Current through Register Vol. 49, No. 6, March 15, 2024
PURPOSE: This amendment adds that retirees can cancel dental and
vision coverage when voluntarily canceling medical coverage.
EMERGENCY STATEMENT: This emergency amendment must be in place by
January 1, 2024, in accordance with the new plan year. Therefore, this emergency amendment is necessary to
serve a compelling governmental interest of protecting members (public entity employee members, retirees, and
their families) enrolled in the Missouri Consolidated Health Care Plan (MCHCP) from the unintended
consequences of confusion regarding eligibility or availability of benefits and will allow members to take
advantage of opportunities for reduced premiums for more affordable options without which they may forego
coverage. Further, it clarifies member eligibility and responsibility for various types of eligible charges,
beginning with the first day of coverage for the new plan year. It may also help ensure that inappropriate
claims are not made against the state and help protect the MCHCP and its members from being subjected to
unexpected and significant financial liability and/or litigation. It is imperative that this amendment be
filed as an emergency amendment to maintain the integrity of the current health care plan. This emergency
amendment fulfills the compelling governmental interest of offering access to more convenient and affordable
medical services to public entity employee members, retirees, and their families as one (1) method of
protecting the MCHCP trust fund from more costly expenses. This emergency amendment reflects changes made to
the plan by the Missouri Consolidated Health Care Plan Board of Trustees. A proposed amendment, which covers
the same material, is published in this issue of the Missouri Register. This emergency amendment complies
with the protections extended by the Missouri and United States Constitutions and limits its scope to the
circumstances creating the emergency. The MCHCP follows procedures best calculated to assure fairness to all
interested persons and parties under the circumstances. This emergency amendment was filed October 27, 2023
becomes effective January 1, 2024 and expires June 28, 2024.
(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:
1. Upon retirement;
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.