LAW
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Ohio Laws and Rules
(A) Employees eligible to participate in the state employee health benefit fund are permanent full-time and permanent part-time employees of the state of Ohio who are paid by warrant of the director of budget and management, and who normally have earnings every pay period, including elected and appointed officials. Employees are eligible to enroll during the first thirty-one days of employment for benefit coverage, excluding vision and dental. For vision and dental coverage, employees become eligible on the first day of the month following completion of one year of continuous employment with the state. Employees and eligible dependents are requested to voluntarily provide their social security number on the enrollment and health care forms in order to be properly enrolled.
(B) Employees who elect to participate in the state employee health benefit fund may also enroll their eligible dependents.
(1) Eligible dependents include:
(a) An employee’s spouse;
(b) Unmarried children from the time of birth until the end of the month in which such children attain the age of nineteen; and
(c) Unmarried children who have attained the age nineteen but have not reached the end of the month in which they attain age twenty-three and who reside with and are wholly dependent upon the employee for their maintenance and support.
(2) Eligible dependents also include unmarried children who are incapable of self-support because of mental retardation or physical disability that commences prior to the end of the month in which he or she attains the appropriate limiting age described in paragraph (B)(1) of this rule and are primarily dependent upon the employee for maintenance and support. Written proof of the child’s incapacity and primary dependency shall be furnished by the employee within thirty-one days of employment with the state or within thirty-one days after the child’s attainment of the appropriate limiting age. Upon request, but not more frequently than annually, satisfactory proof of the continuance of such incapacity and dependency shall be provided.
(3) The term “children” includes the employee’s own or legally adopted children; any stepchild or foster child who depends upon the employee for support and who normally resides in the employee’s household; children or stepchildren of divorced or separated parents when the children are not residing with the employee but required by law to be supported by the employee; children for whom the employee has been appointed legal guardian; or children attending an accredited school even though not residing at home as long as he or she meets the other dependency requirements. No person will be considered a dependent while in the armed forces.
(4) When a husband and wife are both state employees, each may elect single coverage or one of them may elect family coverage through the state’s primary plan or through a health maintenance organization. A child who is eligible as an employee of the state is not eligible as the dependent of a parent who is also a state employee.
(C) Effective dates of coverage are determined as follows:
(1) Benefit coverage for employees who enroll in the state employee health benefit fund within thirty-one days of their day of hire will be effective on the first day of the month following the date on which they enrolled.
(2) Dependent coverage will be effective concurrent with the employee’s coverage provided the employee elected to cover his or her dependents when enrolling. Covered employees have thirty-one days from the date they acquire their eligible dependent in which to enroll for dependent coverage, as provided in paragraph (F)(1) of this rule. Such coverage will take effect on the first day of the month following the date of enrollment.
(3) Vision and dental care coverage for employees and their eligible dependents will become effective on the first day of the month following the employee’s completion of one year of continuous employment with the state. When a covered employee acquires his first eligible dependent, the dependent’s coverage will be effective on the first day of the following month.
(D) The director shall establish employee contribution levels for the benefits provided by the state employee health benefit fund.
(E) An open enrollment period shall be established by the director of administrative services. During such period, eligible employees and their eligible dependents who are not covered by the state employee health benefit fund may enroll without imposition of any limitations or waiting periods. Coverage for those persons enrolling during an open enrollment period shall be effective on the first day of the second month following the open enrollment month. During the open enrollment period, employees will also have the right to exercise their dual choice option offered by the state of Ohio to its employees with respect to health maintenance organizations.
(F) In the following situations an employee may enroll in the state employee health benefit fund or increase coverage at a time other than during open enrollment.
(1) An employee with single coverage may change to family coverage, effective the first day of the month following the request, provided the request is within thirty-one days:
(a) After marriage;
(b) Prior to expected birth, or after the birth of child; or
(c) After the receipt of final papers of adoption or legal guardianship of a child.
(2) An employee who becomes divorced may enter the state employee health benefit fund effective the first day of the month following the date of the request provided the request is made within thirty-one days after the final divorce decree.
(3) A husband and wife who are both state employees may change their coverage as follows:
(a) From two single coverages to one-family coverage in either name;
(b) From family coverage in the name of one spouse to the name of the other spouse;
(c) From family coverage in either name to single coverage for both.
(4) An employee covered by his or her spouse’s employer’s group insurance plan may enter the state employee health benefit fund within thirty-one days of termination of the spouse’s coverage when the spouse dies, is laid off, resigns, or is removed involuntarily.
(5) An employee may change from family coverage to single coverage at any time.
(6) An employee covered by a health maintenance organization (HMO) who changes residence from the service area of the HMO may change coverage to the state employee health benefit fund if application is made within thirty-one days of the change in residence.
(7) An employee who has been on an approved leave of absence and did not continue health care coverage may enter the state employee health benefit fund effective on the first day of the month following the date of the request, provided the request is within thirty-one days of the return to work.
(G) Employees and dependents will cease to be covered by the fund as of the end of the last day of the month in which any of the following events occur: (1) termination of state employment by the employee; (2) withdrawal of the employee from the fund by means of written notice from the employee to the employee’s appointing authority indicating the employee’s desire to withdraw from the fund; or (3) cessation of the employee’s contributions to the fund. In the event of transfer of coverage to a health maintenance organization following an open enrollment period, coverage under the fund will cease immediately prior to coverage beginning under the health maintenance organization. Employees covered by the state employee health benefit fund, whose participation in the fund is terminated, may be eligible for conversion to coverage on a direct payment basis provided by the administrator.
(H) The department of administrative services shall determine eligibility of all employees and dependents, and termination of coverage.
(I) The director shall determine the health, vision, medical hospital, dental, surgical and major medical benefits and any deductibles, co-payments, conditions or limitations of such benefits to be provided for employees covered by the state employee health benefit fund, and to make such changes to the benefits from time to time as may be required to reasonably provide health care for such employees and dependents with funds available for such purposes.
Effective: 12/01/2006
R.C. 119.032 review dates: 09/14/2006 and 12/01/2011
Promulgated Under: 119.03
Statutory Authority: 124.09(A)
Rule Amplifies: 124.87
Prior Effective Dates: 3/18/82, 5/18/87 (Emer.), 8/2/87, 8/22/88 (Emer.), 11/13/88, 2/4/96, 7/1/97, 9/28/97, 5/24/98