145-4-03 Health care coverage.

(A) Dental, vision, and health care coverage for an eligible primary benefit recipient may be available upon application on a form provided by the public employees retirement system. A primary benefit recipient may enroll an eligible dependent as defined in rule 145-4-09 of the Administrative Code.

(B)

(1) Except as provided in this paragraph, applications for health care coverage must be received by the public employees retirement system not later than sixty days after the benefit recipient's initial benefit payment. During this sixty-day period, a recipient may make one change to the filed application. If the application is received more than sixty days after the benefit recipient's initial benefit payment or the benefit recipient fails to file an application within that period, the benefit recipient shall be treated as described in paragraph (E) of this rule.

(2) The system may accept and process an application received more than sixty days after the benefit recipient's initial benefit payment if either of the following occur:

(a) The system determines that a physical or mental incapacity prevented the benefit recipient from making application within the initial sixty day benefit period. The effective date of coverage shall be determined in accordance with rule 145-4-04 of the Administrative Code.

(b) The benefit recipient did not apply for coverage and later submits an application due to involuntary termination of coverage under another group plan. The benefit recipient shall submit the application within thirty-one days of the involuntary termination together with proof of such termination. If the application is received on or before the tenth day of a month, the coverage is effective on the first day of the month following receipt of the application. Otherwise, the coverage is effective on the first day of the second month following receipt of the application.

(C) Upon the recommendation of the actuary retained by the board, the board shall determine annually the portion of the self-supporting rate it shall pay for eligible benefit recipients and eligible dependents enrolled in health care coverage.

(D) An ineligible individual, as defined in rule 145-4-06 of the Administrative Code, may be enrolled in a health care plan administered by a third party health care administrator(s). Such ineligible individual shall pay all required premiums directly to the health care administrator in the time and manner prescribed by the third party health care administrator. Except to the extent required under paragraph (H) of this rule, the retirement system shall not be responsible for any premiums, claims, or withholding of premiums for such health care plan.

(E)

(1) An eligible benefit recipient may defer enrollment in health care coverage. The deferral applies to both the benefit recipient and the benefit recipient's dependents.

(2) A benefit recipient who is described in paragraph (E)(1) of this rule or who waived coverage under a version of this rule in effect prior to January 1, 2014, may enroll by filing an application for enrollment in health care coverage during one of the following:

(a) The annual open enrollment period for health care coverage, except that the deferral or waiver remains effective until January first of the next year;

(b) Within sixty days of involuntary termination of coverage under another group plan, and with proof of such termination, except that the deferral or waiver remains effective until the first day of the month following receipt if the application is received by the tenth day of the preceding month, otherwise the deferral or waiver remains effective until the first day of the second month following receipt of the application.

(F) An individual who is eligible for health care coverage from more than one benefit may not enroll for health care coverage simultaneously under more than one benefit.

(G)

(1) Regardless of the reason for eligibility, all enrolled benefit recipients and dependents shall enroll in medicare part B at the benefit recipient or eligible dependent's first eligible date.

(2) All enrolled benefit recipients and dependents shall enroll in medicare part A at the benefit recipient or eligible dependent's first eligible date if the benefit recipient or dependent can do so without payment of a premium for the coverage.

(3) For any period that a benefit recipient or dependent is eligible but fails to enroll in medicare part A or B as required by this paragraph, the health care claims paid by the retirement system shall be reduced by the coverage the individual should have received if enrolled in medicare part A or B.

(H) The retirement system shall offer continuation coverage, as applicable, in accordance with the requirements of the Consolidated Omnibus Budget and Reconciliation Act of 1985 ("COBRA"), 42 United States Code 300gg-1 .

(I) An enrolled benefit recipient's coverage shall be rescinded if the benefit recipient is convicted of falsification under section 2921.13 of the Revised Code regarding the health care coverage or performs an act, practice or omission that constitutes fraud or makes an intentional misrepresentation of material fact regarding the health care coverage. The effective date of the termination of coverage shall be the earlier of the date of the conviction or the act, practice or omission that constitutes fraud or an intentional misrepresentation of material fact, unless otherwise limited by Ohio law. The retirement system shall notify the benefit recipient of the rescission at least thirty days prior to processing the rescission. The rescission applies to all enrolled dependents and all coverage options.

Effective: 01/01/2014
R.C. 119.032 review dates: 09/26/2013 and 09/29/2018
Promulgated Under: 111.15
Statutory Authority: 145.09 , 145.58
Rule Amplifies: 145.58 , 145.584
Prior Effective Dates: 8/20/76, 12/9/88, 4/1/93, 6/29/96, 5/4/00, 10/9/00, 3/22/02, 8/8/02, 1/1/03, 4/15/04, 1/1/05, 1/1/07, 1/1/09, 1/1/11, 1/1/12, 9/7/12, 12/10/12, 1/7/13 (Emer.), 3/24/13