Current through Register Vol. 49, No. 18, September 16, 2024
PURPOSE: This amendment adds that retirees can cancel
dental and vision coverage when voluntarily canceling medical
coverage.
(1) Terms and
Conditions. This rule provides the terms and conditions for membership in the
Missouri Consolidated Health Care Plan (MCHCP). Public entities and members are
required to provide complete, true, and accurate information to MCHCP in
connection with enrollment, change, or cancellation processes, whether by
online, written, or verbal communication. MCHCP may rely on, but reserves the
right to audit, any information provided by a public entity or member and seek
recovery and/or pursue legal action to the extent the public entity or member
has provided incomplete, false, or inaccurate information.
(2) Eligibility Requirements.
(A) Active Employee Coverage. An active
employee is one who is employed and meets the minimum number of hours worked
per year as established by his/her employer.
1. If the public entity allows
elected/appointed officials to participate in medical coverage, the definition
of an employee includes elected/appointed officials where applicable.
2. The entity will determine the eligibility
requirements of waiting periods, required number of working hours, pay status,
and contribution levels.
3. An
active employee cannot be covered as an employee and as a dependent.
4. If an active employee has been enrolled as
a dependent of another MCHCP subscriber as allowed by these rules, and the
subscriber dies before coverage as a dependent goes into effect, the active
employee may elect coverage as a subscriber within thirty-one (31) days of the
date of death.
5. If one (1) spouse
is an active state employee or retiree with MCHCP benefits and the other is an
active public entity employee or retiree with MCHCP benefits, each spouse may
enroll under his or her employer's plan or together under one (1) employer's
plan. The spouses cannot have coverage in both places.
(B) Retiree Coverage.
1. An employee may participate in an MCHCP
plan when s/he retires if s/he is fully vested in the retirement plan upon
termination and the public entity remains with MCHCP. The public entity must
make the benefits available to all retirees, past and future, who meet the
vesting requirements. The employee may elect coverage for him/herself and
dependents and his/her spouse/child(ren), provided the employee and his/her
spouse/child(ren) have been continuously covered for health care benefits-
A. Through MCHCP since the effective date of
the last open enrollment period;
B.
Through MCHCP since the initial date of eligibility; or
C. Through group or individual medical
coverage for the six (6) months immediately prior to retirement. Proof of prior
group or individual coverage (letter from previous insurance carrier or former
employer with dates of effective coverage and list of persons covered) is
required.
2. If the
retiree's spouse is an active public entity employee or retiree and enrolled in
MCHCP, both spouses may transfer to coverage under the plan in which his/her
spouse is enrolled or from his/her spouse's coverage to his/her coverage at any
time as long as both spouses are eligible for MCHCP coverage and their coverage
is continuous.
3. If a retiree who
is eligible for coverage elects not to be continuously covered for him/herself
and his/her spouse/child(ren) with MCHCP from the date first eligible, or does
not apply for coverage for him/herself and his/her spouse/child(ren) within
thirty-one (31) days of his/her eligibility date, the retiree and his/her
spouse/child(ren) shall not thereafter be eligible for coverage unless
specified elsewhere herein.
(C) Survivor Coverage.
1. At the time of a vested active employee
subscriber's death, his/her survivor(s) may elect to continue coverage if the
survivor(s) had MCHCP coverage at the time of the subscriber's death. The
deceased subscriber's spouse/child(ren) who do not have MCHCP coverage at the
time of the death may elect MCHCP coverage and become a survivor if the
spouse/child(ren) had coverage through group or individual medical coverage for
the six (6) months immediately prior to the subscriber's death. In that case,
proof of prior group or individual coverage (letter from previous insurance
carrier or former employer with dates of effective coverage and list of persons
covered) is required.
2. At the
time of a retiree or terminated vested subscriber's death, his/her survivor(s)
may elect to continue coverage if the survivor(s) had MCHCP coverage at the
time of the subscriber's death.
3.
If a survivor subsequently marries and elects to add his/her new spouse to
his/her coverage and the survivor dies, the new spouse's coverage ends at
midnight on the last day of the month of the survivor's death (e.g. If the
survivor dies November 3, new spouse's last day of coverage is November 30).
Unless otherwise specified in this rule, the new spouse is not eligible to
enroll for coverage at the time of the survivor's death.
4. If there are multiple survivors, once
enrolled, the spouse will become the subscriber or, if there are only children,
the youngest enrolled child will become the subscriber.
(D) Terminated Vested Coverage.
1. An active employee may enroll him/herself
and his/her spouse/child(ren) in an MCHCP plan when his/her employment with the
public entity terminates if s/he is vested and is eligible for future benefits
in a retirement plan with the public entity when s/he reaches retirement age.
The employee must elect to continue coverage within thirty-one (31) days of the
last day of the month in which his/her employment is terminated. The employee
may elect or continue coverage if the terminated vested employee and his/her
spouse/child(ren) had coverage-
A. Through
MCHCP since the effective date of the last open enrollment period;
B. Through MCHCP since the initial date of
eligibility; or
C. Through group or
individual medical coverage for the six (6) months immediately prior to
termination of employment. Proof of prior group or individual coverage (letter
from previous insurance carrier or former employer with dates of effective
coverage and list of persons covered) is required.
2. If a terminated vested employee does not
elect coverage within thirty-one (31) days of their eligibility date, or if
s/he cancels or loses his/her coverage or dependent coverage, the terminated
vested employee and his/her dependents cannot enroll at a later date.
3. The terminated vested employee may
temporarily continue coverage for him/herself and his/her dependents under the
provisions of Consolidated Omnibus Budget Reconciliation Act (COBRA).
(E) Long-Term Disability Coverage.
1. An employee is eligible for long-term
disability coverage if the employee is eligible for long-term disability
benefits from the public entity and the employee may elect or continue coverage
if the employee with long-term disability coverage and his/her
spouse/child(ren) had coverage-
A. Through
MCHCP since the effective date of the last open enrollment period;
B. Through MCHCP since the initial date of
eligibility; or
C. Through group or
individual medical coverage for the six (6) months immediately prior to
becoming eligible for long-term disability benefits. Proof of prior group or
individual coverage (letter from previous insurance carrier or former employer
with dates of effective coverage and list of persons covered) is
required.
2. If an
enrolled, vested, long-term disability subscriber becomes ineligible for
disability benefits, the long-term disability subscriber and his/her dependents
will have continuous coverage as a terminated vested subscriber. If an enrolled
long-term disability subscriber is not vested and becomes ineligible for
disability benefits, coverage is terminated and the subscriber and his/her
dependents are offered COBRA benefits. If an enrolled long-term disability
subscriber becomes ineligible for disability benefits and returns to work, the
subscriber is considered a new employee and must submit a form to enroll. If
the employee's spouse is an active state employee or retiree, s/he may transfer
coverage under the plan in which his/her spouse is enrolled. If the employee
wishes to be covered individually at a later date, s/he can make the change, as
long as coverage is continuous.
(F) Elected/Appointed Official Coverage.
1. If the public entity allows
elected/appointed officials to participate in medical coverage, the definition
of an active employee includes elected/appointed officials.
(G) Dependent Coverage. Eligible
dependents include:
1. Spouse.
A. Active Employee Coverage of a Spouse.
(I) If both spouses have access to MCHCP
benefits through two (2) different public entities, the employee and his/her
spouse may elect to enroll in coverage separately through his/her respective
employer or together through one (1) of the employers. The employee cannot have
coverage through both public entities.
(II) If both spouses are employed by the same
public entity with access to MCHCP benefits, the employee and spouse may elect
coverage either as individuals or under the spouse (if allowed by the
employer).
B. Retiree
Coverage of a Spouse.
(I) A public entity
retiree may enroll as a spouse under a public entity employee's coverage or
elect coverage as a retiree;
2. Children.
A. Children may be covered through the end of
the month in which they turn twenty-six (26) years old if they meet one (1) of
the following criteria:
(I) Natural child of
subscriber or spouse;
(II)
Legally-adopted child of subscriber or spouse;
(III) Child legally placed for adoption of
subscriber or spouse;
(IV)
Stepchild of subscriber. Such child will continue to be considered a dependent
after the stepchild relationship ends due to the death of the child's natural
parent and subscriber's spouse;
(V)
Foster child of subscriber or spouse. Such child will continue to be considered
a dependent child after the foster child relationship ends by operation of law
when the child ages out if the foster child relationship between the subscriber
or spouse and the child was in effect the day before the child ages
out;
(VI) Grandchild for whom the
subscriber or spouse has legal guardianship or legal custody;
(VII) A child for whom the subscriber or
spouse is the court-ordered legal guardian under a guardianship of a minor.
Such child will continue to be considered a dependent child after the
guardianship ends by operation of law when the child becomes eighteen (18)
years old if the guardianship of a minor relationship between the subscriber or
spouse and the child was in effect the day before the child became eighteen
(18) years old;
(VIII) Child of a
dependent as long as the parent is a dependent on the child's date of birth.
The dependent and his/her child must remain continuously covered on the plan
from the dependent's child's date of birth for the child of the dependent to
remain eligible;
(IX) Child of a
dependent when paternity by the dependent is established after birth as long as
the parent is a dependent on the date the child's paternity was established the
dependent and his/her child must remain continuously covered on the plan from
the dependent's child's date of birth for the child of the dependent to remain
eligible;
(X) Child for whom the
subscriber or spouse is required to provide coverage under a Qualified Medical
Child Support Order (QMCSO); or
(XI) A child under twenty-six (26) years, who
is eligible for MCHCP coverage as a subscriber, may be covered as a dependent
of a public entity employee.
B. A child who is twenty-six (26) years old
or older and is permanently disabled in accordance with subsection (5)(F), may
be covered only if such child was disabled the day before the child turned
twenty-six (26) years old and has remained continuously disabled.
C. A child may only be covered by one (1)
parent if his/her parents are married to each other and are both covered under
an MCHCP medical plan.
D. A child
may have dual coverage if the child's parents are divorced or have never
married, and both have coverage under an MCHCP medical plan. MCHCP will only
pay for a service once, regardless of whether the claim for the child's care is
filed under multiple subscribers' coverage. If a child has coverage under two
(2) subscribers, the child will have a separate deductible, copayment, and
coinsurance under each subscriber. The claims administrator will process the
claim and apply applicable cost-sharing using the coverage of the subscriber
who files the claim first. The second claim for the same services will not be
covered. If a provider files a claim simultaneously under both subscribers'
coverage, the claim will be processed under the subscriber whose birthday is
first in the calendar year. If both subscribers have the same birthday, the
claim will be processed under the subscriber whose coverage has been in effect
for the longest period of time; or
3. Changes in dependent status. If a
dependent loses his/her eligibility, the subscriber must notify MCHCP within
thirty-one (31) days of the loss of eligibility. Coverage will end on the last
day of the month that the completed form is received by MCHCP or the last day
of the month MCHCP otherwise receives credible evidence of loss of eligibility
under the plan.
(3) Enrollment Procedures.
(A) Active Employee Coverage.
1. The public entity must enroll or waive
coverage for a new employee by submitting a form signed by the employee and the
payroll representative within thirty-one (31) days of his/her eligibility date.
A new employee's coverage begins on the first day of the month after the hire
date and the applicable waiting period.
2. An active employee may elect, change, or
cancel coverage for the next plan year during the annual open enrollment
period.
3. An active employee may
elect or change cover-age for himself/herself and/or for his/her
spouse/child(ren) if one (1) of the following occurs:
A. Occurrence of a life event, which includes
marriage, birth, adoption, and placement of child(ren). A special enrollment
period of thirty-one (31) days shall be available beginning with the date of
the life event. It is the employee's responsibility to notify MCHCP of the life
event;
(I) If paternity is necessary to
establish the life event and was not established at birth, the date that
paternity is established shall be the date of the life event; or
B. Employer-sponsored group
coverage loss. An employee and his/her spouse/child(ren) may enroll within
sixty (60) days due to an involuntary loss of employer-sponsored coverage under
one (1) of the following circumstances:
(I)
Employer-sponsored medical, dental, or vision plan terminates;
(II) Eligibility for employer-sponsored
coverage ends;
(III) Employer
contributions toward the premiums end; or
(IV) COBRA coverage ends; or
C. If an active employee or
his/her spouse/child(ren) loses MO HealthNet or Medicaid status, s/he may
enroll in an MCHCP plan within sixty (60) days of the date of loss;
or
D. If an active employee or
active employee's spouse receives a court order stating s/he is responsible for
covering a child(ren), the active employee may enroll the child(ren) in an
MCHCP plan within sixty (60) days of the court order; or
E. If an active employee submits an Open
Enrollment Worksheet or an Enroll/Change/Cancel/Waive form that is incomplete
or contains obvious errors, MCHCP will notify the public entity's Human
Resource Department of such by mail, phone, or secure message. The corrected
form must be submitted to MCHCP by the date enrollment was originally due to
MCHCP or ten (10) business days from the date the notice was mailed or sent by
secure message or phone, whichever is later.
4. If an active employee is enrolled and does
not complete enrollment during the open enrollment period, the employee and
his/her dependents will be enrolled at the same level of coverage in the plan
offered by the public entity for the new year. If the public entity offers two
(2) plan options, the employee and his/her dependents will be enrolled at the
same level of coverage in the low cost plan offered by the public entity,
effective the first day of the next calendar year.
(B) Retiree Coverage.
1. To enroll or continue coverage for
him/herself and his/her dependents at retirement, the employee must submit one
(1) of the following:
A. A completed
enrollment form within thirty-one (31) days of retirement date. Coverage is
effective on retirement date; or
B.
A completed enrollment form within thirty-one (31) days of retirement date with
proof of prior medical, dental, or vision coverage under a separate group or
individual insurance policy for six (6) months immediately prior to his/her
retirement if s/he chooses to enroll in an MCHCP plan at retirement and has had
insurance coverage for six (6) months immediately prior to his/her
retirement.
2. A retiree
may later add a spouse/child(ren) to his/her current coverage if one (1) of the
following occurs:
A. Occurrence of a life
event, which includes marriage, birth, adoption, and placement of child(ren). A
special enrollment period of thirty-one (31) days shall be available beginning
with the date of the life event. It is the employee's responsibility to notify
MCHCP of the life event;
(I) If paternity is
necessary to establish the life event and was not established at birth, the
date that paternity is established shall be the date of the life event;
or
B. Employer-sponsored
group coverage loss. A retiree may enroll his/her spouse/child(ren) within
sixty (60) days due to an involuntary loss of employer-sponsored coverage under
one (1) of the following circumstances, and the coverage was in place for
twelve (12) months immediately prior to the loss:
(I) Employer-sponsored medical, dental, or
vision plan terminates;
(II)
Eligibility for employer-sponsored coverage ends;
(III) Employer contributions toward the
premiums end; or
(IV) COBRA
coverage ends.
3. If coverage was not maintained while on
disability, the employee and his/her dependents may enroll him/herself and
his/her spouse/child(ren) within thirty-one (31) days of the date the employee
is eligible for retirement benefits subject to the eligibility provisions
herein.
4. A retiree may change
from one (1) medical plan to another during open enrollment but cannot add
coverage for a spouse/child(ren). If a retiree is not already enrolled in
medical, dental, and/or vision coverage, s/he cannot enroll in additional
coverage during open enrollment.
5.
If a retiree submits an Open Enrollment Worksheet or an
Enroll/Change/Cancel/Waive form that is incomplete or contains obvious errors,
MCHCP will notify the retiree of such by mail, phone, or secure message. The
retiree must submit a corrected form to MCHCP by the date enrollment was
originally due to MCHCP or ten (10) business days from the date the notice was
mailed or sent by secure message or phone, whichever is later.
6. If a retiree is enrolled and does not
complete enrollment during the open enrollment period, the retiree and his/her
dependents will be enrolled at the same level of coverage in the plan offered
by the public entity for the new year. If the public entity offers two (2) plan
options, the retiree and his/her dependents will be enrolled at the same level
of coverage in the low cost plan offered by the public entity, effective the
first day of the next calendar year.
(C) Terminated Vested Coverage.
1. A terminated vested subscriber may later
add a spouse/child(ren) to his/her coverage if one (1) of the following occurs:
A. Occurrence of a life event, which includes
marriage, birth, adoption, and placement of children. A special enrollment
period of thirty-one (31) days shall be available beginning with the date of
the life event. It is the employee's responsibility to notify MCHCP of the life
event;
(I) If paternity is necessary to
establish the life event and was not established at birth, the date that
paternity is established shall be the date of the life event; or
B. Employer-sponsored group
coverage loss. A terminated vested subscriber may enroll his/her
spouse/child(ren) within sixty (60) days due to an involuntary loss of
employer-sponsored coverage under one (1) of the following circumstances and
the coverage was in place for twelve (12) months immediately prior to the loss:
(I) Employer-sponsored medical, dental, or
vision plan terminates;
(II)
Eligibility for employer-sponsored coverage ends;
(III) Employer contributions toward the
premiums end; or
(IV) COBRA
coverage ends.
2. An enrolled terminated vested subscriber
may change from one (1) medical plan to another during open enrollment but
cannot add a spouse/child(ren). If an enrolled terminated vested subscriber is
not already enrolled in medical, dental, and/or vision coverage, s/he cannot
enroll in additional coverage during open enrollment.
3. If a terminated vested subscriber submits
an Open Enrollment Worksheet or an Enroll/Change/Cancel/Waive form that is
incomplete or contains obvious errors, MCHCP will notify the terminated vested
subscriber of such by mail, phone, or secure message. The terminated vested
subscriber must submit a corrected form to MCHCP by the date enrollment was
originally due to MCHCP or ten (10) business days from the date the notice was
mailed or sent by secure message or phone, whichever is later.
4. If a terminated vested subscriber is
enrolled and does not complete enrollment during the open enrollment period,
the terminated vested subscriber and his/her dependents will be enrolled at the
same level of coverage in the plan offered by the public entity for the new
year. If the public entity offers two (2) plan options, the terminated vested
subscriber and his/her dependents will be enrolled at the same level of
coverage in the low cost plan offered by the public entity, effective the first
day of the next calendar year.
(D) Long-Term Disability Coverage.
1. A long-term disability subscriber may add
a spouse/child(ren) to his/her current coverage if one (1) of the following
occurs:
A. Occurrence of a life event, which
includes marriage, birth, adoption, and placement of child(ren). A special
enrollment period of thirty-one (31) days shall be available beginning with the
date of the life event. It is the employee's responsibility to notify MCHCP of
the life event;
(I) If paternity is necessary
to establish the life event and was not established at birth, the date that
paternity is established shall be the date of the life event; or
B. Employer-sponsored group
coverage loss. A long-term disability subscriber may enroll his/her
spouse/child(ren) within sixty (60) days due to an involuntary loss of
employer-sponsored coverage under one (1) of the following circumstances and
the coverage was in place for twelve (12) months immediately prior to the loss:
(I) Employer-sponsored medical, dental, or
vision plan terminates;
(II)
Eligibility for employer-sponsored coverage ends;
(III) Employer contributions toward the
premiums end; or
(IV) COBRA
coverage ends.
2. An enrolled long-term disability
subscriber may change from one (1) medical plan to another during open
enrollment but cannot add a spouse/child(ren). If an enrolled long-term
disability subscriber is not already enrolled in medical, dental, and/or vision
coverage, s/he cannot enroll in additional coverage during open
enrollment.
3. If a long-term
disability subscriber submits an Open Enrollment Worksheet or an
Enroll/Change/Cancel/Waive form that is incomplete or contains obvious errors,
MCHCP will notify the long-term disability subscriber of such by mail, phone,
or secure message. The long-term disability subscriber must submit a corrected
form to MCHCP by the date enrollment was originally due to MCHCP or ten (10)
business days from the date the notice was mailed or sent by secure message or
phone, whichever is later.
4. If a
long-term disability subscriber is enrolled and does not complete enrollment
during the open enrollment period, the long-term disability subscriber and
his/her dependents will be enrolled at the same level of coverage in the plan
offered by the public entity for the new year. If the public entity offers two
(2) plan options, the long-term disability subscriber and his/her dependents
will be enrolled at the same level of coverage in the low cost plan offered by
the public entity, effective the first day of the next calendar year.
(E) Survivor Coverage.
1. A survivor must submit a form and a copy
of the death certificate within thirty-one (31) days of the first day of the
month after the death of the employee.
A. If
the survivor does not elect coverage within thirty-one (31) days of the first
day of the month after the death of the employee, s/he cannot enroll at a later
date.
B. If the survivor marries,
has a child, adopts a child, or a child is placed with the survivor, the
spouse/child(ren) must be added within thirty-one (31) days of birth, adoption,
placement, or marriage.
C. If
eligible spouse/child(ren) are not enrolled when first eligible, they cannot be
enrolled at a later date.
2. A survivor may later add a
spouse/child(ren) to his/her current coverage if one (1) of the following
occurs:
A. Occurrence of a life event, which
includes marriage, birth, adoption, and placement of children. A special
enrollment period of thirty-one (31) days shall be available beginning with the
date of the life event. It is the employee's responsibility to notify MCHCP of
the life event;
(I) If paternity is necessary
to establish the life event and was not established at birth, the date that
paternity is established shall be the date of the life event; or
B. Employer-sponsored group
coverage loss. A survivor may enroll his/her spouse/child(ren) within sixty
(60) days [if the spouse/child(ren) involuntarily loses] due to an involuntary
loss of employer-sponsored coverage under one (1) of the following
circumstances and the coverage was in place for twelve (12) months immediately
prior to the loss:
(I) Employer-sponsored
medical, dental, or vision plan terminates;
(II) Eligibility for employer-sponsored
coverage ends;
(III) Employer
contributions toward the premiums end; or
(IV) COBRA coverage ends.
3. A survivor may
change from one (1) medical plan to another during open enrollment but cannot
add a spouse/child(ren). If a survivor is not already enrolled in medical,
dental, and/or vision coverage, s/he cannot enroll in additional coverage
during open enrollment.
4. If a
survivor submits an Open Enrollment Worksheet or an Enroll/Change/Cancel/Waive
form that is incomplete or contains obvious errors, MCHCP will notify the
survivor of such by mail, phone, or secure message. The survivor must submit a
corrected form to MCHCP by the date enrollment was originally due to MCHCP or
ten (10) business days from the date the notice was mailed or sent by secure
message or phone, whichever is later.
5. If a survivor is enrolled and does not
complete enrollment during the open enrollment period, the survivor and his/her
dependents will be enrolled at the same level of coverage in the plan offered
by the public entity for the new year. If the public entity offers two (2) plan
options, the survivor and his/her dependents will be enrolled at the same level
of coverage in the low cost plan offered by the public entity, effective the
first day of the next calendar year.
(4) Effective Date Provision. In no
circumstances can the effective date be before the eligibility date. The
effective date of coverage shall be determined, subject to the effective date
provisions as follows:
(A) Employee and
Dependent Effective Dates.
1. A new employee
and his/her eligible dependents or an employee rehired after his/her coverage
terminates and his/her eligible dependent(s) are eligible to participate in the
plan on the first day of the month following the employee's eligibility date,
as determined by the employer. Except at initial employment, an employee and
his/her eligible dependents' effective date of coverage is the first of the
month coinciding with or after the eligibility date and after the waiting
period. Except for coverage being added due to a birth, adoption, or placement
of child(ren), the effective date of coverage cannot be prior to the date of
receipt of the enrollment by MCHCP.
2. The effective date of coverage for a life
event shall be as follows:
A. Marriage.
(I) If a subscriber enrolls and/or enrolls
his/her spouse before a wedding date, coverage becomes effective on the wedding
date. The monthly premium is not prorated.
(II) If an active employee enrolls within
thirty-one (31) days of a wedding date, coverage becomes effective the first of
the month coinciding with or after receipt of the enrollment form, unless
enrollment is received on the first day of a month, in which case coverage is
effective on that day;
B. Newborn.
(I) If a subscriber or employee enrolls an
eligible newborn within thirty-one (31) days of birth date, coverage becomes
effective on the newborn's birth date.
(II) If a subscriber or employee enrolls an
eligible spouse and/or child(ren) within thirty-one (31) days of the birth of
the newborn, coverage becomes effective on the newborn's birth date or the
first of the month after enrollment is received, subject to proof of
eligibility. The monthly premium will not be prorated.
(III) If a subscriber does not elect to
enroll a newborn of a dependent child within thirty-one (31) days of birth,
s/he cannot enroll the newborn of a dependent at a later date;
C. Child where paternity is
established after birth. If a subscriber enrolls a child within thirty-one (31)
days of the date paternity is established, coverage becomes effective on the
first day of the next month after enrollment is received, unless enrollment is
received on the first day of a month, in which case coverage is effective on
that day;
D. Adoption or placement
for adoption.
(I) If a subscriber or employee
enrolls an adopted child within thirty-one (31) days of adoption or placement
of a child, coverage becomes effective on the date of adoption or placement for
adoption;
(II) If a subscriber or
employee enrolls an eligible spouse and/or children within thirty-one (31) days
of an adoption or placement for adoption, coverage may become effective on the
date of adoption, or date of placement for adoption, or the first of the month
after enrollment is received, subject to proof of eligibility. The monthly
premium will not be prorated;
E. Legal guardianship and legal custody.
(I) If a subscriber or employee enrolls a
dependent due to legal guardianship or legal custody within thirty-one (31)
days of guardianship or custody effective date, coverage becomes effective on
the first day of the next month after enrollment is received, unless enrollment
is received on the first day of a month, in which case coverage is effective on
that day;
F. Foster
care.
(I) If a subscriber or employee enrolls
a foster child due to placement in the subscriber or employee's care within
thirty-one (31) days of placement, coverage becomes effective on the first day
of the next month after enrollment is received, unless enrollment is received
on the first day of a month, in which case coverage is effective on that day;
or
G. Employee.
(I) If an employee enrolls due to a life
event or loss of employer-sponsored coverage, the effective date for the
employee is the first day of the next month after enrollment is received,
unless enrollment is received on the first day of a month, in which case
coverage is effective on that day.
(II) If the life event is due to a birth,
adoption, or placement of child(ren), coverage becomes effective on the
newborn's birth date, date of adoption, or date of placement for adoption. The
monthly premium will not be prorated;
3. An employee and his/her eligible
dependent(s) who elect coverage and/or change coverage levels during open
enrollment shall have an effective date of January 1 of the following
year.
4. Coverage is effective for
a dependent child the first of the month coinciding with or after the Qualified
Medical Child Support Order is received by the plan or date specified by the
court.
(5)
Proof of Eligibility.
(A) MCHCP reserves the
right to request proof of eligibility at any time. If such proof is not
received or is unacceptable as determined by MCHCP, coverage for the applicable
dependent or spouse/child(ren) will be terminated or will not take
effect.
(B) An employee and/or
his/her spouse/child(ren) enrolling due to a loss of other coverage. The
employee must submit documentation of proof of loss to MCHCP through his/her
public entity's Human Resource Department within sixty (60) days of
enrollment.
(C) A retiree,
survivor, terminated vested subscriber, or long-term disability subscriber
enrolling his/her spouse/child(ren) due to a loss of other coverage must submit
documentation of proof of loss of coverage for his/her spouse/child(ren) within
sixty (60) days of enrollment.
(D)
Documentation is also required when a subscriber attempts to terminate a
spouse's/child(ren)'s coverage in the case of divorce or death.
(E) The employee is required to notify MCHCP
on the appropriate form of the spouse's/child's name, birth date, eligibility
date, and Social Security number.
(F) Disabled dependent.
1. An employee may enroll his/her permanently
disabled child when first eligible or an enrolled permanently disabled
dependent turning age twenty-six (26) years and may continue coverage beyond
age twenty-six (26) years, provided the following documentation is submitted to
the plan prior to the end of the month of the dependent's twenty-sixth birthday
for the enrolled permanently disabled dependent or within thirty-one (31) days
of enrollment of the permanently disabled child:
A. Evidence from the Social Security
Administration (SSA) that the permanently disabled dependent or child was
entitled to and receiving disability benefits prior to turning age twenty-six
(26) years; and
B. A benefit
verification letter dated within the last twelve (12) months from the SSA
confirming the child is still considered disabled.
2. If a disabled dependent or child over the
age of twenty-six (26) years is determined to be no longer disabled by the SSA,
coverage will terminate the last day of the month in which the disability ends
or never take effect for new enrollment requests.
3. Once the disabled dependent's coverage is
cancelled or terminated, s/he will not be able to enroll at a later
date.
(6)
Military Leave.
(A) Military Leave for an
Active Employee.
1. For absences of thirty
(30) days or less, coverage continues as if the employee has not been
absent.
2. For absences of
thirty-one (31) days or more, coverage ends unless the employee elects to pay
for coverage under the Uniformed Services Employment & Reemployment Rights
Act (USERRA). The agency payroll representative notifies MCHCP of the effective
date of military leave. An employee who is on military leave is eligible for
continued coverage for medical, vision, and dental care for the lesser of:
a) twenty-four (24) months beginning on the
date the leave begins; or
b) the
day after the date the employee fails to apply for or return to their position
of employment after leave.
3. If the employee is utilizing annual and/or
compensatory balances and staying on payroll, the dependent coverage is at the
active employee monthly premium.
4.
If the employee does not elect to continue USERRA coverage for his/her eligible
dependent(s), coverage ends effective the last day of the month in which the
leave begins.
5. The employee must
submit a form within thirty-one (31) days of the employee's return to work to
be reinstated for the same level of coverage with the same plan as prior to the
leave, or if the employee was on military leave during open enrollment or while
on military leave had a qualifying life event, the employee may change plans
and add his/her spouse/child(ren). The employee must submit a form and an
official document indicating the separation date if s/he elects coverage after
thirty-one (31) days of returning to work. The form and the official document
must be submitted within sixty (60) days from the date of loss of
coverage.
6. Coverage may be
reinstated the first of the month in which the member returns to employment,
the first of the month after return to employment, or the first of the month
after the loss of military coverage.
(B) Military Leave for a Retired Member.
1. A retiree must terminate his/her coverage
upon entry into the armed forces of any country by submitting a form and copy
of his/her activation papers within thirty-one (31) days of his/her activation
date.
2. Coverage will be
terminated the last day of the month of activation. Coverage may be reinstated
at the same level upon discharge by submitting a copy of his/her separation
papers and form within thirty-one (31) days of the separation date.
3. Coverage will be reinstated as of the
first of the month in which the employee returns from active duty, the first of
the month after the employee returns, or the first of the month after the loss
of military coverage.
4. If the
retired member fails to reinstate coverage, s/he cannot enroll at a later
date.
5. If the retiree terminates
his/her coverage, dependent coverage is also terminated.
6. If a retiree does not elect to continue
USERRA coverage for his/her dependent(s), coverage ends effective the last day
of the month in which the leave begins.
(7) Termination.
(A) Unless stated otherwise, termination of
coverage shall occur on the last day of the calendar month coinciding with, or
after the happening of, any of the following events, whichever shall occur
first:
1. Failure to make any required
contribution toward the cost of coverage;
2. Entry into the armed forces of any
country;
3. With respect to active
employee(s) and his/her dependents, termination of employment in a position
covered by the MCHCP, except as expressly specified otherwise in this
rule;
4. With respect to
dependents, upon divorce or legal separation from the subscriber or when a
dependent is no longer eligible for coverage. A subscriber must terminate
coverage for his/her enrolled ex-spouse and stepchild(ren) at the time his/her
divorce is final;
A. The public entity shall
notify MCHCP when any of subscriber's dependents cease to be a dependent as
defined in this chapter.
B. When a
subscriber drops dependent coverage after a divorce, s/he must submit a
completed form, a copy of the divorce decree, and current addresses of all
affected dependents. Coverage ends on the last day of the month in which the
divorce decree and completed form are received by MCHCP or MCHCP otherwise
receives credible evidence of a final divorce that results in loss of member
eligibility under the plan;
5. Death of dependent. The dependent's
coverage ends on the date of death;
A. The
public entity shall notify MCHCP of a dependent's death;
6. A member's act, practice, or omission that
constitutes fraud or the member makes an intentional misrepresentation of
material fact;
7. A member's
threatening conduct or perpetrating violent acts against MCHCP or an employee
of MCHCP; or
8. A member otherwise
loses benefit eligibility.
(B) MCHCP may rescind coverage due to
non-payment of a premium, fraud, or intentional misrepresentation. MCHCP shall
provide at least thirty (30) days written notice before it rescinds
coverage.
(C) Termination of
coverage shall occur immediately upon discontinuance of the plan, subject to
the plan termination provision specified in
22 CSR
10-3.080(1).
(D) If a member receives covered services
after the termination of coverage, MCHCP may recover the contracted charges for
such covered services from the subscriber or the provider, plus its cost to
recover such charges, including attorneys' fees.
(8) Voluntary Cancellation of Coverage.
(A) A subscriber may cancel medical coverage,
which will be effective on the last day of the month in which the form is
received by MCHCP to cancel coverage.
1. If a
subscriber has his/her premium collected pre-tax by qualified payroll deduction
through a cafeteria plan, the subscriber may only cancel medical coverage if
the reason given is allowed by the cafeteria plan.
2. A subscriber may reinstate medical
coverage after a voluntary cancellation by submitting an
Enroll/Change/Cancel/Waive form prior to the end of current coverage.
(B) If a member receives covered
services after the voluntary cancellation of coverage, MCHCP may recover the
contracted charges for such covered services from the subscriber or the
provider, plus its cost to recover such charges, including attorneys'
fees.
(C) A subscriber cannot
cancel medical coverage on his/her dependents during divorce or legal
separation proceedings unless s/he submits a notarized letter from his/her
spouse stating s/he is agreeable to termination of coverage pending divorce. If
premiums are collected pre-tax through a cafeteria plan, medical coverage can
only be cancelled at the time of divorce.
(D) A subscriber may only cancel dental
and/or vision coverage during the year for him/herself or his/her dependents
for one (1) of the following reasons:
2. When beginning a
leave of absence;
3. No longer
eligible for coverage;
4. When new
coverage is taken through other employment;
5. When the member enrolls in Medicaid;
or
6. When a retiree cancels
medical coverage.
(9) Continuation of Coverage.
(A) Leave of Absence.
1. An employee on an approved leave of
absence may continue participation in the plan by paying the required
contributions. The employing public entity must officially notify MCHCP of the
leave of absence and any extension of the leave of absence by submitting the
required form.
2. If the employee
does not elect to continue coverage, coverage for the employee and his/her
covered dependents is terminated effective the last day of the month in which
the employee is employed.
3. If the
employee's spouse is an active employee or retiree, the employee may transfer
coverage under the plan in which the spouse is enrolled. If the employee wishes
to be covered individually at a later date, s/he can make the change as long as
coverage is continuous. When the employee returns to work, s/he and his/her
spouse must be covered individually.
4. Any employee on an approved leave of
absence who was a member of MCHCP when the approved leave began, but who
subsequently terminated coverage in MCHCP while on leave, may recommence
his/her coverage in the plan at the same level (employee only or employee and
dependents) upon returning to employment directly from the leave, or if the
employee was on leave of absence during open enrollment or while on leave of
absence had a qualifying life event or loss of employer-sponsored coverage, the
employee may change plans and add spouse/child(ren). For coverage to be
reinstated, the employee must submit a completed Enroll/Change/Cancel/Waive
form within thirty-one (31) days of returning to work. Coverage is reinstated
on the first of the month coinciding with or after the date the form is
received. Coverage will be continuous if the employee returns to work in the
subsequent month following the initial leave date.
5. If the employee chooses to maintain
employee coverage but not coverage for his/her dependents, the employee is
eligible to regain dependent coverage upon return to work.
(B) Leave of Absence-Family and Medical Leave
Act (FMLA).
1. An employee must be approved
for a leave of absence under FMLA and meet the requirements and guidelines set
forth by FMLA and his/her public entity for his/her employer to continue to pay
the monthly contribution toward the employee's and his/her dependents'
coverage. Coverage is continuous unless the employee chooses to cancel
coverage.
2. If the employee
cancels coverage, coverage ends on the last day of the month in which MCHCP
received a premium payment.
3. If
the employee canceled coverage, the employee may reinstate coverage by
submitting a completed form within thirty-one (31) days of returning to work.
Coverage will be reinstated with the same plan and level of coverage as
enrolled in prior to the employee taking the leave of absence. If the employee
was on FMLA leave during MCHCP's annual open enrollment, or if while the
employee was on FMLA leave, the employee had a qualifying life event or loss of
employer-sponsored coverage, the employee may change plans and add a
spouse/child(ren) within thirty-one (31) days of returning to work.
4. If the employee continued coverage and is
unable to return to work after his/her FMLA leave ends, his/her coverage will
be continuous at the retiree rate or the employee may cancel
coverage.
(10) Federal Consolidated Omnibus Budget
Reconciliation Act (COBRA).
(A) Eligibility.
In accordance with COBRA, eligible employees and their dependents may
temporarily continue their coverage when coverage under the plan would
otherwise end. Coverage is identical to the coverage provided under MCHCP to
similarly-situated employees and family members. If members cancel COBRA
coverage, they cannot enroll at a later date.
1. Employees voluntarily or involuntarily
terminating employment (for reasons other than gross misconduct) or receiving a
reduction in the number of hours of employment may continue coverage for
themselves and their dependent(s) for eighteen (18) months at their own
expense.
2. If a subscriber
marries, has a child, or adopts a child while on COBRA coverage, subscriber may
add such eligible spouse/child(ren) to the subscriber's plan if MCHCP is
notified within thirty-one (31) days of the marriage, birth, or adoption. The
subscriber may also add eligible spouse/child(ren) during open
enrollment.
3. Dependents may
continue coverage for up to thirty-six (36) months at their own expense if the
employee becomes eligible for Medicare.
4. A surviving dependent who has coverage due
to the death of a non-vested employee may elect coverage for up to thirty-six
(36) months at their own expense.
5. A divorced or legally-separated enrolled
spouse and stepchild(ren) may continue coverage at their own expense for up to
thirty-six (36) months.
6. Children
who would no longer qualify as dependents may continue coverage for up to
thirty-six (36) months at their (or their parent's/guardian's) own
expense.
7. If the Social Security
Administration determines a COBRA member is disabled within the first sixty
(60) days of coverage and the disability continues during the rest of the
initial eighteen- (18-) month period of continuation of coverage, the member
may continue coverage for up to an additional eleven (11) months.
8. If the eligible member has Medicare prior
to becoming eligible for COBRA coverage, the member is entitled to coverage
under both.
(B) Premium
Payments.
1. Initial payment for continuation
coverage must be received within forty-five (45) days of election of
coverage.
2. After initial premium
payment, MCHCP bills on the last working day of the month. There is a
thirty-one- (31-) day grace period for payment of regularly scheduled monthly
premiums.
3. Premiums for continued
coverage will be one hundred two percent (102%) of the total premium for the
applicable coverage level. Once coverage is terminated under the COBRA
provision, it cannot be reinstated.
(C) Required Notifications.
1. To be eligible for COBRA, the subscriber
or applicable member must notify MCHCP of a divorce, legal separation, a child
turning age twenty-six (26), or Medicare entitlement within sixty (60) days of
the event date.
2. The human
resource/payroll office of the subscriber must notify MCHCP of an employee's
death, termination, or reduction of hours of employment.
3. If a COBRA participant is disabled within
the first sixty (60) days of COBRA coverage and the disability continues for
the rest of the initial eighteen- (18-) month period of continuing coverage,
the member must notify MCHCP that s/he wants to continue coverage within sixty
(60) days, starting from the latest of:
1)
the date on which the SSA issues the disability determination;
2) the date on which the qualifying event
occurs; or
3) the date on which the
member receives the COBRA general notice. The member must also notify MCHCP
within thirty-one (31) days of any final determination that the individual is
no longer disabled.
(D) Election Periods.
1. When MCHCP is notified that a
COBRA-qualifying event has occurred, MCHCP notifies eligible members of the
right to choose continuation coverage.
2. Eligible members have sixty (60) days from
the date of coverage loss or notification from MCHCP, whichever is later, to
inform MCHCP that they want continuation coverage.
3. If eligible members do not choose
continuation coverage within sixty (60) days of lost coverage or notification
from MCHCP, coverage ends.
(E) Continuation of coverage may be cut short
for any of these reasons-
1. The state of
Missouri no longer provides group health coverage to any of its
employees;
2. Premium for
continuation coverage is not paid on time;
3. The employee or dependent becomes covered
(after the date s/he elects COBRA coverage) under another group health plan
that does not contain any exclusion or limitation with respect to any
pre-existing condition s/he may have;
4. The employee or dependent becomes entitled
to Medicare after the date s/he elects COBRA coverage; or
5. The employee or dependent extends coverage
for up to twenty-nine (29) months due to disability and there has been a final
determination that the individual is no longer disabled.
(F) MCHCP assumes coverage for existing COBRA
members until their eligibility period expires or until the public entity
terminates coverage with MCHCP, whichever occurs first.
(11) Missouri State Law COBRA Wrap Around
Provisions.
(A) Missouri law provides that if
a member loses group health insurance coverage because of a divorce, legal
separation, or the death of a spouse, the member may continue coverage until
age sixty-five (65) under two (2) conditions-
1. The member continues and maintains
coverage under the thirty-six- (36-) month provision of COBRA; and
2. The member is at least fifty-five (55)
years old when COBRA benefits end. The qualified beneficiary must apply to
continue coverage through the wrap-around provisions and will have to pay the
entire premium. MCHCP may charge up to an additional twenty-five percent (25%)
of the applicable premium.
(B) For a member to continue coverage under
this subsection, a member must either-
1.
Within sixty (60) days of legal separation or the entry of a decree of
dissolution of marriage or prior to the expiration of a thirty-six- (36-) month
COBRA period, the legally-separated or divorced spouse who seeks such coverage
shall give MCHCP written notice of the qualifying event, including his/her
mailing address; or
2. Within
thirty (30) days of the death of an employee whose surviving spouse is eligible
for continued coverage or prior to the expiration of a thirty-six- (36-) month
COBRA period, the public entity or surviving spouse shall give MCHCP written
notice of the death and the mailing address of the surviving spouse.
(C) Within fourteen (14) days of
receipt of the notice, MCHCP shall notify the legally-separated, divorced, or
surviving spouse that coverage may be continued. The notice shall include:
1. A form for election to continue the
coverage;
2. The amount of premiums
to be charged and the method and place of payment; and
3. Instructions for returning the elections
form by mail within sixty (60) days after MCHCP mails the notice.
(D) Continuation of coverage
terminates on the last day of the month prior to the month the subscriber turns
age sixty-five (65). The right to continuation coverage shall also terminate
upon the earliest of any of the following:
1.
The state of Missouri no longer provides group health coverage to any of its
employees;
2. Premium for
continuation coverage is not paid on time;
3. The date on which the legally-separated,
divorced, or surviving spouse becomes insured under any other group health
plan;
4. The date on which the
legally-separated, divorced, or surviving spouse remarries and becomes insured
under another group health plan; or
5. The date on which the legally-separated,
divorced, or surviving spouse reaches age sixty-five (65).
(12) Members who are eligible for
Medicare benefits under Part A, B, or D must notify MCHCP of their eligibility
and provide a copy of the member's Medicare card within thirty-one (31) days of
the Medicare eligibility date. If Medicare coverage begins before turning age
sixty-five (65), the member will receive a Medicare disability questionnaire
from MCHCP. The member must return the completed questionnaire to MCHCP for the
Medicare eligibility information to be submitted to the medical
vendor.
(13) Members are required
to disclose to the claims administrator whether or whether not they have other
health coverage and, if so, information about the coverage. Once the
information is received, claims will be reprocessed subject to all applicable
rules.
(14) Communications to
Members.
(A) It is the member's
responsibility to ensure that MCHCP has current contact information for the
member and any dependent(s).
(B) A
member must notify MCHCP of a change in his/her mailing or email address as
soon as possible, but no later than thirty-one (31) days after the
change.
(C) It is the
responsibility of all members who elect to receive plan communication through
email to ensure plan emails are not blocked as spam or junk mail by the member
or by the member's service provider.
(D) Failure to update a mailing or email
address may result in undeliverable mail/email of important informational
material, delayed or denied claims, loss of coverage, loss of continuation
rights, missed opportunities relating to covered benefits, and/or liability for
claims paid in error.
(15) Deadlines. Unless specifically stated
otherwise, MCHCP computes deadlines by counting day one (1) as the first day
after the qualifying event. If the last day falls on a weekend or state
holiday, the plan administrator may receive required information on the first
working day after the weekend or state holiday.
*Original authority: 103.059, RSMo
1992.