Chapter 5505-7 Benefits

Effective: 12/16/2011
R.C. 119.032 review dates: 12/16/2016
Promulgated Under: 111.15
Statutory Authority: 5505.07
Rule Amplifies: 5505.17
Prior Effective Dates: 1/1/1986, 12/1/1987, 10/21/2005, 4/27/2006

5505-7-04 Health Care.

(A) Benefit recipients and eligible dependents may enroll in any plan offered pursuant to section 5505.28 of the Revised Code.

(1) The annual premium cost for each category of coverage will be determined by the board prior to the annual open enrollment period.

(2) All provisions of this rule are subject to current health care contracts and amendments.

(3) The board may implement cost control measures as it deems necessary.

(4) Only benefit recipients and dependents who are enrolled under highway patrol retirement system medical coverage are eligible for prescription drug coverage.

(B) The spouse and dependent children of a retirant who is receiving a monthly benefit are eligible for health care, subject to the following conditions:

(1) A spouse is a wife or husband as set forth in a statutorily-valid certificate of marriage or as recognized by judgment of a court establishing a common-law relationship.

(2) Dependent children are stepchildren who are residing in the same household as the retirant, natural children, or adopted children.

(3) The board may require documented proof of marriage or parenthood before approving spouse or dependent coverage.

(C) Upon death of a retirant or member, the surviving spouse and dependent children are eligible for health care coverage, subject to the following conditions:

(1) The surviving spouse is a wife or husband as set forth in a statutorily-valid certificate of marriage or as recognized by judgment of a court establishing a common-law relationship.

(2) Dependent stepchildren, residing in the same household as the retirant or member, who had coverage at the time of the retirant's or member's death, may continue coverage, provided that the surviving spouse elects to continue coverage.

(3) In the event that a surviving spouse remarries, health care eligibility shall continue only to the extent that coverage existed prior to the remarriage.

(D) Open enrollment for all health care options will be November 1 through November 30 each year.

(1) Eligible benefit recipients and dependents may enroll in or delete coverage only during open enrollment, except to the extent of (a) a qualifying event that affects that individual's eligibility for health benefits or (b) a medicare rule.

(2) Qualifying events include -

(a) Change in marital status,

(b) Birth or adoption of a child,

(c) Change in employment status, or

(d) Death.

(3) The effective date of coverage will be -

(a) January 1 for an addition during open enrollment.

(b) The beginning of the month following the receipt of an enrollment form based on a qualifying event.

(c) The date of marriage for the addition of a new spouse or stepchild.

(d) The date of birth for the addition of a newborn.

(e) The adoption date for the addition of a newly-adopted child.

(4) Upon request, an eligible benefit recipient or dependent may designate an effective date of coverage that is the beginning of a month no later than two months after the effective date under paragraph (D)(3) of this rule.

(5) To qualify for coverage, an enrollment form based upon a qualifying event must be received by the retirement system no later than sixty days after the event.

(E) A termination of coverage will be effective at the end of the month during which an enrollment change form is received.

(1) Health care eligibility for the spouse and dependent children shall terminate under the following conditions:

(a) At the end of the month in which the spouse is no longer married to the benefit recipient.

(b) At the end of the month in which the child (i) is no longer a dependent of the retirant, (ii) gains access to medical coverage through employment, regardless of cost, (iii) marries, or (iv) attains the age of twenty-six.

(2) Health care eligibility of a dependent child of a deceased member or retirant will terminate at age twenty-six.

(F)

(1) Notwithstanding the provisions of paragraph (E)(1)(b) of this rule, health care coverage will continue for a disabled dependent child who -

(a) Is unmarried,

(b) Is mentally or physically incapable of earning his or her own living,

(c) Became so incapable prior to the attainment of the limiting age for coverage of children, and

(d) Is chiefly dependent upon the retirant for support and maintenance.

(2) To determine whether a disabled dependent child qualifies for coverage under this section, the retirement board may require -

(a) A physician's statement,

(b) An independent medical examination,

(c) Two years of federal tax returns from both the parents and the dependent child, and

(d) Any other information that the board deems relevant.

(G)

(1) A benefit recipient who has access to medical and/or prescription coverage through employment must secure it as primary coverage, regardless of cost. Alternatively, the benefit recipient may elect to secure primary coverage through a spouse's employment. Notwithstanding this provision, primary dental and vision coverage and secondary medical and prescription coverage may be elected through the highway patrol retirement system. The requirement that primary prescription coverage be obtained through an employer is effective for pension benefits payable beginning after December 31,2010.

(2) A dependent who has access to medical and/or prescription coverage through employment must secure it as primary coverage, regardless of cost. Alternatively, the dependent may elect to secure primary coverage through a parent's employment. Notwithstanding this provision, primary dental and vision coverage and secondary medical and prescription coverage may be elected through the highway patrol retirement system.

(3) A dependent who has access, as a benefit recipient of another retirement system or pension plan, to medical and/or prescription coverage must secure it as primary coverage, regardless of cost. Notwithstanding this provision, primary dental and vision coverage and secondary medical and prescription coverage may be elected through the highway patrol retirement system. A dependent who had coverage through the highway patrol retirement system prior to January 1, 2011 may continue that coverage until it is interrupted.

(4) Paragraphs (G)(1), (G)(2), and (G)(3) of this rule will not apply to a participant who has both medicare part A and medicare part B coverage.

(5) If the cost of primary coverage pursuant to paragraph (G)(1), (G)(2), or (G)(3) of this rule exceeds twenty-five per cent of the gross income provided by the source of primary coverage, the benefit recipient may apply for a hardship exemption on a form prescribed by the board.

(H) An individual who receives benefits in accordance with section 5505.16, 5505.17, or 5505.18 of the Revised Code will be reimbursed for medicare part B premiums upon the receipt of evidence of coverage, up to a maximum amount established by the board.

(1) Evidence will consist of a medicare HIC number or other verification provided by the social security administration.

(2) The reimbursement amount for the following year will be established by the board no later than the December meeting.

(3) Reimbursement will be effective the month following receipt of evidence of coverage and will be added to each monthly pension payment.

(4) Reimbursement will not be due to a benefit recipient who is eligible to receive reimbursement from an employer, another retirement plan, or any other entity.

(5) An individual who is eligible for medicare part B coverage who does not enroll will have reduced coverage. Medical claims that would have been covered by medicare part B will not be covered.

(6) To the extent that a participant becomes eligible for medicare part B, from that date forward, the participant must purchase medicare part B coverage in order to have the full benefit of coverage. A benefit recipient is not required to purchase retroactive medicare part B coverage in order to qualify for full benefits.

(7) The board reserves the right terminate medical and prescription coverage of an individual who does not maintain medicare part B coverage.

(I) If it is available at no cost, a participant is required to enroll in medicare part A. The board reserves the right to terminate medical and prescription coverage of an individual who does not maintain medicare part A coverage that is available at no cost.

(J) Anyone who is eligible for a benefit based only on (1) an election in accordance with section 5505.162 of the Revised Code or (2) being an alternate payee under section 5505.261 of the Revised Code is not eligible for health care coverage or medicare part B reimbursement.

Replaces: 5505-7-04