: ORS 243.061-302, 659A.060-069, 743.600-602 & 743.707
PEBB 6-2018, amend filed 08/15/2018, effective 08/15/2018
PEBB 2-2017, f. & cert. ef. 8-17-17
PEBB 1-2013, f. & cert. ef. 9-24-13
Reverted to PEBB 7-2010, f. 12-10-10, cert. ef. 1-1-11
PEBB 2-2011(Temp), f. & cert. ef. 8-5-11 thru 1-31-12
Suspended by PEBB 1-2011(Temp), f. & cert. ef. 3-9-11 thru 8-4-11
PEBB 7-2010, f. 12-10-10, cert. ef. 1-1-11
PEBB 3-2009, f. 9-29-09 cert. ef. 10-1-09
PEBB 2-2008, f. & cert. ef. 8-1-08
PEBB 2-2007, f. 9-28-07, cert. ef. 10-1-07
PEBB 3-2004, f. & cert. ef. 10-7-04
PEBB 1-2004, f. & cert. ef. 7-2-04
PEBB 1-2002, f. 7-30-02, cert. ef. 8-1-02
PEBB 1-1999, f. 12-8-99, cert. ef. 1-1-00

Or. Admin. R. 101-020-0032 Open Enrollment

(1) Active and other eligible employees may make benefit plan changes, new plan elections, enroll eligible individuals, or terminate only certain individuals during the annual open enrollment period. All plan elections or enrollments are subject to paragraph (6) of this rule. Eligible employees must submit plan elections, enrollments, or enrollment terminations as instructed during the designated period.

(2) Open enrollment coverage begins the first day of the new plan year. When coverage must receive plan-underwriting approval, the appropriate documents must be submitted to the plan by December 31st of the current plan year, the effective date of the coverage will be the first day of the month after approval in the new plan year.The exception is UNUM, enrollment can be done at any time and the effective date of coverage is the first of the month following approval.

(3) During the open enrollment period, the eligible employee is accountable for enrolling and providing coverage to only those individuals who will meet PEBB eligibility criteria for coverage the first day in the new plan year. The eligible employee is accountable during open enrollment for ensuring that only those individuals who meet PEBB eligibility are enrolled in the new plan year.

(a) Employees can terminate an individual currently receiving coverage, electronically or by using a form, if they know the individual will be ineligible for coverage the first day of the plan year or the employee no longer wants to provide coverage to the individual even though the individual will continue to meet eligibility. When terminated by an employee as part of the open enrollment period the individual’s coverage ends the last day of the last month of the current plan year. PEBB can audit an employee’s benefit record and investigate the reason why an individual will no longer receive coverage in the new plan year. When necessary PEBB can correct the coverage termination date of a terminated individual and take the appropriate termination of coverage action as provided by OAR 101-020-0025.

(b) Employees are not to use the open enrollment period to remove individuals who have lost eligibility or will lose eligibility. Employees must remove individuals who lose eligibility from their coverage and benefit record by submitting the correct midyear change forms to the agency or to PEBB. See OAR 101-020-0025.

(4) The agency must provide an eligible employee who becomes newly eligible or hired after the open enrollment period but before the start of the new plan year an opportunity for open enrollment elections.

(5) The agency must provide eligible employees away from work due to FMLA, CBIW, active military duty, or other approved employer leave status where the employer continues the employee’s core benefits, an opportunity for open enrollment elections before the start of the new plan year.

(6) Benefit plan elections are irrevocable for the new plan year except as specified in OAR 101-020-0050 or 101-020-0037.

History

Statutory/Other Authority: ORS 243.061 - 302
Statutes/Other Implemented: ORS 243.061 - 302
PEBB 6-2018, amend filed 08/15/2018, effective 08/15/2018
PEBB 2-2017, f. & cert. ef. 8-17-17
PEBB 7-2010, f. 12-10-10, cert. ef. 1-1-11
PEBB 2-2007, f. 9-28-07, cert. ef. 10-1-07

Or. Admin. R. 101-020-0037 Correcting Enrollment Errors and Open Enrollment Errors

(1) Employee enrollment errors occur when an eligible employee provides incorrect information or fails to make correct selections when making benefit plan elections. An employee’s failure to initiate timely enrollment rights either electronically or via paper form is not considered an employee error. For the purpose of this rule, an enrollment action means that the employee during the allowable enrollment times must take an action to enroll, add to, save an active enrollment, or change benefit plan enrollment elections, or enroll, add to, save an active enrollment, or change coverage of individuals. The eligible employee is responsible for identifying enrollment errors and maintaining a valid and accurate enrollment.

(a) PEBB authorizes the agency to correct employee enrollment errors when reported by the employee within 30 days of the original eligibility date or midyear plan change date. Corrections are prospective to the first of the month following the date the agency received the correction request.

(A) PEBB must review all employee requests to correct enrollment errors received after 30 days of the original eligibility date or the midyear plan change date. If the correction is approved, the effective date is the first of the month following the receipt of the employee’s correction request.

(B) Enrollment error correction requests considered beyond 30 days of the eligibility date or the midyear plan change date must demonstrate facts and circumstances that clearly establish an employee error occurred.

“Example: As a new employee, Anne enrolled in the Dependent Care Flexible Spending Account. Anne does not have any eligible dependents. Six months later Anne realizes the error after her first Health Care FSA claim is rejected. Anne may request an enrollment correction from PEBB.”

(b) PEBB authorizes the agency to correct an employee’s open enrollment error. The agency may receive employee correction request after the open enrollment end date but no later than the last day of February of the new plan year.

“Example: Ann enrolled in the wrong dental plan during open enrollment. Ann identified the error and submitted her open enrollment correction form in December. The effective date of the correction is January 1st.” “Example: Ann enrolled in the wrong dental plan. Ann identified the error and submitted her open enrollment correction form in January. The effective date of the correction is February 1st.”

(d) PEBB must review all employee open enrollment correction requests received beyond the timelines for open enrollment corrections.

(2) PEBB Administrator has the authority to grant exceptions to PEBB Administrative Rules when there are extenuating circumstances which can be supported by documentation and verified by PEBB staff.

History

Statutory/Other Authority: ORS 243.061 - 302
Statutes/Other Implemented: ORS 243.061 - 302
PEBB 6-2018, amend filed 08/15/2018, effective 08/15/2018
PEBB 2-2017, f. & cert. ef. 8-17-17
PEBB 7-2010, f. 12-10-10, cert. ef. 1-1-11
PEBB 3-2009, f. 9-29-09 cert. ef. 10-1-09
PEBB 2-2008, f. & cert. ef. 8-1-08
Renumbered from 101-040-0080, PEBB 2-2007, f. 9-28-07, cert. ef. 10-1-07
PEBB 1-2006, f. & cert. ef. 11-28-06
PEBB 3-2005, f. 8-31-05, cert. ef. 9-1-05
PEBB 1-2005, f. & cert. ef. 4-14-05
PEBB 3-2004, f. & cert. ef. 10-7-04
PEBB 1-2004, f. & cert. ef. 7-2-04
PEBB 1-2003, f. & cert. ef. 12-4-03

Or. Admin. R. 101-020-0038 Correcting Processing Errors

(1) Administrative processing errors occur when benefit plan elections are processed incorrectly in the payroll and benefit system by the agency, PEBB, or third party administrative staff, or PEBB carrier. Administrative error also includes when a newly eligible employee does not receive correct enrollment information or materials within 30 days of the eligibility date.

(a) PEBB must review all processing errors on PEBB optional plans (non-health carriers).

(A) Approval letters for a plan that requires underwriting are not official documents for enrollments unless the enrollment is entered into the PEBB system.

(B) If the enrollment is not entered into the system due to an administrative error, the member may pay all retro premiums back to the first of the month following carrier approval or re-apply for the coverage during an upcoming open enrollment period or within 30 days of a qualifying midyear event (Medical evidence may be required).

(C) PEBB will not be held responsible for processing errors made outside of PEBB. The eligible employee is responsible for identifying enrollment errors and maintaining a valid and accurate enrollment.

(b) PEBB authorizes the agency to correct processing errors identified within 30 days of the eligibility date or the midyear plan change date. Corrections are retroactive to the first of the month following the date the agency received the original paper form or electronic equivalent. The agency must reconcile all premium discrepancies.

(c) PEBB must review all processing error correction requests identified after 30 days of the eligibility date or the midyear plan change date. If approved, corrections are retroactive to the first of the month following the date the paper form or electronic equivalent was first received by the agency. The agency must reconcile all premium discrepancies.

(d) PEBB authorizes the agency to correct open enrollment processing errors. The agency must receive requests for correction after the open enrollment end date but no later than the last day of February of the new plan year.

(e) PEBB must review all open enrollment correction requests received after the last day of February of the new plan year.

(f) When a newly eligible employee fails to receive enrollment information within 30 days of the eligibility date or receives incorrect information, benefit plan elections will be effective retroactive to the first of the month following the eligibility date. Verification must be received by PEBB to consider the request.

History

Statutory/Other Authority: ORS 243.061 - 302
Statutes/Other Implemented: ORS 243.061 - 302
PEBB 6-2018, adopt filed 08/15/2018, effective 08/15/2018

Or. Admin. R. 101-020-0040 Late Enrollment

(1) Late enrollment occurs when an eligible employee fails to enroll themselves, eligible family members, domestic partner, or a domestic partner’s child in benefit plans within the required time period.

(2) An enrolled employee requesting late enrollment for a family member, domestic partner, or domestic partner’s dependent child must provide supporting documentation that shows an inability to enroll the individual when first eligible because of circumstances beyond the employee’s control.

(3) A newly eligible employee approved for late enrollment receives only employee basic life insurance coverage and may only elect medical and dental coverage for themselves, spouse, domestic partner, or dependent children. If late enrollment is approved, benefit coverage is effective the first of the month following receipt of the completed enrollment forms.

(4) Following receipt of the completed forms, late enrollment of an employees’s biological newborn dependent child will be retroactive to the first of the month following the date of birth if completed forms are received during the first twelve months of life.

History

Statutory/Other Authority: ORS 243.061 - 302
Statutes/Other Implemented: ORS 243.061-302, 659A.060-069, 743.600-602 & 743.707
PEBB 6-2018, amend filed 08/15/2018, effective 08/15/2018
PEBB 3-2009, f. 9-29-09 cert. ef. 10-1-09
PEBB 2-2008, f. & cert. ef. 8-1-08
PEBB 2-2007, f. 9-28-07, cert. ef. 10-1-07
PEBB 1-2006, f. & cert. ef. 11-28-06
PEBB 3-2005, f. 8-31-05, cert. ef. 9-1-05
PEBB 3-2004, f. & cert. ef. 10-7-04
PEBB 1-2004, f. & cert. ef. 7-2-04
PEBB 1-2003, f. & cert. ef 12-4-03
PEBB 1-2002, f. 7-30-02, cert. ef. 8-1-02
PEBB 1-2001, f. & cert. ef. 9-6-01
PEBB 1-2000, f. 11-15-00, cert. ef. 1-1-01
PEBB 1-1999, f. 12-8-99, cert. ef. 1-1-00

Or. Admin. R. 101-020-0045 Returning to Work

(1) Refer to the following rules for an employee returning to paid regular status from the following leave status:

(a) Continuation of Benefits for Injured Workers (CBIW). See OAR 101-030-0010.

(b) Federal Family Medical Leave Act (FMLA). See OAR 101-030-0015.

(d) Active Military Duty Leave (USERRA). See OAR 101-030-0022.

(2) A benefit eligible employee who is not in a current benefit eligible stability period and is returning to paid regular status must work at least half-time in the month of return to be eligible for core benefits and optional plan coverage the following month if returning from:

(a) A leave without pay that is not listed in subsection (1) of this rule and has a break in active employee coverage; or

(b) A reduction in hours below benefit eligibility criteria, unless the employee is a benefit eligible employee in a job share position.

(3) Any benefit eligible employee returning to paid regular status within 30 days without a break in core coverage from either a leave not listed in (1) of this rule or from an employment termination will have all available previous coverage reinstated. The employee cannot make benefit plan changes. A benefit eligible employee who:

(a) Is not in a current benefit eligible stability period, must work at least half-time in the month of return for benefits to be active the following month.

(b) Is in a current benefit eligible stability period will receive benefits in the month following the return to work regardless of the number of paid regular status hours in the month of return.

Example 1: Gary is employed by an agency and receives PEBB benefits. On May 20 Gary begins a leave without pay that does not provide for continued benefits throughout the leave. Gary worked more than 80 hours in May, and the agency correctly schedules his benefit coverage end date as June 30. Gary returns to paid regular status June 5, within 30 days of the leave start and with no break in core coverage. If Gary is in a current benefit eligible stability period, his return to paid regular status will reinstate his coverage for July 1. If he is not in a current benefit eligible stability period, he must work 80 hours in June for his coverage to continue in July. Gary cannot make any election changes to his enrollments.

Example 2: Mark terminates employment at his agency on May 31. At the time of his termination he is in a current benefit stability period. . Mark had 80 paid hours in the month of May; therefore, his agency ends his coverage on June 30. Mark is rehired by an agency as a temporary employee, his hire date is July 1. This is less than 30 days; however, a break in coverage occurred on June 30. Even if Mark is in a current benefit eligible stability period his benefits will not be reinstated until August 1.

(4) A temporary or impermanent position benefit eligible employee who is in a current benefit eligible stability period and has no hours of service for either 13 weeks, or a period lasting at least four weeks and longer than the employee’s prior employment, is considered a new employee upon return to regular pay status. Benefits are not reinstated.

(5) A permanent previously benefit eligible employee returning to a permanent benefit eligible position within 12 months of the prior core benefit termination date is not required to work at least half-time in the month of return to be eligible for benefits the following month. The agency will reinstate the previous plan enrollments, if available, effective the first of the month following the employee’s return to work. The reinstatement excludes Health and Dependent Care Flexible Spending Accounts, Commuter Accounts, and Long Term Care. The employee may make midyear plan changes to their enrollments within 30 days of the return to work date. This rule applies regardless of the employee’s current stability period status.

(6) A permanent benefit eligible employee who terminates employment for at least 13 weeks, and later returns to work must start a new initial measurement period.

(a) When returning to a permanent position benefits are reinstated according to (5) or (6) of this rule.

(b) When returning as a temporary worker the employee is not reinstated to benefits and will enroll for benefits according to temporary employee benefit policy.

(7) Any previously active benefit eligible employee returning to paid regular status in a benefit eligible position after a termination of core benefits of 12 months or longer must enroll as a newly eligible employee.

History

Statutory/Other Authority: ORS 243.061 - 302
Statutes/Other Implemented: ORS 243.061 - 302 & 659A.060-069
PEBB 2-2017, f. & cert. ef. 8-17-17
PEBB 1-2015, f. & cert. ef. 5-12-15
PEBB 3-2014(Temp), f. & cert. ef. 11-12-14 thru 5-10-15
PEBB 7-2010, f. 12-10-10, cert. ef. 1-1-11
PEBB 3-2009, f. 9-29-09 cert. ef. 10-1-09
PEBB 2-2008, f. & cert. ef. 8-1-08
PEBB 2-2007, f. 9-28-07, cert. ef. 10-1-07
PEBB 3-2005, f. 8-31-05, cert. ef. 9-1-05
PEBB 3-2004, f. & cert. ef. 10-7-04
PEBB 1-2004, f. & cert. ef. 7-2-04
PEBB 1-2002, f. 7-30-02, cert. ef. 8-1-02
PEBB 1-2001, f. & cert. ef. 9-6-01
PEBB 1-2000, f. 11-15-00, cert. ef. 1-1-01
PEBB 1-1999, f. 12-8-99, cert. ef. 1-1-00

Or. Admin. R. 101-020-0047 Transfer

(1) When an eligible employee transfers from one PEBB participating organization to another, the organization losing the employee must pay the benefit amount for the month following the transfer, regardless of hours worked at that organization.

Exception: An eligible employee transfers mid-month from part-time to full time and submits enrollment forms to the gaining organization prior to the end of the month. In this case, the gaining organization pays the full benefit amount for the month following the transfer.

(2) All PEBB benefit plan elections transfer from the PEBB organization losing the employee to the organization gaining the employee without a lapse in insurance coverage.

(3) Benefit plan changes or elections are not permitted solely due to a transfer.

History

Statutory/Other Authority: ORS 243.061-302
Statutes/Other Implemented: ORS 243.061-302
Renumbered from 101-040-0020, PEBB 2-2007, f. 9-28-07, cert. ef. 10-1-07
PEBB 3-2005, f. 8-31-05, cert. ef. 9-1-05
PEBB 3-2004, f. & cert. ef. 10-7-04
PEBB 1-2004, f. & cert. ef. 7-2-04
PEBB 1-2001, f. & cert. ef. 9-6-01
PEBB 1-1999, f. 12-8-99, cert. ef. 1-1-00

Or. Admin. R. 101-020-0050 Midyear Benefit Plan Changes

(1) Eligible employee plan elections are irrevocable for the plan year. There are limited exceptions to the irrevocability rule if certain conditions or events are met. These events fall into three broad groups:

(a) Qualified Status Changes (QSC), which include:

(A) Changes in the eligible employee's legal marital status, such as marriage or divorce;

(B) Changes in the eligible employee's number of dependents, such as birth or adoption of a child;

(C) Changes in the employment status of the eligible employee or family member, such as the start or end of employment, or a change from part-time to full time;

(D) Changes in the eligibility of a dependent, such as attaining a certain age;

(E) Changes in the residence of the eligible employee , or;

(F) Changes in the eligible employee's domestic partnership.

(b) Cost or coverage changes. For example:

(A) An increase in out-of-pocket premium cost imposed by the employer;

(B) A reduction or a loss in the spouse's or domestic partner's group plan benefits, or;

(c) Other laws or court orders. For example: National Medical Support Notice, Medicare, or HIPAA related special enrollments.

(2) The eligible employee may request only those midyear plan change elections that are consistent with the event.

Example: In the middle of the plan year, John moves from his current medical plan’s service area and can no longer access the plan’s closed panel of providers. However, all of John’s other coverages (dental, life, etc.) remain active for his new address. John may request to change his medical plan, because it is consistent with the event due to a move from his current medical plan’s service area. John may not request to change or add any other elections at this time because that would not be consistent with the allowable midyear event occurrence.

(3) Eligible employees experiencing a qualified midyear event, and who request a change of enrollment elections must complete and submit to their agency the correct update forms and all required documentation within 30 days of the event. Agencies receiving employee midyear change requests can make only those changes that are consistent with the event. All election changes are effective the later of the first of the month after receiving all required update forms and documents or the event date. Agencies will not process enrollment request changes when enrollment and change request information is incomplete or missing required documentation.

(4) The tag-a-long rule applies when the eligible employee experiences a QSC addition of a new family member, domestic partner, or domestic partner’s child. The rule allows the employee to add another eligible family member, domestic partner, or domestic partner’s child who was previously eligible for PEBB plan coverage but never added to coverage, to be added to coverage.

History

Statutory/Other Authority: ORS 243.061 - 302
Statutes/Other Implemented: ORS 243.061 - 302, 659A.060 - 069, 743.600 - 602 & 743.707
PEBB 2-2017, f. & cert. ef. 8-17-17
PEBB 7-2010, f. 12-10-10, cert. ef. 1-1-11
PEBB 2-2007, f. 9-28-07, cert. ef. 10-1-07

Or. Admin. R. 101-020-0052 Surcharges

(1) For the purposes of this rule, the following definitions apply:

(a) Double Coverage means a subscriber/employee that is also an eligible dependent and is enrolled in two PEBB/PEBB or PEBB/OEBB medical plans.

(b) OEBB means the Oregon Educators Benefit Board in Oregon.

(c) Subscriber/employee means the individual who subscribes to their employer’s health plan. For the purposes of this rule, a subscriber excludes a COBRA participant, part-time employee, retiree or self-pay member.

(d) Dependent means and includes a dependent child as defined by OAR 101-015-0011, Spouse as defined by OAR 101-015-0005, and Domestic Partner as defined by OAR 101-015-0011.

(e) Surcharge means an extra fee deducted from the employee’s monthly pay.

(2) Tobacco Use Surcharge:

(a) Employees and spouses/Domestic Partners who are enrolled in a PEBB medical plan and use tobacco products may pay a monthly surcharge. The surcharge is deducted from the employee’s monthly paycheck. The monthly surcharges are determined by the PEBB Board.

(b) Employees who opt-out of a PEBB medical plan are not subject to this surcharge.

(c) Tobacco usage status can be updated prospectively at any time during the plan year by completing and submitting a Midyear change form.

(3) Spouse/Domestic Partner Other Group Coverage Surcharge:

(a) Employees will pay a monthly surcharge if the spouse/Domestic Partner is covered on the employee’s PEBB plan and chooses to not enroll in their own employer’s medical coverage (non-PEBB coverage). The monthly surcharges are determined by the PEBB Board.

(b) Employees who have a spouse/Domestic partner who opts out of PEBB coverage are not subject to this surcharge.

(c) Employees may submit a Midyear change form if this changes anytime during the plan year. The change request form must be submitted to their employer’s payroll or university benefits office within 30 days of the change. Changes take effect prospectively upon receipt of the appropriate form.

(4) Double Coverage:

(a) Effective January 1, 2021, any active full-time employees who cover an eligible dependent that is also enrolled as a subscriber for either a PEBB or an OEBB-sponsored medical plan will be assessed a monthly surcharge.

(b) The amount of the surcharge is determined annually by the PEBB Board.

(d) The subscriber will only pay one double coverage surcharge no matter how many dependents are double covered.

(e) The Double Coverage surcharge does not apply to Opt Out, Retirees, COBRA participants, self-pay participants or part-time employees.

History

Statutory/Other Authority: ORS 243.061 - 243.302
Statutes/Other Implemented: ORS 243.125(1), ORS 243.125(3)
PEBB 7-2020, adopt filed 12/22/2020, effective 12/22/2020

Or. Admin. R. 101-020-0059 Commuter Accounts (Fringe Benefits)

(1) There are two individual account types within Commuter Accounts, Transportation and Parking. Each type allows enrolled employees to claim tax free reimbursement of certain employment related commuter expenses. The accounts are fringe benefits and federal Internal Revenue Service (IRS) regulations govern the accounts.

(2) Enrolled employees reduce their taxable income because they contribute to the account monthly through a pre-tax salary reduction. The employer does not contribute to the accounts.

(3) Employees can enroll, terminate, or make changes to an existing account throughout a plan year. A qualifying midyear change event is not required to make a change to the account.

(4) Enrollment in either account type requires a minimum monthly contribution. Each year the IRS sets an available maximum monthly contribution, the limit is subject to change. The Board reviews and approves PEBB changes to employee monthly minimum and maximum contributions. Only one contribution each month is permitted.

(5) Refunds of account funds without a claim and reimbursement submission process is not permitted. Fund transfers between the account types is not permitted.

(6) An employee’s account funds will forfeit to PEBB when an account is inactive. An inactive account means, that for six consecutive months there has not been either an employee monthly contribution or a claim reimbursement processed.

(7) The Transportation Account provides reimbursement for employee only work-related commuting expenses for bus, ferry, rail, monorail streetcar, train, or vanpooling expenses. You may not use a Transportation Account to pay for agency-sponsored transit passes when payroll already deducts the value of those passes from your pay pre-tax.

(a) Transit Pass Expenses are expenses incurred for a pass, token, fare card, voucher, or similar item for transportation using Mass Transit Facilities. These include public or commercial facilities. Commercial facilities are those provided by any person in the business of transporting persons for compensation or hire if such transportation is provided in a vehicle with a seating capacity of at least six adults (excluding the driver).

(b) Commuter Highway Vehicle (Vanpool) expenses must be in connection with travel between the employee’s residence and place of employment. A commuter highway vehicle is any highway vehicle with a seating capacity of at least six adults (not including the driver). At least 80% of the mileage must be for purposes of transporting employees in connection with travel between their residences and their places of employment. The number of employees transported for such purposes must be, on average, at least half of the adult seating capacity of the vehicle.

(8) The Parking Account provides a reimbursement for certain parking expenses incurred to work. You may not use a Parking Account to pay for monthly state lot parking, because payroll already deducts that cost from your pay pre-tax. The allowed expenses for parking are:

(a) At or near the business premise of the employer;

(b) At a location from which to commute to work by mass transit facilities or commuter highway vehicle (carpool).

(9) Employees submit reimbursement claims for incurred or paid for expenses during the current plan year.

(a) All claims for the current plan year must be submitted by January 15 of the following plan year. Submission of previous year claims after that date will result in a claim denial.

(b) Previous year unused funds remain in the employee’s account and can be used for current year expense reimbursement if the employee’s eligibility and the account’s eligibility remain as active.

(d) Reimbursement cannot be made for more than the cash balance in the account.

(e) Reimbursement claimed for a month can be for no more than the maximum monthly amount in effect during the timeframe of the requested reimbursement.

(f) Reimbursement without a submission of a qualified claim for expenses incurred or paid are not permitted.

(10) Employees who remain employed but terminate the account can remain a participant if the account remains active. Inactive accounts forfeit to PEBB, see (6) of this rule.

(11) Employees terminating employment will not have an account contribution taken from their final pay. Former employees cannot participate in the Commuter Account. If funds remain in the account after termination, the employee may submit claims for incurred or paid for expenses that occurred before the employment termination for up to six months from termination. The account forfeits to PEBB after six months if funds remain in the account.

History

Statutory/Other Authority: ORS 243.061 - 243.302
Statutes/Other Implemented: ORS 243.061 - 243.302
PEBB 6-2018, amend filed 08/15/2018, effective 08/15/2018
PEBB 2-2016, f. & cert. ef. 8-24-16

Or. Admin. R. 101-020-0060 Dependent Care Flexible Spending Account

Employees may use a Dependent Care Flexible Spending account (Dependent Care FSA) to be reimbursed for employment-related dependent care expenses for eligible dependents that allow the employee and his or her spouse to be “gainfully employed.” The plan is subject to federal Revenue Code requirements and Internal Revenue Service regulations.

(2) Employees enrolled in a Dependent Care FSA contribute a pre-tax amount from each month’s salary during the plan year. Employees receive reimbursement from the account during the plan year for incurred qualified Dependent Care expenses by submitting a claim.

(3) FSA plans are annual plans, eligible employees must enroll for each plan year to participate. The enrollment does not roll over from one plan year to the next. All plan year FSA enrollments terminate December 31. The period of coverage is the 12 months during the plan year.

(4) An employee’s failure to take an enrollment action is not considered an employee enrollment error. An enrollment action means that the employee during the allowable enrollment times must take an action to enroll, add to, save an active enrollment, or change benefit plan enrollment elections.

(5) The eligible employee is responsible for identifying enrollment errors and maintaining a valid and accurate Dependent Care flexible spending enrollment. The employee has 30 days from date of their first paycheck with their Dependent Care FSA enrollment to request a correction. The exception is open enrollment see OAR101-020-0037 (c).

(6) PEBB must review enrollment errors reported by the employee. Corrections, if allowable, must be consistent with the IRS regulations that govern flexible spending accounts.

(7) An employee’s pretax contribution under a Dependent Care FSA in a calendar year is (not exhaustive list):

(a) $5,000 if the employee is married and filing a joint return or if the employee is single parent.

(b) $2,500 if the employee is married but files separately.

(c) When a spouse’s employer also has a dependent care FSA plan, the $5000 limit applies to the total amount of pre-tax dependent care assistance that the employee and his or her spouse, as a couple, can receive in any tax year from all employer-sponsored plans.

(d) The limit is not affected by the number of qualified persons an employee has.

(8) To qualify as employment-related dependent care expenses, the expenses must be incurred in order to enable the employee (and the employee’s spouse) to be gainfully employed. The dependent care must have been for qualifying individuals. In general (not exhaustive) a qualifying individual is a tax dependent who is:

(a) A dependent of the taxpayer (i.e., a qualifying child) who has not attained age 13; or

(b) A dependent of the taxpayer (i.e., a qualifying child or a qualifying relative) who is physically or mentally incapable of caring for himself or herself; and has the same principal place of residence as the taxpayer for more than half of the year; or

(c) The spouse of the taxpayer if the spouse is physically or mentally incapable of caring for himself or herself and has the same principal place of residence as the taxpayer for more than half the year.

(9) The annual contribution to the account cannot exceed the allowable federal annual maximum.

(a) The employee’s monthly contribution is the annual contribution election amount pro-rated per each month of the plan year.

(b) PEBB requires a minimum monthly contribution amount.

(d) An employee may not change their contribution unless they experience a qualified mid-year plan change event that allows the change.

(e) Some OUS employees may have fewer months (9 or 10) of contribution during the plan year. Employees that receive less than 12 months of paychecks during the plan year must indicate during enrollment the months in which they will not receive a paycheck. For employees who receive less than 12 paychecks in a plan year, the electronic system and the paper enrollment form provide check boxes to indicate the months in which no contribution will be made.

(10) Claims are reimbursed for qualified expenses incurred while the Dependent Care FSA coverage was actively in force. Active participation ends the last day of the month that a contribution is received for that month.

(a) The amount of reimbursement available to a participant at any time during the period of coverage is restricted to the amount previously contributed by the participant, less any amounts reimbursed.

(b) A reimbursement exception is made for eligible expenses incurred in the month following the employee’s end of participation or loss of plan eligibility, if the month is in the current plan year (not during the grace period) and the employee submits a claim within 90 days after the plan participation end date.

(11) A grace period for qualified claim and reimbursement extends through March 15 of each new plan year. During the grace period, FSA participants may incur claims against any remaining previous plan year FSA funds up to March 15 in the new plan year. The qualified claim submission deadline for previous plan year account fund reimbursements is March 31 of the new plan year.

(12) FSAs are “use it or lose it” accounts. Any previous plan year funds remaining in the account beyond March 31 of the new plan year forfeit to PEBB plan administration.

(13) Refunds of account funds without a timely claim and reimbursement submission process are not permitted. Fund transfers between the account types are not permitted.

(14) The Dependent Care FSA contributions can continue during a protected leave such as FMLA/OFLA, CBIW, or Active Military Duty; however, in general, most claims incurred during the leave will not be eligible for reimbursement.

(a) Employees may revoke the FSA account enrollment during the approved protected leave.

(b) Employees taking a LWOP and not in a protected leave will have their Dependent Care FSA revoked during the leave.

(15) Final contribution at termination of employment or leave.

(a) An OSPS employee will not have a contribution taken from their final paycheck.

"Example: Ann’s last day of work is September 16. Her final check will not have a contribution taken. Ann’s participation ends September 30.

(b) An OUS employee who meets the 80-hour work rule will have a contribution taken from their final paycheck, in accordance with OAR 101-020-0002."

"Example 1: Ann’s last day of work is June 6. She has less than 80 hours of work for the month. Ann’s final check will not have a contribution taken. Ann’s participation ends May 31."

"Example 2: Ann’s last day of work is June 20. She has more than 80 hours of work for the month. Ann’s final check will have a contribution taken. Ann’s participation ends June 30."

(16) An eligible employee who separates from the employer and returns to work in a benefit eligible position within 12 months is not reinstated in the Dependent Care FSA. They may enroll within 30 days of their new benefit eligible date.

History

Statutory/Other Authority: ORS 243.061 - 302
Statutes/Other Implemented: ORS 243.061 - 302
PEBB 6-2018, amend filed 08/15/2018, effective 08/15/2018
PEBB 2-2017, f. & cert. ef. 8-17-17
PEBB 2-2016, f. & cert.ef. 8-24-16
PEBB 1-2016, f. & cert. ef. 7-12-16
PEBB 3-2009, f. 9-29-09 cert. ef. 10-1-09
Renumbered from 101-040-0050, PEBB 2-2007, f. 9-28-07, cert. ef. 10-1-07
PEBB 3-2005, f. 8-31-05, cert. ef. 9-1-05
PEBB 3-2004, f. & cert. ef. 10-7-04
PEBB 1-2004, f. & cert. ef. 7-2-04
PEBB 1-2003, f. & cert. ef. 12-4-03
PEBB 1-2002, f. 7-30-02, cert. ef. 8-1-02
PEBB 1-2001, f. & cert. ef. 9-6-01
PEBB 1-1999, f. 12-8-99, cert. ef. 1-1-00

Or. Admin. R. 101-020-0065 Health Flexible Spending Arrangement

(1) An eligible employee may enroll in a pretax Health Care Flexible Spending Account (Health Care FSA). An Health Care FSA is regulated by various federal government regulations. Health Care FSAs can be defined in part by the following categories.

(a) It is a self-insured medical reimbursement plan subject to certain Internal Revenue Code requirements.

(b) It is a flexible spending account subject to additional requirements in the IRS regulations.

(c) It is a group health plan subject to COBRA, HIPAA, health care reform and other federal mandates that affect group health plans.

(2) Employees enrolled in a Health Care FSA contribute a pre-tax amount from each month’s salary during the plan year. Employees receive reimbursement from the account for qualified incurred health expenses during the plan year by submitting claims.

(3) FSA plans are annual plans, eligible employees must enroll for each plan year in order to participate. FSA plan enrollments do not roll over from one plan year to the next. All plan year FSA enrollments terminate December 31.The period of coverage is the 12 months during PEBB’s plan year.

(5) The eligible employee is responsible for identifying enrollment errors and maintaining a valid and accurate Health Care flexible spending enrollment. The employee has 30 days from date of their first paycheck with their Health Care FSA enrollment to request a correction. The exception is open enrollment see OAR 101-020-0037(c).

(6) PEBB must review enrollment errors reported by the employee. Corrections if allowable must be consistent with the IRS regulations that govern flexible spending accounts.

(7) The annual employee contribution to the FSA account cannot exceed the allowable federal annual maximum.

(a) The employee’s monthly contribution is the employee’s elected annual contribution amount pro-rated per each month of the plan year.

(b) PEBB requires a minimum monthly contribution amount.

(d) An employee may not change their monthly contribution unless they experience a qualified mid-year plan change event that allows the change.

(8) FSA accounts have uniform coverage. Uniform coverage means that an employee’s maximum contribution amount for the plan year is available at all times while the account is active. The amount available is reduced for prior reimbursements made in the current plan year. Uniform coverage is provided throughout the period of coverage.

(9) Expenses must be incurred by the employee, spouse, the employee’s children who have not attained age 27 as of the end of the employee’s taxable year, or who are the employee’s tax dependents for health coverage purposes.

(10) A grace period for qualified claim and reimbursement extends through March 15 of each new plan year. During the grace period, FSA participants may incur claims against any remaining previous plan year FSA funds up to March 15 in the new plan year. The qualified claim submission deadline for previous plan year account fund reimbursements is March 31 of the new plan year.

(11) FSAs are “use it or lose it” accounts. Any previous plan year funds remaining in the account beyond March 31 of the new plan year forfeit to PEBB plan administration.

(12) Refunds of account funds without a timely claim and reimbursement submission process is not permitted. Fund transfers between the account types is not permitted.

(13) Employees taking an approved protected leave, for example, FMLA/OFLA, CBIW, or Active Military Duty Leave are entitled to continuation of the their Health Care FSA while on the leave.

(a) If the leave is a substituted paid leave, then the employee’s contribution for continuation must be paid by payroll deduction.

(b) An agency may offer one or more of the following options to an employee who continues the FSA account coverage while on a protected unpaid leave. Before commencing the leave, or shortly thereafter, the employee and the agency must agree to one of the following options for employee contribution.

(A) Prepay. The employee is given the opportunity to prepay their premium share due during the leave period before the leave begins. The prepay option cannot be the sole option offered to employees on approved protected leave.

(B) Pay as you go. The employee pays the cost of coverage in installments during the leave. Contributions are paid with after-tax dollars or with pre-tax dollars to the extent that the employee receives compensation (e.g., unused sick or vacation days) during the leave.

(C) Catch-up options. The employer and employee agree in advance that the employer will advance payment of the employee’s share of the contribution during the leave and that the employee will repay the advanced amounts when the employee returns to work.

(D) Revoke Coverage. Employees may revoke the FSA account enrollment during the leave.

(14) An employer is not required to continue the benefits of an employee who fails to make required payments while on a protected leave provided notice procedures are followed. Refer to OAR 101-20-0002(7)(d) for employee non-payment notices and benefit termination. If the employer chooses to continue the health coverage of an employee who fails to pay his or her share of the premium or contribution payments, the employer is permitted to recoup the employee’s premium.

(15) Employees who terminate FSA participation during the plan year can receive reimbursement for qualified claim expenses incurred while the Health Care FSA coverage was actively in force. No reimbursement is allowed for expenses incurred after the account terminates. Active participation ends the last day of the month that a contribution is received for that month.

(16) OUS and some academic OSPS employees that enroll based on their 9- or 10-month pay contributions are considered actively participating during the months of no contribution. For example, during months of June and July when they are not actively at work.

(17) Final contribution at termination of employment or a leave without pay terminating the FSA:

(a) OSPS, the employee will not have a contribution taken from their final paycheck.

"Example: Ann’s last day of work is September 16. Her final check will not have a contribution taken. Ann’s participation ends September 30."

(b) An OUS employee who meets the 80-hour work rule will have a contribution taken from their final paycheck, in accordance with OAR 101-020-0002.

"Example 1: Ann’s last day of work is June 6. She has less than 80 hours of work for the month. Ann’s final check will not have a contribution taken. Ann’s participation ends May 31."

"Example 2: Ann’s last day of work is June 20. She has more than 80 hours of work for the month. Ann’s final check will have a contribution taken. Ann’s participation ends June 30."

(18) An eligible employee terminating employment or going on an approved unprotected leave of absence, may continue to participate in the Health Care FSA up to the end of the current plan year through COBRA. There must be a positive FSA account balance and all contributions are paid post tax to the COBRA administrator.

(19) When called to active duty for a period of at least 180 days or for an indefinite period, an employee can request a qualified reservist distribution from a Health Care FSA. The eligible employee must be a member of the Army National Guard of the United States, the Army Reserve, Navy Reserve, Marine Corps Reserve, Air National Guard of the United States, Air Force Reserve, Coast Guard Reserve, or Reserve Corps of the Public Health Service.

(a) The following conditions must be met by the eligible employee in order to elect the qualified reservist distribution:

(A) Contributions to the Health Care FSA account for the plan year as of the date of the request for a distribution exceed the reimbursements received from the Health Care FSA Account for the plan year as of that date.

(B) The agency receives a copy of the order or call to active duty along with the distribution request form. An order or call to active duty of less than 180 days duration must be supplemented by subsequent calls or orders to reach a total of 180 or more days.

(C) During the period beginning with the date of the order or call to active duty and ending on the last eligible day of the plan year during which the order or call occurred, the employee submits a qualified reservist distribution election form to the agency.

"Example: An eligible employee is called to active duty on September 13, of the current plan year and wants a Health Care FSA qualified reservist distribution. The employee must request the qualified reservist distribution between September 13, and March of the following plan year."

(b) The distribution amount paid to the eligible employee is equal to the contributions to the Health Care FSA Account for the plan year as of the date of the distribution request, minus any reimbursements received by the employee for the plan year as of that date. A qualified reservist distribution is included in an eligible employee’s gross income and reported as wages for the year it is paid.

"Example: An eligible employee elects Health Care FSA benefits of $1,000 for the current plan year, and during the first six months of the plan year, makes Health Care FSA contributions of $500 and receives Health FSA reimbursements of $200 for qualified medical care expenses. The employee is called to active duty for an indefinite period and on June 30 requests a reservist distribution from the agency. The employee will receive a distribution of $300, and the agency must add that amount to the employee’s taxable wages for the current tax year."

(c) The Health Care FSA Account is closed as of the date of the request for a reservist distribution. An employee forfeits the right to receive reimbursements for medical care expenses incurred during the period that begins on the date of the distribution request and ending on the last day of the Plan Year.

(20) An employee who separates from the employer and returns to work in a benefit eligible position within 12 months is not reinstated in the Health Care FSA. They may enroll within 30 days of their new benefit eligible date.

History

Statutory/Other Authority: ORS 243.061 - 243.302
Statutes/Other Implemented: ORS 243.061 - 243.302
PEBB 9-2018, temporary amend filed 08/22/2018, effective 08/22/2018 through 02/17/2019
PEBB 7-2018, amend filed 08/17/2018, effective 08/18/2018
PEBB 6-2018, amend filed 08/15/2018, effective 08/15/2018
PEBB 2-2017, f. & cert. ef. 8-17-17
PEBB 1-2016, f. & cert. ef. 7-12-16
PEBB 3-2009, f. 9-29-09 cert. ef. 10-1-09
Renumbered from 101-040-0055, PEBB 2-2007, f. 9-28-07, cert. ef. 10-1-07
PEBB 3-2005, f. 8-31-05, cert. ef. 9-1-05
PEBB 3-2004, f. & cert. ef. 10-7-04
PEBB 2-2004(Temp), f. 7-13-04, cert. ef. 8-31-04 thru 2-27-05

Or. Admin. R. 101-020-0066 Public Employees' Benefit Board Appeal Procedure

(1) Eligible employees may submit appeal requests to PEBB concerning PEBB policy, eligibility, or plan enrollments. PEBB staff and the Board Appeals Subcommittee use relevant state and federal regulations, policy, PEBB’s documented Internal Revenue Code (IRC) 125 Cafeteria plan, and Oregon Administrative Rules to provide appeal decisions.

(2) PEBB does not accept appeals related to contracted plans or plan administrators, such as but not limited to medical, dental, life, disability, COBRA, and long term care, services, decisions, or claims. The Board’s Appeal Committee may hear appeals concerning benefit design.

(3) If PEBB rescinds plan coverage due to an individual’s ineligibility for coverage, the ineligible individual may appeal the rescission decision to PEBB using this rule. Until the appeal process for the rescission is exhausted the individual’s premium and claim payments will continue as if the rescission had not occurred. Upon final appeal determination and the rescission is upheld the employee will be responsible to pay all claims and premium payments paid by the Plan or PEBB during the period of ineligibility.

(4) Eligible Employees, or individuals who believe they received an incorrect or unfair decision from PEBB staff, an employing agency, retiree plan administrator, or an individual notified of a rescission have three levels of PEBB appeal.

(a) Level One: An eligible employee who believes he or she received an incorrect or unfair decision from PEBB, an employing agency, or retiree plan administrator, or an individual notified of a rescission may appeal the decision to PEBB. The appeal must be within 30 days the decision or action considered by the employee or individual as unfair or incorrect.

(A) The employee or individual must submit the appeal to PEBB using the correct forms and provide any supporting documentation for the appeal.

(B) A PEBB Benefit Analyst will review the appeal documents and may request additional information from the employee, individual, employer, or plan. Information requested from the employee must be received within 10 business days or PEBB will close the appeal.

(C) The analyst will complete the review of the appeal within 30 days from the date PEBB receives all necessary appeal documentation. PEBB will notify the employee or individual of any delay.

(D) When the review is complete, the analyst will provide a written explanation and determination to the employee or individual. If the appeal is denied, continued appeal steps will be included in the document.

(b) Level Two: An eligible employee or an individual who is dissatisfied with a Level One appeal determination may within 30 days of the level one determination request a Level Two review from the PEBB Plan Design Manager.

(A) The employee or individual must submit the request to the Plan Design Manager in writing and provide new supporting documentation. The manager may request additional information from the employee, the employer, or plan. Information requested from the employee must be received within 10 business days or PEBB will close the appeal.

(B) The Plan Design Manager will review the request and determine whether to provide a determination to the employee or individual, or to move the request directly to the third level of appeals.

(C) If the Plan Design Manager completes a review, the employee or individual will receive a written letter of explanation and determination. If the appeal is denied, continued appeal steps will be included in the document.

(D) If the Plan Design Manager sends the appeal directly to Level Three without providing a determination, the employee will receive written notice.

(c) Level Three: An eligible employee or individual receiving both a first and second level appeal denial can request that the Board Appeals Subcommittee review the appeal. The Subcommittee can also review appeals submitted directly to them by the Plan Design Manager. The Board Appeals Subcommittee will provide a final decision to the employee or the individual.

(A) An employee or individual requesting a Level Three review must submit the request in writing to the Plan Design Manager within 30 days of the Level Two determination date.

(B) The Subcommittee appeal determination requires a majority vote of the members. If an agreement cannot be reached, the appeal may be referred to the full Board. Decisions by the full Board require a majority vote. The Appeals Subcommittee may render a decision to the employee or individual and also refer the issue to the full Board for a benefit policy review.

(C) When the Subcommittee completes a review, or in the case of a full Board review, the employee or individual will receive a written explanation and determination within 30 days after the meeting.

(5) An individual may appeal the Subcommittee or Board’s decision as provided under the Oregon Administrative Procedures Act, ORS Chapter 183

History

Statutory/Other Authority: ORS 243.061 - 302
Statutes/Other Implemented: ORS 243.061 - 302
PEBB 9-2018, temporary amend filed 08/22/2018, effective 08/22/2018 through 02/17/2019
PEBB 2-2017, f. & cert. ef. 8-17-17
PEBB 1-2013, f. & cert. ef. 9-24-13
PEBB 3-2010, f. 9-23-10, cert. ef. 10-1-10

Division 30 CONTINUATION OF INSURANCE — ACTIVE EMPLOYEES

Or. Admin. R. 101-030-0005 Continuation of Group Medical and Dental Insurance Coverage under the Consolidated Omnibus Budget Reconciliation Act (COBRA)

COBRA allows an eligible individual who is losing an employer’s group health plan coverage due to a qualifying event to continue coverage for a limited time. PEBB COBRA is a self-pay premium by the eligible individual.

(1) PEBB participating organizations will issue an initial COBRA notice to all newly eligible employees and individuals that explains the right to continue employer medical and dental insurance plans if lost.

(a) The notice must be mailed to the eligible employee's address of record immediately following enrollment in PEBB medical or dental insurance plans or personally delivered to the employee. The notice must include all PEBB covered individuals residing at the address, including family members, a domestic partner, and a domestic partner's dependent children. Agencies must send a separate notice to the address of record for eligible individuals residing separately from the eligible employee.

(b) An initial COBRA notice must be mailed to individuals who become newly eligible for PEBB coverage due to marriage or the formation of a domestic partnership.

(2) To initiate COBRA eligibility a COBRA triggering event must occur causing the loss of benefit coverage. COBRA triggering events include:

(a) An involuntary reduction in hours or layoff.

(b) A strike or lockout.

(d) The termination of employment.

(e) Retirement.

(f) A dependent child no longer satisfying eligibility requirements.

(g) The loss of employer-sponsored group coverage for dependents due to Medicare eligibility.

(h) A divorce or termination of a domestic partnership.

(i) The death of the employee.

(3) All individuals losing eligibility due to a triggering event must receive a COBRA continuation notice. PEBB participating organizations must notify PEBB’s Third Party Administrator (TPA) within 30 days of the date of benefit eligibility. The date eligibility is lost is the COBRA triggering event date.

(a) The PEBB TPA mails a COBRA notice of continuation, to each eligible individual at their last address of record when eligibility for PEBB-sponsored insurance coverage is lost. The TPA must mail the notice to each eligible individual within 14 days of receiving the notification.

(b) An eligible employee has 60 days from the date of the COBRA notice to activate their COBRA rights of continuation. PEBB-sponsored insurance coverage must be continuous through COBRA implementation.

(4) An eligible individual continuing PEBB medical or dental insurance coverage or both under COBRA provisions has the same rights as active eligible employees for making changes during the open enrollment period and is eligible for qualified midyear changes.

(5) An eligible employee ending employment may continue to participate in the Healthcare Flexible Spending Account through COBRA up to the end of the current plan year if when the triggering event occurs:

(a) They have a positive balance in their account; and

(b) They self-pay contributions to the account. Contributions after employment ends are paid on an after-tax basis.

History

Statutory/Other Authority: ORS 243.061 - 302
Statutes/Other Implemented: ORS 243.061-302, 659A.060 - 069 & 743.600 - 602
PEBB 11-2018, temporary amend filed 12/03/2018, effective 01/01/2019 through 06/29/2019
PEBB 2-2017, f. & cert. ef. 8-17-17
PEBB 1-2013, f. & cert. ef. 9-24-13
PEBB 2-2007, f. 9-28-07, cert. ef. 10-1-07
PEBB 3-2004, f. & cert. ef. 10-7-04
PEBB 1-2004, f. & cert. ef. 7-2-04
PEBB 1-2003, f. & cert. ef 12-4-03
PEBB 1-2002, f. 7-30-02, cert. ef. 8-1-02
PEBB 1-1999, f. 12-8-99, cert. ef. 1-1-00

Or. Admin. R. 101-030-0007 Portability of Medical Insurance Coverage

Some PEBB sponsored group medical insurance plans allow portability. An eligible individual enrolled in one of these medical plans may continue insurance coverage under the plan’s portability provisions before, during, or at the end of the period that medical insurance coverage is provided under COBRA, if:

(1) They were continuously covered for 180 days or more under one or more PEBB sponsored group medical insurance plans and they lost eligibility for group medical insurance coverage;

(2) They are not covered by another group medical insurance plan, Medicare, or TriCare;

(3) They enroll in a continued medical insurance plan under the portability provisions within 63 days after termination of the group medical insurance coverage; and

(4) They comply with all requirements of the applicable insurance carrier for continuation of medical insurance coverage under the carrier’s portability plan provisions.

History

Statutory/Other Authority: ORS 243.061-302
Statutes/Other Implemented: ORS 243.061-302
Renumbered from 101-030-0035, PEBB 2-2007, f. 9-28-07, cert. ef. 10-1-07
PEBB 1-2004, f. & cert. ef. 7-2-04
PEBB 1-2001, f. & cert. ef. 9-6-01
PEBB 1-1999, f. 12-8-99, cert. ef. 1-1-00

Or. Admin. R. 101-030-0010 Continuation of Group Health Benefit Coverage for Injured Workers (CBIW)

(1) The state is required by ORS 659A.060-069 to continue to pay the benefit amount for PEBB health benefit coverage in effect at the time an eligible employee has a work-related injury or illness. The benefit amount may continue for up to 12 consecutive months or until one of the events listed in ORS 659A.063 occurs, whichever occurs first. Health benefit coverage for this purpose includes the medical, dental, vision, and prescription drug coverage of the employee, family members, and domestic partner.

(2) An eligible employee may continue coverage for life, accidental death and dismemberment and Long Term Care insurance plans for up to 12 months if they self-pay the premiums to the agency.

(3) Refer to OAR 101-020-0002(7)(d) for employee premium payment requirements.

(4) When an employee returns to work within 12 months, they will have their previous enrollment for medical, dental, life, and disability insurance reinstated the first of the month following their return to work. The employee may make midyear plan changes within 30 days of the date they return to work.

(5) An employee returning to work will not be reinstated in any pretax Flexible Spending Accounts, or PEBB Commuter Accounts. They may reenroll within 30 days of the date they return to work.

(6) A previously benefit eligible employee returning to paid regular status immediately following CBIW is not required to work at least half-time in the month they return to be eligible for benefits the following month.

(7) A COBRA qualifying event occurs at the end of the CBIW continuation period, or when the current benefit eligible stability period ends the allowable benefit period, if the employee has not returned to paid regular status.

History

Statutory/Other Authority: ORS 243.061 - 302 & 659A.060 - 069
Statutes/Other Implemented: ORS 243.061 - 302 & 659A.060 - 069
PEBB 2-2017, f. & cert. ef. 8-17-17
PEBB 1-2015, f. & cert. ef. 5-12-15
PEBB 3-2014(Temp), f. & cert. ef. 11-12-14 thru 5-10-15
PEBB 7-2010, f. 12-10-10, cert. ef. 1-1-11
PEBB 2-2007, f. 9-28-07, cert. ef. 10-1-07
PEBB 3-2004, f. & cert. ef. 10-7-04
PEBB 1-2004, f. & cert. ef. 7-2-04
PEBB 1-1999, f. 12-8-99, cert. ef. 1-1-00

Or. Admin. R. 101-030-0015 Continuation of Core Benefit Coverage for Employees Covered under the Federal Family Medical Leave Act (FMLA) and the Oregon Family Leave Act (OFLA)

(1) Employees taking approved FMLA or OFLA leave are entitled to the continuation of employer provided health coverage. The agency is obligated to maintain the employee’s health coverage under the same conditions that would have applied had the employee not been in leave.

(a) If the FMLA or OFLA leave is substituted paid leave, then the employee’s share of premiums for continuation must be paid by payroll deduction.

(b) An agency may offer one or more of the following options, to an employee who continues core benefit coverage while on an unpaid FMLA or OFLA leave. Before commencing the leave, or shortly thereafter, the employee and the agency must agree to one of the following options for employee premium share.

(C) Catch-up options. The employer and employee agree in advance that the employer will advance payment of the employee’s share of the cost of coverage during the leave and that the employee will repay the advanced amounts when the employee returns to work.

(D) Revoke Coverage. Employees may revoke the employer offered core health coverages during the leave. In this event the agency sends a COBRA notice of availability.

(2) Employees enrolled as Opt Out, receiving cash in lieu of medical benefits, do not receive the monthly payment when in leave without pay status, regardless of approved FMLA or OFLA leave.

(3) An employer is not required to continue the benefits of an employee who fails to make required payments while on FMLA or OFLA leave provided notice procedures are followed. Refer to OAR 101-020-0002(7)(d) for employee non-payment notices and benefit termination. If the employer chooses to continue the health coverage of an employee who fails to pay his or her share of the premium payments the employer is permitted to recoup the employee’s premium.

(4) A Health Care FSA is a group health plan under FMLA or OFLA. Refer to OAR 101-020-0065(9) regarding required payment options during a FMLA or OFLA leave. Prepayment cannot be the only method offered for FSA continuation during FMLA or OFLA leaves.

(5) An eligible employee may continue the following optional plans during the approved FMLA or OFLA leave by self-paying premiums or contributions to the agency:

(a) All Optional Life Insurances:

(b) Short Term and Long Term Disability,

(d) Long Term Care

(6) An agency must provide a benefit eligible employee who is in FMLA or OFLA leave during the annual open enrollment period the opportunity to select benefits for the coming plan year.

(7) An employee returning to paid regular status the first day following the end of an approved FMLA or OFLA leave or as scheduled, or an employee in a current benefit eligible stability period is not required to work at least half-time in the month of return to be eligible for benefits the following month. Core benefits and optional coverages are reinstated if available retroactive to the first day of the month that the employee returns to work.

(a) The employee must self-pay premiums for optional insurance plan reinstatements for the month in which they return.

(b) An employee returning to work will not be reinstated in Long Term Care unless the employee had continued the coverage by self-paying premiums during the leave.

(c) An employee’s FSA enrollment status, active or terminated, will depend on the employee’s FSA continuation status during the leave. If the employee’s FSA enrollment terminated during the leave the employee may enroll.

(8) An employee that waives all coverages for the leave period and returns to paid regular status beyond 30 days of loss of coverage but within 12 months from the loss of coverage, is reinstated to coverage and can make midyear plan changes within 30 days of the date they return to work. This includes enrollment for a FSA account or long term care.

(9) An employee who does not return to paid regular status the first work day immediately following the end of approved FMLA or OFLA leave as scheduled, and is not in a current benefit eligible stability period is considered the same as if returning from an unprotected leave without pay. The employee is required to work at least half time 80 hours in the month of return to receive reinstated benefits the following month. See OAR 101-020-0045(2)(a).

(10) A COBRA qualifying event occurs when (i) the employee does not return to work as scheduled the first day after the qualified leave ends and is not in a current stability status, or (ii) the employee terminates employment.

History

Statutory/Other Authority: ORS 243.061 - 302
Statutes/Other Implemented: ORS 243.061 - 302 & 659.A150 - 186
PEBB 2-2017, f. & cert. ef. 8-17-17
PEBB 1-2016, f. & cert. ef. 7-12-16
PEBB 1-2015, f. & cert. ef. 5-12-15
PEBB 3-2014(Temp), f. & cert. ef. 11-12-14 thru 5-10-15
PEBB 7-2010, f. 12-10-10, cert. ef. 1-1-11
PEBB 2-2008, f. & cert. ef. 8-1-08
PEBB 2-2007, f. 9-28-07, cert. ef. 10-1-07
PEBB 3-2004, f. & cert. ef. 10-7-04
PEBB 1-2004, f. & cert. ef. 7-2-04
PEBB 1-1999, f. 12-8-99, cert. ef. 1-1-00

Or. Admin. R. 101-030-0020 Continuation of Group Medical and Dental Insurance Coverage for Employees Covered under the Oregon Family Leave Act (OFLA) — ORS 659A.150-186

(1) A permanent, temporary or impermanent benefit eligible employee who qualifies for OFLA leave will continue benefits as outlined in OAR 101-020-0005 according to the their benefit eligible current stability status at the time the leave starts.

(2) When benefits continue during OFLA because of the employee’s current benefit eligible stability status, refer to OAR 101-20-0002(7)(d) for employee premium payment requirements.

(3) If active employee’s PEBB insurance coverage ends, the employee will receive a COBRA election notice. See OAR 101-030-0005.

(4) See OAR 101-020-0045 Returning to Work.

History

Statutory/Other Authority: ORS 243.061-302 & 659A.150-186
Statutes/Other Implemented: ORS 243.061-302 & 659A.150-186
PEBB 1-2015, f. & cert. ef. 5-12-15
PEBB 3-2014(Temp), f. & cert. ef. 11-12-14 thru 5-10-15
PEBB 2-2007, f. 9-28-07, cert. ef. 10-1-07
PEBB 3-2004, f. & cert. ef. 10-7-04
PEBB 1-2004, f. & cert. ef. 7-2-04
PEBB 1-1999, f. 12-8-99, cert. ef. 1-1-00

Or. Admin. R. 101-030-0022 Continuation of Benefit Coverage for Employees on Active Military Leave

(1) The state will continue to pay the benefit amount for core benefit coverage in effect at the time an eligible employee begins active military duty. This benefit coverage will continue for the duration of the active military leave, up to 24 consecutive months. The agency may end this coverage before or during the 24 months of active duty only if the member submits a signed written request to end the coverage.

(2) An eligible employee may continue the following optional plans during active military duty up to 12 months by self-paying premiums or contributions to the agency:

(a) Optional Life Insurances,

(b) Accidental Death and Dismemberment Insurance,

(d) Health Flexible Spending Account (FSA).

(3) An eligible employee on active military leave during open enrollment may make open enrollment benefit elections. The employee may allow another individual to make plan elections in the employee’s absence by providing documentation of a power of attorney to the agency. Enrollment in a Health FSA must occur during open enrollment in order to participate in the new plan year.

(4) An eligible employee who returns to work within 24 months will have available previous optional plan enrollments reinstated retroactive to the first day of the month the employee returns. A returning employee is not required to work at least half-time in the month they return to be eligible for benefits the following month.

(a) The employee must self-pay premiums for optional insurance plan reinstatements for the month in which they return.

(b) An employee returning to work will not be reinstated in Long Term Care, Commuter Accounts or any FSA, unless contributions to their Health FSA and Long Term Care while on military leave continued.

(5) A COBRA qualifying event occurs when an eligible employee:

(a) Is no longer in active duty status or paid regular status, and does not return to work following the allowed decompression time;

(b) Remains in active duty status after 24 months of active duty, or;

History

Statutory/Other Authority: ORS 243.061 - 302
Statutes/Other Implemented: ORS 243.061-302 & 408.240
PEBB 2-2017, f. & cert. ef. 8-17-17
PEBB 7-2010, f. 12-10-10, cert. ef. 1-1-11
PEBB 3-2009, f. 9-29-09 cert. ef. 10-1-09
PEBB 2-2008, f. & cert. ef. 8-1-08
PEBB 2-2007, f. 9-28-07, cert. ef. 10-1-07
PEBB 3-2005, f. 8-31-05, cert. ef. 9-1-05
PEBB 3-2004, f. & cert. ef. 10-7-04
PEBB 1-2004, f. & cert. ef. 7-2-04
PEBB 1-2003, f. & cert. ef 12-4-03

Or. Admin. R. 101-030-0026 Employer Designated Furlough Leaves

The State of Oregon as the employer may designate furlough leave without pay. Furlough leave does not affect an employee’s eligibility or current enrollment in medical, dental, and employee basic life insurance.

History

Statutory/Other Authority: ORS 243.061 - 302
Statutes/Other Implemented: ORS 243.061-302 & 292.05
PEBB 2-2009, f. 7-29-09, cert. ef. 8-1-09
PEBB 1-2009(Temp), f. & cert. ef. 2-24-09 thru 8-22-09

Or. Admin. R. 101-030-0027 Non-medical Leave Without Pay (LWOP) — Continuation of Optional Insurance Plans

An eligible employee who is in a non-medical LWOP status may continue coverage for optional life insurances, accidental death and dismemberment insurance plans and Long Term Care (LTC) for up to 12 months if they self-pay the premium to the agency. The employee is not eligible to continue short term or long term disability insurance plans while on LWOP.

History

Statutory/Other Authority: ORS 243.061 - 302
Statutes/Other Implemented: ORS 243.061 - 302
PEBB 2-2017, f. & cert. ef. 8-17-17
PEBB 2-2007, f. 9-28-07, cert. ef. 10-1-07

Or. Admin. R. 101-030-0070 Life, Disability, and Accidental Death and Dismemberment Insurance — Continuation of Coverage

(1) When an eligible employee separates from state service optional life insurance coverage may continue through the plan, not PEBB, as follows:

(a) Portability. An eligible employee terminating employment, other than for disability or retirement, may continue the employee’s optional employee, spouse, and domestic partner life insurance coverage at the group rate, plus billing fees. The policy remains a term life insurance policy. The employee must apply directly to the plan within 30 days of the date coverage ends. Portability is not available for employee basic life or dependent life coverage. A survivor of a covered eligible employee may continue optional life insurance through the plan upon the death of the employee.

(b) Conversion Rights. An eligible employee terminating employment for any reason, including disability or retirement, or experiencing a reduction in hours to less than 80 paid regular hours in the month, may be eligible to convert the employee’s term life insurance coverage. Not all policy types are available for conversion. The employee must apply directly to the plan within 30 days of the date insurance coverage ends. A survivor of a covered eligible employee may convert life insurance coverage through the plan upon the death of the employee.

(c) Retiree Life Insurance Option. An eligible employee who retires may purchase the Retiree Life Insurance Option without submitting evidence of insurability. The employee must apply directly to the insurance plan within 30 days of the date insurance coverage ends.

(d) Transfer of Premium Payment for Optional Employee Life Insurance. When two active eligible employees are married or in a domestic partnership and both are state employees, one employee can transfer their optional life insurance coverage to the other employee's life insurance coverage or to themselves upon:

(A) Terminating employment for any reason;

(B) Beginning an active military leave;

(D) Termination of their domestic partnership, or;

(E) Retirement. The remaining employed eligible employee must submit the completed and signed transfer form to their agency within 30 days of the date of the events listed in (1)(d) of this rule.

(2) There are no portability, conversion, or rollover continuation options for short term or long term disability or accidental death and dismemberment insurance coverage.

History

Statutory/Other Authority: ORS 243.061 – 302
Statutes/Other Implemented: ORS 243.061 – 302
PEBB 1-2013, f. & cert. ef. 9-24-13
Renumbered from 101-020-0070, PEBB 7-2010, f. 12-10-10, cert. ef. 1-1-11
PEBB 2-2007, f. 9-28-07, cert. ef. 10-1-07

Division 50 RETIREE RULES

Or. Admin. R. 101-050-0005 PEBB Retiree Health Plan Eligibility

(1) An active employee enrolled in PEBB plans immediately prior to retirement and who meets PEBB retiree plan eligibility may continue participation in PEBB health plans upon retiring.

(2) To be eligible a retiring employee must not be eligible for Medicare and be:

(a) Receiving a service or disability retirement allowance under the Public Employees Retirement System (PERS) or under any other retirement or disability benefit plan or system offered by the State of Oregon for its officers and employees;

(b) Eligible to receive a service retirement allowance under PERS and have reached earliest retirement age under ORS Chapter 238; or;

(c) Eligible to receive a service retirement allowance or pension under another retirement benefit plan or system offered by the State of Oregon and has reached earliest retirement age under the plan or system.

(3) Retiree plan eligibility for other individuals: A spouse, domestic partner, dependent child, and domestic partner's dependent child who each meet PEBB eligibility, are not Medicare eligible, and received coverage through the employee's active PEBB plans immediately prior to retirement are eligible for retiree plan coverage. When the retiring employee is Medicare eligible and not eligible for PEBB retiree plans, individuals receiving active coverage through the employee immediately prior to the retirement are eligible for retiree plan enrollment.

(4) If an individual covered by a PEBB retiree plan becomes Medicare eligible or loses PEBB eligibility while receiving retiree plan coverage, the individual must terminate from the plan. The exception is for Medicare eligibility because of end-stage renal disease. Individuals on the retiree plan who are not Medicare eligible and continue to meet PEBB eligibility may remain on the plan.

(5) A former eligible employee who first elects COBRA and later becomes eligible as a retired employee may enroll in PEBB retiree health plans at any time during or immediately following COBRA.

History

Statutory/Other Authority: ORS 243.061 - 243.302
Statutes/Other Implemented: ORS 243.061 - 302 & 659A.060 - 659A.069
PEBB 2-2017, f. & cert. ef. 8-17-17
PEBB 3-2010, f. 9-23-10, cert. ef. 10-1-10
PEBB 2-2007, f. 9-28-07, cert. ef. 10-1-07
PEBB 3-2005, f. 8-31-05, cert. ef. 9-1-05
PEBB 3-2004, f. & cert. ef. 10-7-04
PEBB 1-2004, f. & cert. ef. 7-2-04
PEBB 1-2002, f. 7-30-02, cert. ef. 8-1-02
PEBB 1-2001, f. & cert. ef. 9-6-01
PEBB 1-1999, f. 12-8-99, cert. ef. 1-1-00

Or. Admin. R. 101-050-0010 Retiree Plan Enrollment and Termination

(1) An active employee meeting PEBB retiree eligibility may enroll themselves and other eligible individuals in PEBB retiree health plans.

(2) Retiree plan coverage must be continuous with active or COBRA PEBB plan enrollments. Employees that retire and receive PEBB plan coverage through another active employee may move to PEBB retiree coverage when the other employee coverage ends.

(3) An active employee meeting PEBB retiree eligibility must submit retiree enrollment forms within 30 days of the date the active employee insurance terminates. Enrollments submitted within this 30-day window are retroactive to the date of active coverage termination.

(4) A Retiree may elect any PEBB full time or part-time health plan. A Retiree may elect medical only, dental only, or medical and dental insurance coverage. If the retiree does not initially enroll in both medical and dental insurance plans, they may not add the other plan later.

(5) PEBB may offer a plan change period for retiree insurance plan participants. The plan change period allows the retiree to change benefit plans. The plan change period does not allow the retiree to add dependents or coverage not already in place.

(6) A retired eligible employee electing to continue PEBB health plans under COBRA can transfer to a PEBB retiree health plan at any time during or immediately following COBRA.

(7) A retired eligible employee and their eligible individuals must terminate from PEBB retiree plans when they:

(a) Fail to self-pay the premiums; or

(b) Fail to continue to meet PEBB eligibility; or

(d) PEBB no longer offers retiree health plan coverage.

(8) Retiree plan coverage termination dates due to loss of eligibility:

(a) Coverage terminates the last day of the month before the month of Medicare eligibility.

Example: Joe becomes Medicare-eligible may 1st because his 65th birthday will be May 15th. Joe’s retiree health coverage will terminate April 30th.

(b) Failure to meet PEBB eligibility requirements; e.g., a dependent ages out of coverage, coverage terminates the last day of the month that the eligibility is lost.

(8) Division 20 Enrollment Rules apply to retirees in the following situations:

(a) Midyear benefit plan changes such as those resulting in the addition of a family member, domestic partner, or domestic partner's dependent child to the retiree's insurance coverage. See OAR 101-020-0050.

(b) Removing an ineligible individual from the retiree's insurance coverage. See OAR 101-020-0025.

History

Statutory/Other Authority: ORS 243.061 - 243.302
Statutes/Other Implemented: ORS 243.061 - 243.302
PEBB 2-2017, f. & cert. ef. 8-17-17
PEBB 3-2010, f. 9-23-10, cert. ef. 10-1-10
PEBB 2-2007, f. 9-28-07, cert. ef. 10-1-07
PEBB 3-2004, f. & cert. ef. 10-7-04
PEBB 1-2004, f. & cert. ef. 7-2-04
PEBB 1-2003, f. & cert. ef. 12-4-03
PEBB 1-2002, f. 7-30-02, cert. ef. 8-1-02
PEBB 1-2001, f. & cert. ef. 9-6-01
PEBB 1-2000, f. 11-15-00, cert. ef. 1-1-01
PEBB 1-1999, f. 12-8-99, cert. ef. 1-1-00

Or. Admin. R. 101-050-0015 Retiree Returning to Work for a PEBB Participating Organization in a Benefit Eligible Status

(1) A retiree returning to work within a PEBB participating organization in a benefit eligible position is eligible for active employee PEBB benefit plans. Insurance coverage must be continuous between active employee benefit plans and retiree plans.

(a) A retiree returning to paid regular status within 12 months will have their previous enrollment for medical, dental, life and disability insurance reinstated the first of the month following their return to work.

(b) A retiree returning to paid regular status 12 months after an active insurance coverage end date must enroll as a newly eligible employee. There is no second guarantee issue of long-term care insurance.

(c) A retiree either enrolling as a new hire or being reinstated to active employee optional life insurance must cancel retiree life that was ported from PEBB when the employee retired.

(2) A retiree enrolled in a PEBB retiree insurance plan may suspend the retiree insurance coverage when enrolled as an active employee in PEBB benefit plans. The employee must notify and request the retiree plan administrator to suspend the retiree coverage.

(3) A retiree receiving a state premium subsidy; e.g, early retirement premium subsidy that returns to active employee status as benefit eligible but chooses to continue coverage under a PEBB retiree or COBRA plan is not eligible to opt out and receive cash in lieu of active employee medical benefits.

History

Statutory/Other Authority: ORS 243.061 - 243.302
Statutes/Other Implemented: ORS 243.061 - 243.302
PEBB 3-2010, f. 9-23-10, cert. ef. 10-1-10
PEBB 2-2007, f. 9-28-07, cert. ef. 10-1-07
PEBB 1-2005, f. & cert. ef. 4-14-05
PEBB 3-2004, f. & cert. ef. 10-7-04
PEBB 1-2004, f. & cert. ef. 7-2-04
PEBB 1-2003, f. & cert. ef. 12-4-03
PEBB 1-2002, f. 7-30-02, cert. ef. 8-1-02
PEBB 1-2001, f. & cert. ef. 9-6-01
PEBB 1-1999, f. 12-8-99, cert. ef. 1-1-00

Or. Admin. R. 101-050-0020 Retiree Survivor Medical and Dental Insurance Coverage

(1) An eligible spouse, domestic partner, dependent child, and dependent child of a domestic partner enrolled in PEBB retiree health plans at the time of a retiree's death (or subscriber’s death) may elect to continue the retiree insurance coverage. The individual electing to continue the coverage becomes the subscriber. Subscribers must self-pay the premiums and maintain continuous coverage. It is the responsibility of the subscriber to notify the retiree plan administrator if they do not want continued coverage.

(2) The retiree plan coverage terminates for a surviving spouse or domestic partner when they:

(a) Remarry or form a domestic partnership; or

(b) Fail to make premium payments; or

(3) The retiree plan coverage terminates for the surviving dependent children of the retiree, spouse, or domestic partner when they:

(a) No longer meet PEBB dependent eligibility requirements (OAR 101-015-0011); or

(b) Fail to make premium payments; or

History

Statutory/Other Authority: ORS 243.061 - 243.302
Statutes/Other Implemented: ORS 243.061-302 & 659A.060 - 659A.069
PEBB 3-2010, f. 9-23-10, cert. ef. 10-1-10
PEBB 2-2007, f. 9-28-07, cert. ef. 10-1-07
PEBB 3-2004, f. & cert. ef. 10-7-04
PEBB 1-2004, f. & cert. ef. 7-2-04
PEBB 1-2002, f. 7-30-02, cert. ef. 8-1-02
PEBB 1-2001, f. & cert. ef. 9-6-01
PEBB 1-1999, f. 12-8-99, cert. ef. 1-1-00

Division 60 PEBB-PROVIDED HEALTH BENEFIT PLAN FOR LIQUOR CONTROL COMMISSION AGENTS

Or. Admin. R. 101-060-0005 Definitions

The following definitions will apply as used in OAR chapter 101 division 60:

(1) “Eligible employee” means a retail sales agent, appointed under ORS 471.705, who is subject to an agency agreement with the Oregon Liquor Control Commission to sell distilled spirits in the Commission’s agency stores. A temporary liquor agent is not considered an eligible employee for PEBB administrative purposes.

(2) “Newly eligible employee” means an agent who has signed a contract with an effective date of July 1, 1985 or later.

History

Statutory/Other Authority: ORS 243.061 - 243.302
Statutes/Other Implemented: ORS 243.061 - 243.302
PEBB 2-2007, f. 9-28-07, cert. ef. 10-1-07
PEBB 1-2004, f. & cert. ef. 7-2-04
PEBB 1-1999, f. 12-8-99, cert. ef. 1-1-00

Or. Admin. R. 101-060-0010 Eligibility for Medical and Dental Insurance Coverage

(1) A newly eligible employee may enroll in medical and dental insurance coverage within 30 days of their contract effective date. Insurance coverage will be effective on the first day of the month following:

(a) The signing of the standard OLCC contract;

(b) The receipt of the completed applicable forms for enrollment in PEBB medical and dental insurance coverage; and

(2) An eligible employee not enrolling in PEBB medical and dental insurance plans during the initial 30 days following their contract effective date may apply during an open enrollment period. Enrollment of a family member, domestic partner and domestic partner's dependent child during a subsequent open enrollment period will be subject to benefit plan limitations for late enrollment of an eligible individual.

History

Statutory/Other Authority: ORS 243.061 - 243.302
Statutes/Other Implemented: ORS 243.061 - 243.302
PEBB 2-2017, f. & cert. ef. 8-17-17
PEBB 2-2007, f. 9-28-07, cert. ef. 10-1-07
PEBB 3-2004, f. & cert. ef. 10-7-04
PEBB 1-2004, f. & cert. ef. 7-2-04
PEBB 1-2001, f. & cert. ef. 9-6-01
PEBB 1-2000, f. 11-15-00, cert. ef. 1-1-01
PEBB 1-1999, f. 12-8-99, cert. ef. 1-1-00

Or. Admin. R. 101-060-0015 Insurance Provision

PEBB may establish insurance rates consistent with the active employees’ group expected actuarial experience including administrative costs.

History

Statutory/Other Authority: ORS 243.061 - 243.302
Statutes/Other Implemented: ORS 243.061 - 243.302
PEBB 1-2004, f. & cert. ef. 7-2-04
PEBB 1-1999, f. 12-8-99, cert. ef. 1-1-00

Division 65 SB 551

Or. Admin. R. 101-065-0001 Administration of SB 551 Program

(1) For purposes of this rule:

(a) “SB 551 eligible member” is defined as a part-time faculty employee who is deemed eligible to receive coverage through PEBB by an Oregon public institution of higher education based on the requirements of SB 551 (2021). “SB 551 eligible member” does not mean or include a part-time faculty member who is currently eligible for employer-paid benefits through the Public Employees Benefit Board (PEBB) or the Oregon Educators Benefit Board (OEBB).

(b) "SB 551 program" is the benefits program established by SB 551(2021) and codified in ORS 350.355.

(c) "PEBB coverage" means coverage that is available to part-time faculty members who are eligible for employer-paid benefits.

(2) SB 551 eligible members may only enroll in employee-only, full time medical/pharmacy, dental and vision coverage. SB 551 members may waive medical/pharmacy coverage, or a combination thereof, subject to carrier specific requirements.

(3) SB 551 members shall not receive any monetary incentives for opting out, declining, or waiving any combination of or all available coverage, or from other incentive programs (i.e., HEM).

(4) SB 551 eligible members are not eligible for the Health Engagement Model (HEM) program.

(5)(a) Individuals currently eligible for and enrolled in PEBB or OEBB coverage as a subscriber or dependent are not eligible to enroll in the SB 551 program, and individuals eligible for and enrolled in the SB 551 program are not eligible to enroll in PEBB coverage.

(b) Individuals enrolled in the SB 551 program, who gain eligibility for PEBB coverage during the plan year, may terminate coverage under the SB 551 program and enroll in PEBB coverage, with no break between coverages. Individuals enrolled in PEBB coverage, who gain eligibility for coverage under the SB 551 program during the plan year, may terminate PEBB coverage and enroll in coverage under the SB 551 program, with no break between coverages. PEBB reserves the right to audit and retroactively terminate PEBB SB 551 coverage.

(6) If the SB 551 eligible member misses their enrollment period to enroll in coverage, they will have the ability to appeal to PEBB for enrollment.

(7) Coverage elected under this section is effective the entire plan year unless the SB 551 eligible member is terminated by PEBB or an Oregon public institution of higher education for failure to meet SB 551 eligibility or participation requirements or enrolls in PEBB coverage under section (5) of this rule.

(8) PEBB will not credit deductibles or out of pocket maximums for SB 551 members who transfer between a PEBB medical plan and an OEBB medical plan.

(9) It shall be the sole responsibility of the Oregon public institution of higher education to determine eligibility for coverage pursuant to ORS 350.355.

(10) It shall be the sole responsibility of the part-time faculty member to submit all information necessary for the Oregon public institution of higher education to make an eligibility determination for SB 551 coverage pursuant to ORS 350.355.

(11) The SB 551 eligible member is eligible to continue coverage through COBRA should their coverage end, and they meet the criteria for COBRA continuation coverage as per OAR 101-030-0005.

History

Statutory/Other Authority: ORS 243.061 to ORS 243.302
Statutes/Other Implemented: ORS 243.125(1), ORS 350.355
PEBB 1-2023, amend filed 12/20/2023, effective 12/21/2023
PEBB 2-2021, adopt filed 12/27/2021, effective 12/27/2021
PEBB 1-2021, temporary adopt filed 09/29/2021, effective 10/01/2021 through 03/29/2022

Division 70 LOCAL GOVERNMENT PARTICIPATION

Or. Admin. R. 101-070-0001 Definitions

“Local Government” means any city, county, or special district or any intergovernmental entity created under ORS chapter 190 in the State of Oregon.

History

Statutory/Other Authority: ORS 243.061-243.302
Statutes/Other Implemented: ORS 243.125(1), ORS 243.129
PEBB 5-2020, amend filed 09/28/2020, effective 09/29/2020
PEBB 1-2014, f. & cert. ef. 5-1-14
PEBB 3-2013(Temp), f. & cert. ef. 12-17-13 thru 6-15-14

Or. Admin. R. 101-070-0005 Participation Requirements

(1) Notice of Interest:

(a) Local Governments choosing voluntarily to participate in PEBB must complete and submit to PEBB a written Notice of Interest to Participate. The following notification timeline applies if the Local Government employs:

(A) 50 or fewer participating, eligible employees - 90 days prior to the Local Government's coverage effective start date with PEBB, or;

(B) 51 participating, eligible employees but fewer than 500 participating, eligible employees — 120 days prior to the Local Government's coverage effective start date with PEBB, or;

(C) More than 501 participating, eligible employees — 180 days prior to the Local Government's coverage effective start date with PEBB.

(b) Local Governments employing more than 501 participating, eligible employees that submit a Notice of Interest may allow individual employee groups entry into the PEBB program upon expiration of collective bargaining agreements that govern employee health and welfare benefits for the individual employee groups.

(c) PEBB reserves the right to extend any deadline or time within which a Local Government must take any action under these rules if the Local Government applies in writing for relief to PEBB and demonstrates in writing that special circumstances warrant the grant of such relief. For the purpose of this subsection, special circumstances that warrant the grant of relief include emergencies that reasonably can be regarded as imposing an obstacle to the Local Government. Special circumstances are circumstances beyond the reasonable control of the individual or organization including, but not limited to, Local Government employee groups facing above average increases in health benefit plan rates that prevent renewal, emergency reorganizations or replacements of the current benefit plans, board of directors or executive officers of the organization, acts of God and comparable practical impediments to an individual's or organization's ability to meet a deadline or achieve the correction of a violation of rules. The grant or denial of relief under this subsection must be determined by the PEBB official specifically delegated that task. PEBB also reserves the right to waive or to permit the correction of minor or technical violations of OAR 101-070-0005.

(2)(a) Financial Participation:

(b) Local Governments must provide PEBB with the most recent two years of medical premium-equivalent rates for self-insured groups and the most recent two years of medical premium rates for fully insured groups before submitting a Notice of Interest. Demographic data and logistical data may be requested as well. This information is used by PEBB's Consultant to perform an actuarial plan comparison.

(A) If an actuarial plan comparison completed by PEBB’s Consultant demonstrates these premium rates are less than 10 percent over PEBB’s costs during the same two-year period, the Local Government may participate at current PEBB premium rates.

(B) If an actuarial plan comparison demonstrates these premium rates are equal to or greater than 10 percent of PEBB’s costs during the same two-year period, PEBB may add a rate surcharge for up to three years, as determined by PEBB's Consultant.

(i) Upon entry into PEBB, Local Governments with 501 or more self-insured employees must either:

(I) Deposit a sufficient monetary reserve by January 1 of the first plan year to finance the stabilization account of the PEBB revolving fund to the PEBB risk-adjusted level as determined by PEBB's Consultant; or

(II) Agree to pay an additional surcharge to premiums to establish a reserve fund for the Local Government over a period of time as determined by PEBB’s Consultant.

(ii) When a Local Government with 501 or more self-insured employees terminates participation in PEBB, the initial contribution paid into the stabilization account of the PEBB revolving fund may be refunded as determined by PEBB’s Consultant.

(iii) When a Local Government provides a cash incentive to a member for opting-out of health coverage and the value of the incentive is 50% or more than the PEBB premium rate for an employee-only tier, PEBB may assess a surcharge to the Local Government.

(iv) Monthly Remittance. For subsections (6) through (11), the terms below have been identified:

(I) "ACH credit" means a payment initiated by a participating Local Government that is cleared through the Automated Clearing House (ACH) network for deposit to the PEBB treasury account;

(II) "ACH debit" means a payment initiated by PEBB and cleared through the ACH network to debit a participating Local Government’s financial account and credit the PEBB treasury account;

(III) “Local Government Payment” means the monthly Local Government Payment to PEBB that includes the contributions of both Local Government as the employer, and its employees as required to pay the monthly premiums in full for selected PEBB benefit plans;

(IV) “Local Government Payment Invoice" means a monthly itemized statement provided by PEBB that includes the enrollment elections of the employees and dependents of a Local Government and the PEBB premium rate associated with the benefit coverage enrollment month.

(V) “Pay-As-Billed” means billing a Local Government based upon its monthly enrollment file in the PEBB benefit management system.

(VI) “Overpayment” means the amount of a Local Government’s monthly payment to PEBB that exceeds the amount due.

(VII) “Underpayment” means a payment submitted by a Local Government that is less than the invoiced amount.

(VIII) “Electronic Funds Transfer” refers to a payment through ACH credit or ACH debit.

(IX) “Due date” means the seventh business day of the current month of coverage.

(v) Local Governments will receive a monthly invoice from PEBB by the first business day of the month of coverage that details the payments due for that month of coverage.

(vi) Local Governments are required to submit payment to PEBB through Electronic Funds Transfer no later than the due date.

(vii) PEBB reserves the right to issue surcharges or take other appropriate measures to Local Governments that submit monthly payments after the due date.

(viii) Local Governments must select an electronic funds transfer method by submitting an Electronic Funds Transfer authorization form to PEBB 45 days prior to participation in a PEBB plan year.

(ix) Local Governments seeking a refund of an overpayment must notify PEBB within 45 calendar days from the date the overpayment occurred.

(x) The Local Government shall submit any underpayment to PEBB as soon as it is discovered.

(I) PEBB will request a refund from a carrier in accordance with the law. The carrier will refund the premium to PEBB back to the date of the termination or the date allowed by law for recoupment.

(II) PEBB will generally reimburse a Local Government overpayment by making an adjustment to the next monthly invoice.

(III) The Local Government must reconcile their monthly invoice and process appropriate termination or Qualified Status Changes. Failure to do this timely will result in the Local Government being responsible for premium costs.

(3) General Participation Requirements

(a) Local Governments who choose to participate in PEBB must comply with PEBB eligibility, enrollment, and continuation of insurance rules as defined in OAR Division 101-10, 101-015 and 101-030, regardless of whether the Local Government is administering a Section 125 Cafeteria Plan.

(b) Local Governments must agree to and sign an inter-governmental agreement (IGA) with PEBB that includes provisions of their participation in the PEBB program, including, but not limited to, the following participation requirements. Local Governments must:

(A) Retain full authority to define employee-employer premium cost share arrangements compliant with Affordable Care Act (ACA) regulations.

(B) Use the PEBB tiered-rate structure for all benefit coverage types.

(D) Comply with the PEBB benefit plan-year cycle, Open Enrollment period, and plan renewal timeline.

(E) Submit all monthly premium payments to PEBB. Premium submission to PEBB is completed through Electronic Funds Transfer, no later than the due date as indicated by PEBB.

(F) Not transfer to any PEBB plan any deductibles or annual out-of-pocket maximums met with a prior carrier.

(G) Agree that the PEBB benefit management system is the authority for managing and reporting all billing, eligibility and enrollment information communicated to the insurance plan carriers by PEBB. Local Governments will update employment changes timely in the PEBB benefit management system as they occur.

(c) Local Governments may allow currently enrolled Early Retirees to participate in PEBB retiree plans only if the retirees participated in the Local Government’s retiree medical plan for at least two years prior to January 1, 2014. The PEBB Retiree Rules as defined in OAR Division 101-50-0005 et. seq. apply to all Early Retirees.

(d) Local Governments may request transfer of term life insurance coverage through the Local Government group life policy to the PEBB term life insurance policy. PEBB will transfer the life insurance amount in force on the last day the prior group coverage was in effect if requested and documented by the Local Government rounded to the nearest multiple of $10,000. Premium rates for the coverage will be at the current PEBB life insurance rate tier structure.

(e) Local Governments that elect to participate in benefit plans provided by PEBB may elect to terminate participation in PEBB, subject to the following rules:

(A) Termination of participation in PEBB will be allowed on a one-time basis only. The Local Government may elect to return to participate in plans provided by PEBB once. Upon returning to PEBB, a Local Government must again satisfy all Notice of Interest and other participation requirements. PEBB's Consultant will perform an actuarial analysis to determine if a surcharge should be applied, as outlined above in (2)(b).

(B) PEBB may terminate participation of a Local Government within three months of entering PEBB if the Local Government fails to perform any action required by Oregon Revised Statutes (ORS) 243.105 to 243.285 and 292.051 or by PEBB rule.

(f) Local Governments may purchase employee benefits not offered by PEBB.

History

Statutory/Other Authority: ORS 243.061 - ORS 243.302
Statutes/Other Implemented: ORS 243.125(1), ORS 243.129
PEBB 5-2020, amend filed 09/28/2020, effective 09/29/2020
PEBB 1-2014, f. & cert. ef. 5-1-14
PEBB 3-2013(Temp), f. & cert. ef. 12-17-13 thru 6-15-14

Division 80 OPERATIONS

Or. Admin. R. 101-080-0010 Hospital Payments

(1) Except as provided in section (10), the maximum reimbursement amount for each claim subject to ORS 243.256 and these rules shall be determined by the carrier applying the applicable percentage of the Medicare rate, or the Medicare rate for similar services or supplies, as of the date of service of the claim.

(2) The actual reimbursement amount for each claim subject to ORS 243.256 and these rules shall be based on the lesser of billed charges, the carrier's contracted rate for the provider, or the maximum reimbursement amount established in ORS 243.256 and these rules.

(3) The carrier shall determine the PEBB member’s cost sharing based on the actual reimbursement amount as determined in section (2) above.

(4) Any actions taken by the Centers for Medicare and Medicaid Services (CMS) that result in retroactive adjustment of the maximum reimbursement amount for an inpatient or outpatient hospital service or supply shall not result in retroactive increases to member cost sharing.

(5) The following payments shall not be included under ORS 243.256(1) or these rules:

(a) services or supplies that are not covered by Medicare

(b) services or supplies provided at Ambulatory Surgery Centers

(d) services or supplies provided at CMS designated children's hospitals that are not reimbursed via the Inpatient Prospective Payment System (IPPS).

(6) If a third-party administrator of a self-insured plan provides total fee-for-service payments to an in-network hospital under ORS 243.256(1) or (2) that exceed twice the total payments at the Medicare rate for the plan year, the self-insured plan third-party administrator will return the difference to PEBB. Moneys returned to PEBB under this rule will be deposited in the Public Employees’ Revolving Fund for purposes consistent with ORS 243.167.

(7) If a fully-insured carrier provides total fee-for-service payments to an in-network hospital under ORS 243.256(1) or (2) that exceed twice the total payments at the Medicare rate for the plan year, the fully-insured carrier will provide PEBB a credit to fully-insured premium rates equivalent to this difference.

(8) If a third-party administrator of a self-insured plan provides total fee-for-service payments to an out-of-network hospital under ORS 243.256(1) or (2) that exceed 1.85 times the total payments at the Medicare rate for the plan year, the self-insured third-party administrator will return the difference to PEBB. Moneys returned to PEBB under this rule will be deposited in the Public Employees’ Revolving Fund for purposes consistent with ORS 243.167.

(9) If a fully-insured carrier provides total fee-for-service payments to an out-of-network hospital under ORS 243.256(1) or (2) that exceed 1.85 times the total payments at the Medicare rate for the plan year, the fully-insured carrier will provide PEBB a credit to fully-insured premium rates equivalent to this difference.

(10) If a carrier or third-party administrator does not reimburse hospitals on a fee-for-service basis, it may pursue an alternative payment method that maintains total payments while taking into account the limits established in ORS 243.256 and described in this rule, including, but not limited to:

(a) value based payments,

(b) capitation payments and

(c) bundled payments. A carrier or third-party administrator using alternative payment methods must provide actuarial calculations that show the payment methods used adhere to the limits specified in ORS 243.256. Such alternative payment methods must be reported to PEBB as part of its benefit plan agreement with the carrier or third-party administrator. If payments under the alternative payment arrangement exceed the limits specified in ORS 243.256 the carrier or third-party administrator will return the difference to PEBB. Moneys returned to PEBB under this rule will be deposited in the Public Employees’ Revolving Fund for purposes consistent with ORS 243.167.

(11) For purposes of this rule, the “Medicare rate” is the amount of reimbursement for a claim that would be paid as if The Centers for Medicare and Medicaid Services (CMS) reimbursed the claim. Therefore, calculation of the maximum reimbursement amount for outpatient services applies the Medicare Ambulatory Payment Classification (APC) or Hospital Outpatient Prospective Payment System (OPPS), and calculation of the maximum reimbursement amount for inpatient services applies the Inpatient Prospective Patient System (IPPS). Claims submitted for reimbursement must include all CMS required modifiers so that all rebates, incentives, or adjustments that would have applied if reimbursed by Medicare would also apply. The "Medicare rate" as defined in this rule is used to determine the maximum reimbursement amount for each claim subject to ORS 243.256 and these rules and in no way prohibits a carrier or third-party administrator from establishing contracted claims reimbursement rates that are lower than the maximum reimbursement amount. This includes contracted claims reimbursement rates informed by Medicare Advantage rates, so long as contacted rates do not exceed the maximum reimbursement established in ORS 243.256 and this rule. Furthermore, this includes capturing data fields on claims for services or supplies that are necessary to determine the Medicare rate for the service or supply to the extent needed to ensure that the actual reimbursement amount does not exceed the maximum reimbursement amount established in ORS 243.256 and this rule.

History

Statutory/Other Authority: ORS 243.061 to ORS 243.302 & ORS 243.125(1)
Statutes/Other Implemented: ORS 243.256
PEBB 8-2020, amend filed 12/22/2020, effective 12/22/2020
PEBB 3-2020, temporary suspends temporary PEBB 1-2020, filed 04/17/2020, effective 04/17/2020 through 09/13/2020
PEBB 1-2020, temporary amend filed 03/18/2020, effective 03/18/2020 through 09/13/2020
PEBB 4-2019, adopt filed 10/21/2019, effective 10/22/2019

Or. Admin. R. 101-080-0020 Exempt Hospitals

(1) As specified in ORS 243.256, these payment limits do not apply to reimbursements paid by a carrier or third-party administrator to:

(a)Type A or type B hospitals (defined in ORS 442.470);

(b) Rural critical access hospitals (defined in ORS 315.613); or

(c)Hospitals that are located in a county with a population of less than 70,000 on August 15, 2017, classified as a sole community hospital by the Centers for Medicare and Medicaid Services, and have Medicare payments composing at least 40 percent of the hospital’s total annual patient revenue.

(2)(a) Total annual patient revenue for a hospital will be calculated using the Allowed Amount for all inpatient and outpatient claim records in the state’s All Payer All Claims (APAC) database for that hospital in a calendar year, and

(b) Total Medicare payments to a hospital will be calculated using the Allowed Amount for all inpatient and outpatient claim records paid by Medicare in the APAC for that hospital in a calendar year.

(3) PEBB will review the calculation under section (2) of this rule at least every three years using the most recent available data in APAC.

History

Statutory/Other Authority: ORS 243.061 to ORS 243.302 & ORS 243.125(1)
Statutes/Other Implemented: ORS 243.256
PEBB 8-2020, amend filed 12/22/2020, effective 12/22/2020
PEBB 4-2019, adopt filed 10/21/2019, effective 10/22/2019