Chapter 3307:1-11 Health Care Services

3307:1-11-01 Health care services - establishment of program and definitions.

(A) Pursuant to sections 3307.39 and 3307.391 of the Revised Code, a health care program is hereby established for certain service retirement and disability benefit recipients and certain dependents of those benefit recipients who meet the conditions of eligibility specified by this chapter of the Administrative Code and the conditions of eligibility for participation in any medical or ancillary plan offered.

(B) The health care program shall consist of such medical plans and ancillary plans as the retirement board may from time-to-time offer. The retirement board shall review the medical and ancillary plans offered at least every two years.

(C) As used in this chapter of the Administrative Code:

(1) "Ancillary plan" shall mean a plan offering auxiliary coverage, such as dental or vision coverage.

(2) "Child" shall mean a biological child, lawfully adopted child or stepchild of a member, of a primary service retirement benefit recipient, or of a disability benefit recipient or a child for whom a member, a primary service retirement benefit recipient, or disability benefit recipient has been legally appointed as guardian, provided that such child has not yet attained age twenty-six.

(3) "Dependent" shall mean a spouse, child, or sponsored dependent as defined in this rule.

(4) "Disabled adult child" shall mean any biological child, child lawfully adopted prior to age eighteen, stepchild of a deceased member, primary service retirement benefit recipient or disability benefit recipient or a child for which a deceased member, primary service retirement benefit recipient or disability benefit recipient has been legally appointed as guardian prior to age eighteen and who is permanently and totally disabled. To determine an adult child meets and continues to meet the requirements in paragraph (C)(4)(b) or (C)(4)(c) of this rule, the same procedure for the determination of "physical or mental incompetency" as outlined in paragraph (I) of rule 3307:1-8-01 of the Administrative Code for survivor benefit eligibility shall be followed. The disabled adult child shall also meet one of the following requirements:

(a) Has never married and has been adjudged physically or mentally incompetent by a court prior to age eighteen or age twenty-two if the child was attending school on at least a two-thirds full-time basis and the child's physical or mental incompetency has been continuous since the court's initial adjudication, or

(b) Has never married and has attained age twenty-six and has been unable to earn a living because of a mental or physical condition that was disabling prior to age eighteen or age twenty-two if the child was attending school on at least a two-thirds full-time basis, provided the disabled adult child has been continuously disabled and unable to earn a living from the initial date that the disabled adult child was determined to have a mental or physical condition that was disabling. The chair of the medical review board shall determine that the child has a mental or physical condition that incapacitated the child before the maximum age specified in this paragraph. As used herein, "unable to earning a living" means that a child was incapable of earning at least sixteen thousand dollars a year for any year before January 1, 2008, and was incapable of earning for each year since January 1, 2008, the federal minium wage as of January first for each year multiplied by two thousand eighty hours, increased by fifty per cent and rounded to the nearest thousand dollars for each year thereafter , or

(c) Has never married, has attained age twenty-six and attends an adult workshop or school for the developmentally disabled operated by a county or state department of developmental disabilities. If attendance has not been continuous since age eighteen or age twenty-two if the child was attending school on at least a two-thirds full-time basis, additional earnings verification may be required in accordance with paragraph (C)(4)(b) of this rule.

(5) "Medical plan" shall mean a plan offering health, medical, hospital, or prescription drug coverage or any combination thereof.

(6) "Plan enrollee" means any individual described in rule 3307:1-11-02 of the Administrative Code who participates in the medical or ancillary plans offered by the retirement system.

(7) "Primary service retirement benefit recipient" shall mean a member who applied for and was granted service retirement benefits under the plan described in sections 3307.50 to 3307.79 of the Revised Code or a plan established under section 3307.81 of the Revised Code that provides health care coverage.

(8) "Retiree," "Service retiree," "Service benefit recipient," "service retirement benefit recipient," and "recipient of a service retirement benefit" shall mean a member who applied for and was granted service retirement benefits under the plan described in sections 3307.50 to 3307.79 of the Revised Code or a plan established under section 3307.81 of the Revised Code.

(9) "Sponsored dependent" includes:

(a) A disabled adult child living in the residence of a primary service retirement benefit recipient, or disability benefit recipient, or in a convalescent center or any other type of institution that retains a disabled adult child temporarily;

(b) A disabled adult child not living in the home of a primary service retirement benefit or disability benefit recipient, but receiving one-half or more support from the primary service retirement benefit recipient or disability benefit recipient, as demonstrated by completion of a financial status form provided by the retirement system or the most recent federal income tax return;

(c) One person age twenty-six or older living in the home of an unmarried primary service retirement benefit recipient or disability benefit recipient or in a convalescent center or any other type of institution that retains a person temporarily, notwithstanding that the primary service retirement benefit recipient or disability benefit recipient does not claim the sponsored dependent as a financial dependent for federal income tax purposes.

(10) "Total service credit" shall be as defined by section 3307.50 of the Revised Code, and as used in this chapter such credit shall not include any credit purchased under former section 3307.741 of the Revised Code but shall include credit purchased under sections 145.297 , 145.298 , 3307.54 (as it existed until July 31, 2014), and 3309.33 of the Revised Code.

(D) A primary service retirement benefit recipient or disability benefit recipient shall provide any information requested by the retirement system to validate the eligibility of a disabled adult child in any medical or ancillary plan offered by the retirement system.

Effective: 02/10/2014
R.C. 119.032 review dates: 11/26/2013 and 06/01/2016
Promulgated Under: 111.15
Statutory Authority: 3307.04
Rule Amplifies: 3307.39 , 3307.391
Prior Effective Dates: 12/23/76, 11/28/77, 3/17/89 (Emer.), 6/1/89, 9/23/91 (Emer.), 5/28/92, 6/22/92 (Emer.), 9/10/92, 2/13/93, 9/1/96, 7/3/97, 9/16/98 (Emer.), 11/27/98, 5/25/00, 7/1/01 (Emer.), 9/17/01, 1/1/04 (Emer.), 3/22/04, 8/9/07, 5/14/09, 10/28/10, 1/1/13, 1/1/14 (Emer)

3307:1-11-02 Health care services - eligibility.

Subject to the requirements of Chapter 3307:1-11 of the Administrative Code and the specific requirements of the various plans that may be offered, the following shall be eligible to participate in the medical and ancillary plans offered by the retirement system:

(A) A primary service retirement benefit recipient whose benefit effective date is prior to January 1, 2004.

(B) A primary service retirement benefit recipient with fifteen or more years of total service credit whose benefit effective date is January 1, 2004 or later.

(C) A disability benefit recipient.

(D) A primary service retirement benefit recipient who was receiving disability benefits and whose benefit effective date is prior to January 1, 2004 and who began receiving service retirement benefits with no break in receipt of monthly benefits following the termination of disability benefits. Service credit used to determine health care eligibility shall be the total service credit used in the calculation of service retirement benefits, which shall not include service credit purchased under section 3307.741 of the Revised Code.

(E) A primary service retirement benefit recipient who was receiving disability benefits; whose benefit effective date is January 1, 2004 or later; and who began receiving service retirement benefits with no break in receipt of monthly benefits following the termination of disability benefits, provided the benefit recipient has fifteen or more years of total service credit. Service credit used to determine health care eligibility shall be the total service credit used in the calculation of service retirement benefits, which shall not include service credit purchased under section 3307.741 of the Revised Code.

(F) A person receiving benefits under a joint and survivor annuity or annuity certain plan of payment described in section 3307.60 of the Revised Code who was eligible for coverage as a dependent of the primary service retirement benefit recipient at the time of the primary service retirement benefit recipient's death, provided:

(1) The effective date of the person's monthly benefits is before January 1, 2004; or

(2) The effective date of the person's monthly benefits is January 1, 2004 or later and the primary service retirement benefit recipient had fifteen or more years of total service credit at the time of retirement.

(G) A person granted survivor benefits under division (C)(2) of section 3307.66 of the Revised Code who was eligible for coverage as a dependent at the time of the member's or disability benefit recipient's death.

(H) A person granted survivor benefits under division (C)(1) of section 3307.66 of the Revised Code who was eligible for coverage as a dependent at the time of the member's or disability benefit recipient's death, provided:

(1) The effective date of survivor benefits or the effective date of disability benefits of the deceased member is before January 1, 2004; or

(2) The effective date of survivor benefits is January 1, 2004 or later and the deceased member had fifteen or more years of total service credit at the time of death.

(I) Dependents of the primary service retirement benefit recipients and disability benefit recipients described in paragraphs (A) to (E) of this rule, including children born after the effective date of a benefit, and to the extent that a medical or ancillary plan allows coverage for sponsored dependents.

(J) Effective January 1, 2009, a plan enrollee, who is not eligible for Medicare part B is not eligible for primary coverage in a medical plan offered pursuant to section 3307.39 of the Revised Code if the plan enrollee is employed and has access to a medical plan with prescription coverage available through the employer or if employees of that employer in comparable positions have access to a medical plan available through the employer provided the medical plan with prescription coverage available through the employer is equivalent to the medical plan with prescription coverage at the cost available to full-time employees as defined by the employer. As used in this rule, "employer" means a public or private entity that acts as an employer and is not limited to an "employer" as defined in section 3307.01 of the Revised Code.

(1) Any secondary coverage provided by a medical plan offered by the retirement system pursuant to section 3307.39 of the Revised Code to a plan enrollee subject to paragraph (J) of this rule shall apply only to those medical expenses not paid by the medical plan with prescription coverage available through the employer and which are covered in the medical plan offered by the retirement system under section 3307.39 of the Revised Code.

(2) The board may require each plan enrollee to annually file a statement disclosing the availability of a medical plan with prescription coverage available through the employer with the board or its designee. The statement shall include the name of the employer, the medical plan available through the employer and such other information that may be required. If a plan enrollee does not enroll in the medical plan available through an employer when it becomes available to a plan enrollee, no medical plan coverage will be provided by the retirement system while the individual was eligible for available employer coverage.

Effective: 02/10/2014
R.C. 119.032 review dates: 11/26/2013 and 06/01/2016
Promulgated Under: 111.15
Statutory Authority: 3307.04
Rule Amplifies: 3307.39 , 3307.61
Prior Effective Dates: 12/23/76, 11/28/77, 3/17/89(Emer.), 6/1/89, 9/23/91 (Emer.), 5/28/92, 6/22/1992 (Emer.), 9/10/92, 2/13/93, 9/1/96, 7/3/97, 9/16/98 (Emer.), 11/27/98, 5/25/00, 7/1/01 (Emer.), 9/27/01, 1/1/04 (Emer.), 3/22/04, 1/08/07, 12/6/07, 5/14/09, 8/12/10 (Emer.), 10/28/10, 1/1/13, 1/1/14 (Emer)

3307:1-11-03 Health care services - cost.

(A) A plan enrollee's cost to participate in the health care program will be determined as follows:

(1) Costs shall be based upon service credit, the effective date of benefits, and such other factors as the retirement board may find relevant. Except as provided in paragraph (A)(3)(c) of this rule, service credit used in calculating a plan enrollee's cost shall be the service credit used in the calculation of service retirement benefits . The retirement board shall annually review costs and premiums charged for participation in the health care program and shall establish a schedule for determining or calculating plan enrollee costs and premiums.

(2) Enrolled benefit recipients shall pay all costs or premiums through benefit deduction unless the amount of a benefit will not cover such costs. In that case, the benefit recipient will be billed directly by the retirement system for any balance remaining through invoices for an initial period not to exceed three months and then by monthly electronic debit of the balance owed. It will be the sole responsibility of the benefit recipient to provide and maintain the information and available funds required for the retirement system to complete the monthly electronic debit. Should the retirement system be unable to debit the payment electronically after the initial three month period, enrollment in the health care program may be terminated. In all events, if payment is not received on or before the first business day of the month the premium is due, enrollment in the health care program may be terminated.

(3) The retirement board will not waive any portion of the cost for:

(a) Service benefit recipients with less than fifteen years of total service credit with an effective date of benefits before January 1, 2004.

(b) Spouses or dependents of service and disability benefit recipients.

(c) Any service benefit recipient who retires or who makes application to retire on or after March 17, 1989 and who has purchased service credit under former section 3307.741 of the Revised Code in order to become eligible for benefits under section 3307.58 of the Revised Code.

Until such time as the service benefit recipient is eligible for benefits under section 3307.58 of the Revised Code without regard to service credit purchased under such section, the benefit recipient and all eligible dependents are eligible for participation in the health care program only by paying all premium and associated costs. At such time as the benefit recipient would be eligible for service retirement benefits under section 3307.58 of the Revised Code without regard to service credit purchased under such section, the retirement board may waive a portion of the cost for a benefit recipient with fifteen or more years of total service credit.

(4) If any person is receiving benefits under a joint and survivor annuity or annuity certain plan of payment described in section 3307.60 of the Revised Code and the effective date of the retiree's monthly benefits is:

(a) Before January 1, 2004, for the later of five years from January 1, 2004 or the effective date of benefits to a service retiree's beneficiary that begins no later than December 1, 2014, costs for the beneficiary and dependents shall be calculated based upon the retiree's years of service and other factors as the retirement board may find relevant. After the five year subsidy period, the retirement board will not waive any portion of the cost. The retirement board will not waive any portion of the cost for a service retiree's beneficiary whose effective date of benefits is on or after January 1, 2015.

(b) On or after January 1, 2004, the retiree must have had fifteen or more years of service credit and the effective date of benefits to a service retiree's beneficiary must begin no later than December 1, 2014, for the service retiree's beneficiary and dependents to qualify for the five year subsidy period. In the event the retiree named multiple beneficiaries under division (A)(4) of section 3307.60 of the Revised Code, the percent subsidy for which the retiree was eligible will be allocated equally among the surviving beneficiaries for the five year subsidy period. After the five year subsidy period, the retirement board will not waive any portion of the cost. The retirement board will not waive any portion of the cost for a service retiree's beneficiary whose effective date of benefits is on or after January 1, 2015.

(c) On or after January 1, 2015, the retirement board will not waive any portion of the cost for a service retiree's beneficiary.

(5) If any person has been granted survivor benefits under division (C)(1) of section 3307.66 of the Revised Code and the effective date of survivor benefits is:

(a) On or after January 1, 2004 and before January 1, 2015, the member must have had fifteen or more years of total service credit for the survivor benefit recipient to qualify for the five year subsidy period unless the member was receiving disability benefits pursuant to section 3307.62 of the Revised Code at the time of death. If the member was a disability recipient at the time of death, the effective date of disability benefits is used for determining whether the member had fifteen or more years of total service credit for the survivor benefit recipient to qualify for the five year subsidy period.

(b) On or after January 1, 2015, the retirement board will not waive any portion of the cost.

(6) If any person has been granted survivor benefits under division (C)(2) of section 3307.66 of the Revised Code before January 1, 2015:

(a) For the later of five years from January 1, 2004 or the effective date of survivor benefits, costs for the survivor benefit recipients and dependents shall be calculated based upon the greater of the member's years of total service credit or fifteen years and other factors as the retirement board may find relevant. After the five year subsidy period, the retirement board will not waive any portion of the cost.

(b) On or after January 1, 2015, the retirement board will not waive any portion of the cost.

(B) A plan enrollee's cost to participate in an ancillary plan shall be the full cost of coverage as specified by the retirement board.

Effective: 09/04/2014
R.C. 119.032 review dates: 06/01/2016
Promulgated Under: 111.15
Statutory Authority: 3307.04
Rule Amplifies: 3307.39 , 3307.61
Prior Effective Dates: 12/23/76, 11/28/77, 3/17/89 (Emer.), 6/1/89, 9/23/91
(Emer.), 5/28/92, 6/22/92 (Emer.), 9/10/92, 2/13/93, 9/1/96, 7/3/97, 9/16/98 (Emer.), 11/27/98, 5/25/00, 7/1/01 (Emer.), 9/17/01, 9/17/02, 1/1/04 (Emer.), 3/22/04, 10/27/06, 1/6/08, 5/14/09, 1/1/14 (Emer.), 2/10/14

3307:1-11-04 Health care services - effective date.

(A) The effective date of coverage in medical and ancillary plans for plan enrollees shall be determined and is limited as follows:

(1) Initial enrollment: When a monthly benefit payment begins, medical and ancillary coverage shall begin as follows:

(a) Service retirement benefit recipients:

(i) On the benefit effective date when the service retirement application is received on or before the benefit effective date, provided the benefit recipient enrolls by the end of the month of the benefit effective date.

(ii) On the first day of the month following the date the service retirement application is received when the benefit effective date is prior to the date the service retirement application is received, provided the benefit recipient enrolls by the end of the month following the month the service retirement application is received.

(b) Disability benefit recipients:

(i) On the benefit effective date when the disability benefit recipient is granted disability benefits on or before the benefit effective date, provided the disability benefit recipient enrolls by the end of the month of the benefit effective date.

(ii) On the first day of the month following the date the disability benefit is granted when the benefit effective date is prior to the date the disability benefit is granted, provided the disability benefit recipient enrolls by the end of the month following the month the disability benefit is granted.

(c) Survivor benefit recipients:

On the benefit effective date when a survivor benefit recipient enrolls by the end of the third month following the month of the member's or disability benefits recipient's death.

(d) Service retiree beneficiary benefit recipients:

(i) On the first of the month following the month of the retiree's death, provided a service retiree beneficiary who was not enrolled as a dependent of a retiree at the time of the retiree's death enrolls by the end of the third month following the month of the retiree's death.

(ii) On the first of the month following the month of the retiree's death when a service retiree beneficiary was enrolled as a retiree's dependent at the time of the retiree's death.

(2) Subsequent enrollment: Coverage shall begin as follows if a benefit recipient does not enroll as permitted under paragraph (A)(1) of this rule and later applies to enroll:

(a) Open enrollment: Coverage will begin on the first day of the next plan year following an open enrollment period specified by the retirement system.

(b) Special enrollment: Except as otherwise specified in this paragraph, coverage will begin on the first of the month following any one of the following qualifying events if the application to enroll is received within thirty-one days of the qualifying event and approved by the retirement system:

(i) Termination of other coverage.

(ii) Coverage for a new spouse of a service retirement benefit recipient or disability benefit recipient.

(iii) Coverage for a biological newborn or lawfully adopted child or stepchild, which will begin on the day of birth or adoption.

Replaces: 330:1-11-04

Effective: 02/10/2014
R.C. 119.032 review dates: 06/01/2016
Promulgated Under: 111.15
Statutory Authority: 3307.04
Rule Amplifies: 3307.39 , 3307.391
Prior Effective Dates: 12/23/76, 11/28/77, 3/17/89 (Emer.), 6/1/89, 9/23/91 (Emer.), 5/28/92, 6/22/92 (Emer.), 9/10/92, 2/13/93, 9/1/96, 7/3/97, 9/16/98 (Emer.), 11/27/98, 5/25/00, 7/1/01 (Emer.), 9/17/01, 7/1/06, 10/28/10, 6/6/11, 1/1/14 (Emer)

3307:1-11-05 Health care services - medicare part B reimbursement.

(A) Pursuant to section 3307.39 of the Revised Code, each recipient of a service retirement, disability or survivor benefit under the STRS defined benefit plan who qualifies to enroll in medicare part B shall be eligible for reimbursement for a portion of the cost of the basic medicare part B premium provided the benefit recipient provides the board with certification of participation in the medicare part B insurance program. Each benefit recipient who qualifies for medicare part B shall certify such participation. The board shall establish eligibility for medicare part B reimbursement and make reimbursement effective the first of the month following receipt of proper certification and such reimbursement shall be based upon service credit and an amount determined by the board, provided the reimbursement amount shall not be less than twenty-nine dollars and ninety cents nor more than ninety per cent of the basic medicare part B premium. Certification of a survivor's medicare part B received within three months of the member's death shall be deemed as being received in the month of the member's death. Beginning January 1, 2015, medicare part B reimbursement shall only be provided if the recipient of a service retirement, disability or survivor benefit is enrolled in a medical plan offered pursuant to section 3307.39 of the Revised Code. A person who begins receiving survivor benefits under section 3307.66 of the Revised Code on or after January 1, 2015 is not eligible to receive medicare part B reimbursement.

(B) If a service retirement benefit recipient dies and the benefit recipient had selected a joint and survivor annuity or annuity certain plan of payment to provide benefits continuing after the recipient's death to more than one beneficiary pursuant to division (A)(4) of section 3307.60 of the Revised Code, the monthly reimbursement amount for medicare part B for which the benefit recipient was eligible shall be divided equally among all beneficiaries and shall only be paid to a beneficiary if he or she becomes eligible for medicare part B for the period as specified in paragraph (C) of this rule.

(C) Each beneficiary eligible under rule 3307:1-11-02 of the Administrative Code who is receiving a continuing monthly benefit under a joint and survivor annuity or annuity certain plan of payment described in section 3307.60 of the Revised Code, who qualifies to enroll in medicare part B, and who, on or after January 1, 2015 is enrolled in a medical plan offered pursuant to section 3307.39 of the Revised Code shall be eligible for reimbursement for a portion of the cost of the medicare part B premium provided the beneficiary provides the board with certification of participation in the medicare part B insurance program. Each beneficiary who qualifies for medicare part B in the future shall certify such participation. For the time periods outlined in paragraphs (C)(1), (C)(2) and (C)(3) of this rule, the board shall establish eligibility for medicare part B reimbursement and make reimbursement effective the first of the month following receipt of proper certification and such reimbursement shall be based upon service credit and an amount determined by the board. The reimbursement amount shall not be less than twenty-nine dollars and ninety cents nor more than ninety per cent of the basic medicare part B premium, except as provided in paragraph (B) of this rule. Certification of a beneficiary's medicare part B received within three months of the retiree's death shall be deemed as being received in the month of the retiree's death. Reimbursement shall be paid to beneficiaries for the period of time as follows:

(1) The board shall make reimbursement for a portion of the cost of medicare part B to a beneficiary or beneficiaries who are receiving continuing monthly benefits under a joint and survivor annuity or annuity certain plan of payment described in section 3307.60 of the Revised Code and who are qualified to enroll in the medicare part B insurance program before January 1, 2008.

(2) When monthly benefits are paid to a beneficiary or beneficiaries who was named by a primary service retirement benefit recipient before January 1, 2008 under a joint and survivor annuity or annuity certain plan of payment described in section 3307.60 of the Revised Code and who begins receiving continuing benefits no later than December 1, 2014 , the board shall make reimbursement for a portion of the cost of medicare part B only to a beneficiary or beneficiaries who qualified to enroll in the medicare part B insurance program before January 1, 2008.

(3) The board shall make reimbursement for a portion of the cost of medicare part B for a five-year period starting January 1, 2008 to all beneficiaries who began receiving continuing monthly benefits under a joint and survivor annuity or annuity certain plan of payment described in section 3307.60 of the Revised Code prior to January 1, 2008, and who are not covered by paragraph (C)(1) of this rule. During the five-year time period, reimbursement shall only be paid for the period of time the beneficiary qualifies for such reimbursement pursuant to paragraph (C) of this rule. After the five-year period, the board shall not provide any reimbursement and the beneficiary or beneficiaries shall be responsible for the full cost of the medicare part B premium.

For beneficiaries who begin receiving continuing benefits under a joint and survivor annuity or annuity certain plan of payment described insection 3307.60 of the Revised Code effective January 1, 2008, but no later than December 1, 2014 , and are not covered by paragraph (C)(2) of this rule, the board shall make reimbursement for a portion of the cost of medicare part B for a five-year period beginning the later of January 1, 2008, or the beneficiary's effective date of receipt of the continuing benefit. During the five-year time period, reimbursement shall only be paid for the period of time the beneficiary qualifies for such reimbursement pursuant to paragraph (C) of this rule. After the five-year period, the board shall not provide any reimbursement and the beneficiary or beneficiaries shall be responsible for the full cost of the medicare part B premium.

(4) The board shall make no reimbursement for the cost of medicare part B to any beneficiary or beneficiaries who do not otherwise qualify as outlined in paragraph (C) of this rule.

(D) The recipient or beneficiary shall certify the amount paid by the recipient or beneficiary for medicare part B coverage, and no reimbursement amount provided under this rule shall exceed the amount paid by the recipient or beneficiary.

(E) For purposes of section 3307.39 of the Revised Code and this rule, "basic medicare part B premium" mean the amount of the standard monthly premium for individuals enrolled in medicare part B coverage as determined by the secretary of health and human services before any adjustments made to the premium, such as an increase in premium for late enrollment or an increase in premium due to a reduction in the premium subsidy based on income.

Effective: 09/04/2014
R.C. 119.032 review dates: 06/01/2016
Promulgated Under: 111.15
Statutory Authority: 3307.04
Rule Amplifies: 3307.39
Prior Effective Dates: 12/23/76, 11/28/1977, 3/17/89 (Emer.), 6/1/89, 9/23/91 (Emer.), 5/28/92, 6/22/92 (Emer.), 9/10/92, 2/13/93, 9/1/96, 7/3/97, 9/16/98 (Emer.), 11/27/98, 5/25/00, 7/1/01 (Emer.), 9/17/01, 1/1/04 (Emer.), 3/22/04, 9/30/04, 11/9/06, 1/1/07 (Emer.), 4/1/07, 3/27/14

3307:1-11-06 Health care services - open enrollment and plan changes.

(A) The state teachers retirement system may annually offer an open-enrollment period during which eligible benefit recipients may enroll or change medical plans for themselves and eligible dependents.

(B) The medical plan option selected by the eligible benefit recipient during open enrollment cannot be changed for the next calendar year, with the following exceptions:

(1) A change in plan administrators, plan levels or both may occur if any of the following conditions are met:

(a) The plan enrollee requests the change within three months before or after the effective date of medicare benefits.

(b) The plan enrollee requests the changes within thirty-one days of receiving a first full monthly benefit.

(c) The plan enrollee is enrolled in a medicare health maintenance organization (HMO) and requests the change at any time.

(d) The plan enrollee requests the change within thirty-one days of one of the following qualifying events:

(i) Marriage

(ii) Birth, adoption, placement for adoption or legal guardianship of a child

(iii) Death

(iv) Divorce or dissolution

(v) Legal separation

(vi) Full loss of premium subsidy

(vii) Termination of other coverage, or

(viii) Upon initial eligibility and enrollment into medicare parts A and B or part B only.

(e) The plan enrollee who enrolls as the beneficiary of a service retirement benefit recipient and who was enrolled as a dependent at the time of the service retirement benefit recipient's death requests a change of plans or plan administrators by the end of the third month following the month of the service retirement benefit recipient's death.

(2) A plan enrollee may change plan administrators only if the following occur:

(a) The plan enrollee is enrolled in a commercial health maintenance organization (HMO) or preferred provider organization (PPO) and experiences a loss of a key provider from the network.

(b) The plan enrollee moves to another service area, which results in different state teachers retirement system sponsored medical care plans being available.

(c) The plan enrollee wants to add a sponsored dependent to his or her coverage and the medical plan he or she is enrolled in does not allow sponsored dependents.

Effective: 09/04/2014
R.C. 119.032 review dates: 06/01/2016
Promulgated Under: 111.15
Statutory Authority: 3307.04
Rule Amplifies: 3307.39
Prior Effective Dates: 12/23/76, 11/28/77, 3/17/89 (Emer.), 6/1/1989, 9/23/91 (Emer.), 5/28/92, 6/22/92 (Emer.), 9/10/92, 2/13/93, 9/1/96, 7/3/97, 9/16/98 (Emer.), 11/27/98, 5/25/00, 7/1/01 (Emer.), 1/1/04 (Emer.), 3/22/04, 5/14/09, 6/12/14

3307:1-11-07 Health care services - health information.

(A) By applying for and accepting participation in any medical plan, ancillary plan, supporting program or other health care plan of any type established and offered by the state teachers retirement board (the "health care program") each participating benefit recipient and enrollee, on behalf of herself or himself and each of their dependents covered under the health care program, acknowledges and agrees that the health care program may use or disclose all individually identifiable health information (as defined at 45 C.F.R. 160.103 ) pertaining to such participating benefit recipient, enrollee or dependent in the health care program for the payment (as defined at 45 C.F.R. 164.501 ) and health care operations (as defined at 45 C.F.R. 164.501 ) purposes of the health care program and otherwise use or disclose such individually identifiable health information as permitted by and under the "Standards for Privacy of Individually Identifiable Health Information," 45 C.F.R. 160 and 45 C.F.R. 164.

(B) The health care program, acting through the retirement board, shall require each person who as to the health care program constitutes a "business associate" (as defined at 45 C.F.R. 160.103 ) of the health care program to maintain the confidentiality of individually identifiable health information that it creates, maintains or receives on behalf of or from the health care program and to enter into a written agreement with the health care program which meets that standard for business associate contracts as specified at 45 C.F.R. 164.504(e) . Individually identifiable health information that meets the requirements for deidentification of health information, as specified in 45 C.F.R. 164 may be used without limitation by the health care program and shall be and shall remain the property of the retirement system.

Effective: 06/06/2011
R.C. 119.032 review dates: 03/22/2011 and 05/27/2016
Promulgated Under: 111.15
Statutory Authority: 3307.04
Rule Amplifies: 3307.39 , 3307.391
Prior Effective Dates: 12/23/76, 11/28/77, 3/17/89 (Emer.), 6/1/89, 9/23/91 (Emer.), 5/28/92, 6/22/92 (Emer.), 9/10/92, 2/13/93, 9/1/96, 7/3/97, 9/16/98 (Emer.), 11/27/98, 5/25/00, 7/1/01 (Emer.), 9/17/01, 7/1/06

3307:1-11-08 Health care services - notice.

(A) Enrolled benefit recipients will be notified in writing at least thirty days in advance of any change in coverage under the medical and ancillary plans.

(B) Benefit recipients will be notified in writing of any changes in the cost of their coverage at least sixty days prior to the effective date of a change.

(C) Notice, as required by any provision of this rule, shall be deemed sufficient, if notice is communicated by regular United States postal service to the benefit recipient at the last known address of the benefit recipient as maintained in the records of the retirement system.

R.C. 119.032 review dates: 03/22/2011 and 03/22/2016
Promulgated Under: 111.15
Statutory Authority: 3307.04
Rule Amplifies: 3307.39 , 3307.391
Prior Effective Dates: 12/23/76, 11/28/77, 3/17/89 (Emer.), 6/1/89, 9/23/91 (Emer.), 5/28/92, 6/22/92 (Emer.), 9/10/92, 2/13/93, 9/1/96, 7/3/97, 9/16/98 (Emer.), 11/27/98, 5/25/00, 7/1/01 (Emer.), 9/17/02, 7/1/06

3307:1-11-09 Long-term care coverage.

(A) Members of the state teachers retirement system may make application to participate in contracts for long-term care coverage offered pursuant to section 3307.391 of the Revised Code, provided:

(1) Application for coverage shall be made directly to the insurer during enrollment periods specified by the state teachers retirement system;

(2) Determination of eligibility for participation under the terms of any such contract shall be made by the insurer; and

(3) Payment for coverage shall be made by the member to the insurer in such amounts and by such methods approved by the state teachers retirement system.

(B) The recipient of any benefit may make application to participate in any such contracts for long-term care coverage, subject to the same conditions as those applicable to members under the terms of paragraph (A) of this rule.

(C) Any individual as defined as eligible under the state teachers retirement system's group policy who has made proper application pursuant to paragraph (A) or (B) of this rule may apply for coverage subject to the same conditions as those applicable to members under the terms of paragraph (A) of this rule, provided that in the case of a spouse, the individual participating pursuant to paragraph (A) or (B) of this rule agrees to remit the cost of such coverage along with his or her own payment.

Effective: 06/06/2011
R.C. 119.032 review dates: 03/22/2011 and 05/27/2016
Promulgated Under: 111.15
Statutory Authority: 3307.04
Rule Amplifies: 3307.39 , 3307.391
Prior Effective Dates: 10/29/91 (Emer.), 1/27/92, 7/1/01 (Emer.), 9/17/01, 7/1/06

3307:1-11-10 Responsibility for health care coverage.

(A) For the purpose of this rule:

(1) "Age and service retirant" means a former member who is receiving a retirement allowance pursuant to section 3307.57 , 3307.58 , 3307.59 or 3307.60 of the Revised Code.

(2) "Cost paid by the benefit recipient" means the amount equal to the percentage as of January 1, 1998 paid by the benefit recipient multiplied by the system's cost per benefit recipient.

(3) "Dependent" means an eligible spouse or child of an eligible benefit recipient.

(4) "Disability benefit recipient" means a member who is receiving a disability benefit or allowance pursuant to section of 3307.57 , 3307.63 , or 3307.631 of the Revised Code.

(5) "Effective benefit date" means the date upon which a benefit payment begins.

(6) "Eligible benefit recipient" means an age and service retirant, disability benefit recipient or survivor benefit recipient who is eligible for health care coverage under this system and another Ohio retirement system.

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

(8) "Ohio retirement system" means public employees retirement system, state teachers retirement system, school employees retirement system, Ohio police and fire pension fund or highway patrol retirement system.

(9) "Survivor benefit recipient" means a beneficiary receiving a benefit pursuant to section 3307.60 or 3307.66 of the Revised Code.

(B) Except as otherwise provided in this rule, this retirement system shall be the system responsible for health care coverage for eligible benefit recipients who receive a benefit or allowance from this system.

(C) This retirement system shall not be the system responsible for health care coverage for eligible benefit recipients in the following situations.

(1) Where an eligible benefit recipient who is an age and service retirant of this system also is an eligible benefit recipient receiving an age and service benefit from another Ohio retirement system and the effective benefit date in this system is later than the effective benefit date in the other system.

(2)

(a) Where an eligible benefit recipient who is a disability benefit recipient of this system also is an eligible benefit recipient receiving an age and service benefit from another Ohio retirement system.

(b) Where an eligible benefit recipient who is a survivor benefit recipient of this system also is an eligible benefit recipient receiving an age and service benefit or a disability benefit from another Ohio retirement system.

(3) Where an eligible benefit recipient who is a disability benefit recipient of this system also is an eligible benefit recipient receiving a disability benefit from another Ohio retirement system and the effective benefit date of the benefit from this system is later than the effective benefit date in the other system.

(4) Where an eligible benefit recipient who is a survivor benefit recipient of this system also is an eligible benefit recipient receiving a survivor benefit from another Ohio retirement system and the effective benefit date of the benefit from this system is later than the effective benefit date in the other system.

(5)

(a) Where the effective benefit dates for an eligible benefit recipient in the situation described in paragraph (C)(1), (C)(3) or (C)(4) of this rule are the same in each system, and the benefit recipient has less service credit in this system than in the other system.

(b) Where the effective benefit dates and service credit for an eligible benefit recipient in the situation described in paragraph (C)(1), (C)(3) or (C)(4) of this rule are the same in each system, and the employee contributions in the account upon which the benefit in this system is based are less than the employee contributions in the account upon which the benefit in the other system was based.

(D)

(1)

(a) Where this system is responsible for health care coverage pursuant to this rule, an eligible benefit recipient of this system who also is an eligible benefit recipient of another Ohio retirement system may irrevocably waive such health care coverage in order to be covered by the other Ohio retirement system, if the other system has agreed in writing to offer such coverage. The waiver is revocable if the benefit recipient is no longer eligible for health care in the other system. Such recipient shall waive such coverage in writing to this system. Health care coverage in this system shall cease with the exception of the medicare Part B premium reimbursement when it is not available to the benefit recipient in the other Ohio retirement system beginning the first of the month following receipt of the waiver by this system.

(b) In the event an eligible benefit recipient has irrevocably waived health care coverage as provided in paragraph (D)(1)(a) of this rule, this system shall:

(i) Promptly notify the other Ohio retirement system the eligible benefit recipient has waived health care coverage and the effective date of such non-coverage; and

(ii) For covered eligible benefit recipients and dependents transfer to the other system annually for each month covered an amount equal to the sum of:

(a) The lesser of this system's average monthly medical including health maintenance organization cost per eligible benefit recipient less the cost paid by the eligible benefit recipient, or the other system's average monthly medical including health maintenance organization cost per eligible benefit recipient.

(b) The lesser of this system's average monthly cost of the prescription drug program per eligible benefit recipient, or the other system's average monthly cost of the prescription drug program per eligible benefit recipient.

(c) The lesser of the monthly cost of the medicare Part B premium that would be reimbursed by this system for the eligible benefit recipient, or the monthly cost of the medicare Part B premium that would be reimbursed by the other system for the eligible benefit recipient.

(d) This system shall transfer the amounts due pursuant to paragraph (D)(1)(b)(ii) of this rule no later than the last business day of February each year for the preceding calendar year after the following occur:

(i) This system receives from the system a list containing the names of eligible benefit recipients and the number of months during which the eligible benefit recipients were covered by the other system for the preceding calendar year; and

(ii) This system prepares an itemized accounting of the amount transferred for each such eligible benefit recipient.

(2)

(a) Where this system is not responsible for health care coverage pursuant to this rule, an eligible benefit recipient of another Ohio retirement system who also is an eligible benefit recipient or dependent of an eligible benefit recipient of this system may irrevocably waive health care coverage in the other system to be covered by this system as a benefit recipient or dependent if otherwise eligible. Health care coverage in this system shall be effective the first of the month following the termination of coverage in the other system.

(b) Where an eligible benefit recipient or dependent of an eligible benefit recipient of this system has waived health care coverage in another Ohio retirement system, this system shall be responsible to provide health care coverage only if this system:

(i) Is promptly notified by the other system that the eligible benefit recipient or dependent has waived health care coverage and the effective date of termination of coverage; and

(ii) For covered eligible benefit recipients and dependents, the other system pays annually to this system for each month covered an amount equal to the sum of:

(a) The lesser of this system's average monthly medical including health maintenance organization cost per eligible benefit recipient less the cost paid by the eligible benefit recipient, or the other system's average monthly medical including health maintenance organization cost per eligible benefit recipient.

(b) The lesser of this system's average monthly cost of the prescription drug program per eligible benefit recipient, or the other system's average monthly cost of the prescription drug program per eligible benefit recipient.

(c) The lesser of the monthly cost of the medicare Part B premium that would be reimbursed by this system for the eligible benefit recipient, or the monthly cost of the medicare Part B premium that would be reimbursed by the other system for the eligible benefit recipient.

(E)

(1) Not later than three years from the effective date of this rule this system shall contact the other retirement systems to review the adequacy of the transfer of funds described in paragraph (D) of this rule.

(2) If there is a material change in this system's plan or circumstances, this system shall notify the other Ohio retirement systems ninety days prior to the effective date of such change to discuss the impact of such change on this rule.

(F) The waiver program outlined in paragraphs (D) and (E) of this rule shall remain in place only for eligible benefit recipients who waived coverage from this system or to this system prior to January 1, 2008.

Effective January 1, 2008, benefit recipients shall not be permitted to waive coverage as outlined in paragraphs (D) and (E) of this rule as the Ohio police and fire pension fund discontinued its waiver program effective January 1, 2008, the Ohio public employees retirement system discontinued its waiver program effective January 1, 2007, and the school employees retirement system discontinued its waiver program effective March 1, 2007. The highway patrol retirement system has never participated with this system in the waiver program outlined in paragraphs (D) and (E) of this rule.

Eligible benefit recipients who waived coverage from this system may apply for enrollment under the state teachers retirement system's health care program during an annual open enrollment period in calendar years 2014 and 2015. Effective January 1, 2016, the state teachers retirement system shall terminate the waiver program in its entirety and no additional transfer of funds pursuant to paragraph (D) of this rule will be made to another Ohio retirement system beyond the final reconciliation of calendar year 2015. Eligible benefit recipients will no longer be bound by the irrevocable waiver as described under paragraphs (D) and (E) of this rule and their participation in the state teachers retirement system health care program shall be in accordance with Chapter 3307:1-11 of the Administrative Code.

Effective: 07/10/2014
R.C. 119.032 review dates: 06/01/2016
Promulgated Under: 111.15
Statutory Authority: 3307.04
Rule Amplifies: 3307.39
Prior Effective Dates: 8/1/98, 7/1/01 (Emer.), 9/17/01, 10/23/07 (Emer.), 1/20/08, 6/6/11

3307:1-11-11 Health care assistance.

(A) As used in this rule:

(1) "Earnings" shall mean the total of all job-related income, pension, disability and survivor benefits received, including any portion of a benefit or increase for which a written notice of waiver has been filed with the retirement board pursuant to section 3307.44 of the Revised Code, with the public employees retirement board pursuant to section 145.562 of the Revised Code or with the school employees retirement board pursuant to section 3309.662 of the Revised Code, social security payments, welfare benefits, workers' compensation benefits, child or spousal support, unemployment benefits, investment income and all reportable income according to the Internal Revenue Code of 1986.

(2) "Low-income earnings threshold" as used in this rule shall be equal to the minimum salary for a teacher with a bachelor's degree and five years experience as defined in section 3317.13 of the Revised Code, provided that in the event an individual experiences a life event once a calendar year has begun, such amounts shall be determined on a prorated basis as of the date the life event took place.

(3) "Liquid assets" shall include cash and all monies readily available to a family unit in savings accounts, checking accounts, money market accounts, trust funds, any publicly traded security or other investment vehicles as the board may from time to time specify.

(4) "Family unit" shall include the qualifying enrollee, spouse and children as defined in paragraph (C)(2) of rule 3307:1-11-01 of the Administrative Code.

(5) A "Qualifying enrollee" shall include a person who:

(a) Was:

(i) Granted service retirement under the STRS defined benefit plan with at least twenty-five years of total service credit at retirement that is not service credit purchased under former section 3307.741 of the Revised Code; or

(ii) Granted disability benefits under the STRS defined benefit plan , or

(iii) Eligible beneficiaries, as defined in paragraph (F) of rule 3307:1-11-02 of the Administrative Code, of retired teachers with at least twenty-five years of total service credit at retirement of that is not service credit purchased under former section 3307.741 of the Revised Code; or

(iv) Eligible survivors, as defined in paragraph (H) of rule 3307:1-11-02 of the Administrative Code, of either active teachers or disabled teachers eligible to retire with at least twenty-five years of total service credit at retirement that is not service credit purchased under former section 3307.741 of the Revised Code; or

(v) Eligible survivors, as defined in paragraph (G) of rule 3307:1-11-02 of the Administrative Code, of either active teachers or disabled teachers not eligible for service retirement; and

(b) Had annual earnings not greater than the low-income earnings threshold for the family unit of the person described in paragraph (A)(5)(a) of this rule and

(c) Had total liquid assets that did not exceed twenty-three thousand eight hundred dollars for the family unit of the person described in paragraph (A) (5)(a) of this rule.

(6) "Life event" includes the death of a spouse, divorce, loss of job or other events as the board may from time to time specify.

(7) "Minimum monthly health care premium" shall mean the lowest monthly premium charged any benefit recipient for any health plan offered by the retirement system.

(B) A qualifying enrollee may make application for health care assistance on a form provided by the retirement system. The effective date of the participation in the health care assistance program shall be the first of the month following the approval of the application. All applications for assistance must be received no later than the fifteenth of the month to be considered for approval for an effective date starting the next month.

(1) Each applicant shall demonstrate eligibility by providing the information specified on the form, which shall include copies of any federal tax return for the applicant, the spouse and any dependent children necessary to validate the earnings reported on an application and shall also include verification of medicare enrollment if applicable.

(2) An applicant who fails to supply all requested information within three months of filing shall be canceled.

(C) A qualifying enrollee receiving health care assistance must annually verify continuing eligibility on a form provided by the retirement system to continue participation in the program. Failure to file the form or supply all requested information shall result in the enrollee no longer qualifying for the program and all health care assistance shall be terminated.

(D) On and after July 1, 2004 and provided that the retirement board has not acted to terminate the health care assistance program hereby created, enrollees whose applications are approved under this rule shall qualify for:

(1) A minimum monthly health care premium in a health plan offered by the retirement system, and

(2) Health care assistance as determined by the board through certain health plans offered by the retirement system.

(3) The minimum monthly health care premium will not be in effect for any period the qualifying enrollee fails to provide verification of his or her medicare enrollment.

(E) For qualifying enrollees making application for health care assistance at the same time application for service retirement or disability benefits are made, health care assistance as described in paragraph (D) of this rule shall take affect the first of the month following the approval of the health care assistance application or the first of the month after the monthly benefit amount is finalized, whichever is later. All applications for health care assistance must be received no later than the fifteenth of the month to be considered for approval for an effective date starting the next month.

(F) Health care assistance under this rule provided as the result of false information submitted on an application shall be terminated immediately. Any person who submits false or misleading information in connection with an application for health care assistance shall immediately repay the amounts of any health care assistance provided to date. If such amounts remain unpaid, they shall be deducted from any future amounts payable under Chapter 3307. of the Revised Code.

Effective: 06/12/2014
R.C. 119.032 review dates: 03/24/2014 and 06/01/2016
Promulgated Under: 111.15
Statutory Authority: 3307.04
Rule Amplifies: 3307.39
Prior Effective Dates: 1/1/04 (Emer), 3/22/04, 7/1/04 (Emer.), 8/26/04, 7/1/07 (Emer.), 9/24/07, 5/14/09

3307:1-11-12 "Health care fund".

(A) The state teachers retirement board shall designate the amount of contributions, if any, that are to be allocated to the health care fund described in division (H) of section 3307.14 of the Revised Code for any year. Any contributions shall be funded by employer contributions to the employer's trust fund and shall include any employer contributions previously allocated by the state teachers retirement board for health care benefits described in section 3307.39 of the Revised Code, together with any earnings credited thereon, with respect to individuals participating in the plan described in either the STRS defined benefit plan or section 3307.81 of the Revised Code in which an individual may receive definitely determinable benefits. Contributions to the health care fund are subordinate to the contributions to the employer's trust fund for retirement benefits under the plans described in the STRS defined benefit plan and section 3307.81 of the Revised Code in which an individual may receive definitely determinable benefits. At no time shall contributions to the health care fund , when added to contributions for any life insurance benefits provided on behalf of eligible benefit recipients, be in excess of twenty-five per cent of the total aggregate actual contributions made to state teachers retirement system since the inception of the health care fund, excluding contributions to fund past service credit. In any event, all contributions to the health care fund shall be reasonable and ascertainable.

(B) If any rights of an individual who is eligible to receive coverage authorized under section 3307.39 of the Revised Code and paid from the health care fund are forfeited as provided in the applicable provisions of the medical and ancillary plans offered by the retirement system, an amount equal to the amount of such forfeiture shall be applied as soon as administratively possible to reduce employer contributions allocated to the health care fund.

(C) The assets of the health care fund shall only be used for the payment of health care benefits, qualified medical expenses, dental and vision coverage, if applicable, and to reimburse the medicare part B premiums paid by eligible benefit recipients.

(D) At no time prior to the satisfaction of all liabilities under this rule and section 3307.39 of the Revised Code shall any assets in the health care fund be used for, or diverted to, any purpose other than as provided in paragraph (C) of this rule and for the payment of administrative expenses relating to the health care fund. Assets in the health care fund may not be used for retirement, disability, or survivor benefits, or for any other purpose for which the other funds of the system are used.

(E) Upon satisfaction of all liabilities under this rule, any assets in the health care fund, if any, that are not used as provided in paragraph (D) of this rule shall be returned to the employers, as required by section 401(h)(5) of the Internal Revenue Code.

(F) It is the intent of the state teachers retirement board in adopting this rule to codify its compliance in all respects with sections 401(a) and 401(h) of the Internal Revenue Code and regulations interpreting those sections. In applying this rule, the board will apply the interpretation that achieves compliance with those sections and preserves the qualified status of the system as a governmental plan under sections 401(a) and 414(d) of the Internal Revenue Code.

(G) This rule is intended to codify past and current practices and procedures of the system with respect to the funding and payment of health care coverage and does not confer any new rights to or create any vested interest in receiving health care coverage for members, retirees, survivors, beneficiaries, or their dependents.

Effective: 06/12/2014
R.C. 119.032 review dates: 03/24/2014 and 06/01/2016
Promulgated Under: 111.15
Statutory Authority: 3307.04
Rule Amplifies: 3307.39
Prior Effective Dates: 1/22/09 (Emer), 4/29/09 (Emer), 7/16/09