Current through Register Vol. 63, No. 9, September 1, 2024
Unless the context indicates otherwise, as used in OEBB
administrative rules, the following definitions will apply:
(1) "Actuarial value" means the expected
financial value for the average member of a particular benefit plan.
(2) "Adverse Benefit Determination" means a
denial, reduction, or termination of, or a failure to provide or make payment
(in whole or in part), for a benefit, including any such denial, reduction,
termination, or failure to provide or make payment that is based on but not
limited to:
(a) A determination of a member's
eligibility to participate in the plan;
(b) A determination that the benefit is not a
covered benefit; or
(c) A
rescission of coverage, whether or not, in connection with rescission, there is
an adverse effect on any particular benefit.
(3) "Affidavit of Domestic Partnership" means
a document that attests the eligible employee and one other eligible individual
meet the criteria in section (15)(b).
(4) "Benefit plan" includes, but is not
limited to, insurance or other benefits including:
(a) Medical (including non-integrated health
reimbursement arrangements (HRAs));
(b) Dental;
(c) Vision;
(d) Life, disability and accidental
death;
(e) Long term
care;
(f) Employee Assistance
Program Plans;
(g) Supplemental
medical, dental and vision coverages (including Integrated General Purpose and
Integrated Post-Deductible health reimbursement arrangements (HRAs); and
Limited Purpose, Post-Separation/Retiree, and Premium Only health reimbursement
arrangements (HRAs));
(h) Any other
remedial care recognized by state law, and related services and
supplies;
(i) Comparable benefits
for employees who rely on spiritual means of healing; and
(j) Self-insurance programs managed by the
Board.
(5) "Benefits"
means goods and services provided under Benefit Plans.
(6) "Board" means the Oregon Educators
Benefit Board which consists of at least ten members appointed by the Governor
and is established under the Oregon Health Authority.
(7) "Child" means and includes the following:
(a) An eligible employee's, spouse's, or
domestic partner's biological son or daughter; adopted child; child placed for
adoption; or legally placed child, who has not reached age 26. An eligible
employee must provide the required custody or legal documents to their Entity
showing proof of adoption, legal guardianship or other court order if enrolling
a child for whom the employee, spouse, or domestic partner is not the
biological parent. Grandchildren are only eligible when the eligible employee
is the legal guardian or adoptive parent of the grandchild.
(b) A person who is incapable of
self-sustaining employment because of a developmental disability, mental
illness, or physical disability. There is no age limit for a dependent child
who is incapable of self-sustaining employment because of a developmental
disability, mental illness, or physical disability. When the dependent child is
26 years of age or older all the following requirements must be met:
(A) The disability must have existed before
attaining age 26.
(B) The employee
must provide evidence to the Entity or OEBB that (1) the person had health plan
coverage, group or individual, prior to attaining age 26, and (2) health plan
coverage continued without a gap until the OEBB health plan effective
date.
(C) The person's attending
physician must submit documentation of the disability to the eligible
employee's OEBB health insurance plan for review and approval. If the person
receives health plan approval, the health plan may review the person's health
status at any time to determine continued OEBB coverage eligibility.
(D)
(i) The
dependent child must be the employee's qualifying IRS dependent and must be
claimed on the eligible employee's most recent years tax return, or
(ii) The child files a tax return and
demonstrates that their adjusted gross income does not exceed 150 percent of
the federal poverty level (FPL), or
(iii) The employee is the legal guardian of
the disabled dependent child.
(c) Eligibility for coverage under this rule
includes people who may not be dependents under federal or state tax law and
may require an Entity to adjust an eligible employee's income based on the
imputed value of the benefit. Imputed taxes may apply, per IRC provisions, when
an employee enrolls and covers dependents on their OEBB coverage that are not
claimed on their federal taxes, and thus are not tax dependents.
(8) "Comparable cost (Medical,
Dental and Vision)" means that the total cost to a district for enrollment in
OEBB plans comparable in design to the district's plan(s) do not exceed the
total cost to a district for enrollment in the district's plan(s) using the
rate(s) in effect or proposed for the benefit plan year.
(9) "Comparable cost (Basic and Optional Life
Insurance, Accidental Death & Dismemberment, and Short and Long Term
Disability)" means that the premium rates of an OEBB plan design option do not
exceed the average, aggregate premium rates of a district's pre-OEBB plan
design in effect the year prior to implementation.
(10) "Comparable plan design (Medical, Dental
and Vision)" means that the actuarial values of two plan designs are within 2.5
percent higher or lower of each other.
(11) "Comparable plan design (Basic and
Optional Life Insurance and Accidental Death & Dismemberment)" means that
90 percent of district employees can obtain a maximum benefit through an OEBB
plan design that is within $2,500 of the maximum benefit obtained through a
pre-OEBB plan design in effect the year prior to implementation.
(12) "Comparable plan design (Short and Long
Term Disability)" means 90 percent of the district employees can obtain the
same elimination period, percentage of covered compensation, definition of
covered compensation, coverage period duration, and maximum payment per benefit
period through an OEBB plan design as through a pre-OEBB plan design in effect
the year prior to implementation.
(13) "Dependent" means and includes the
eligible employee's spouse or domestic partner, or child as defined by OAR
111-010-0010(7), unless otherwise defined in another OEBB rule.
(14) "Documented entity policies" means
Entities' policies and practices that apply to an employee group and are
submitted to the Oregon Educators Benefit Board during the plan selection
process. Entities' policies and practices must be identified and submitted with
the applicable employee group plan selections.
(15) "Eligible Domestic partner," unless
otherwise defined by a collective bargaining agreement or documented district
policy in effect on January 31, 2008, means and includes the following:
(a) An unmarried individual of the same sex
who has entered into a "Declaration of Domestic Partnership" with the eligible
employee that is recognized under Oregon law; or
(b) An unmarried individual of the same or
opposite sex who has entered into a partnership that meets the following
criteria:
(A) Both are at least 18 years of
age;
(B) Are responsible for each
other's welfare and are each other's sole domestic partners;
(C) Are not married to anyone and have not
had a spouse or another domestic partner within the prior six months. If
previously married, the six-month period starts on the final date of
divorce;
(D) Share a close personal
relationship and are not related by blood closer than would bar marriage in the
State of Oregon;
(E) Have jointly
shared the same regular and permanent residence for at least six months
immediately preceding the date the Affidavit of Domestic Partnership is signed
and submitted to the Entity; and
(F) Are jointly financially responsible for
basic living expenses defined as the cost of food, shelter and any other
expenses of maintaining a household. Financial information must be provided if
requested.
(G) The eligible
employee and domestic partner must jointly complete and submit to the Entity an
Affidavit of Domestic Partnership form, within five business days of the
electronic enrollment date or the date the Entity received the
enrollment/change form. If the affidavit is not received, coverage will
terminate for the domestic partner retroactive to the effective date.
(c) The eligible employee must
notify the Entity within 31 days of meeting all criteria as defined in
111-010-0015 (15)(b) or obtaining the "Declaration of Domestic Partnership"
which is recognized under Oregon law.
(d) Entities' must calculate and apply
applicable imputed value tax for domestic partners covered under OEBB benefit
plans.
(16) "Educational
Entity" means public school districts (K-12), education service districts
(ESDs), community colleges and public charter schools participating in
OEBB.
(17) "Eligible employee"
means and includes an employee of an Educational Entity or Local Government who
is actively working or on paid or unpaid leave that is recognized by federal or
state law, and:
(a) Is employed in a half time
or greater position or is in a job-sharing position; or
(b) Meets the definition of an eligible
employee under a separate OEBB rule or under a collective bargaining agreement
or documented district policy in effect on January 31, 2008; or
(c) Is an employee of a community college who
is covered under a collectively bargained contract and has worked a class load
of between 25 percent and 49 percent for a minimum period of two years and is
expected to continue to work a class load of at least 25 percent.
(18) "Eligible Early Retiree"
means and includes a previously eligible employee who is:
(a) Not Medicare-eligible; or
(b) Under 65 years old; and
(A) Receiving a service or disability
retirement allowance or pension under the Public Employees Retirement System
(PERS) or under any other retirement or disability benefit plan or system
offered by an OEBB participating organization for its employees;
(B) Eligible to receive a service retirement
allowance under PERS and has reached earliest retirement age under ORS Chapter
238;
(C) Eligible to receive a
pension under ORS 238A.100 to 238A.245 and has reached earliest retirement age
as described in ORS 238A.165; or
(D) Eligible to receive a service retirement
allowance or pension under another retirement benefit plan or system offered by
an OEBB participating organization and has reached earliest retirement age
under the plan or system.
(19) "Employee Group" means employees and
early retirees of a similar employment type, for example administrative,
represented classified, non-represented classified, confidential, represented
licensed, or non-represented licensed, within an Entity. If one or more
collective bargaining unit exists within an employee group, each unit will be
considered a separate employee group.
(20) "Entity" means an Educational Entity,
Local Government or Special district.
(21) "Flexible benefit plan" includes plans
that allow contributions on a tax-favored basis including health savings
accounts.
(22) "Health
Reimbursement Arrangement (HRA)" means an account established and funded solely
by the employer that can be used to pay for qualified health care expenses for
eligible employees and their spouses and federal tax dependents, up to a
maximum dollar amount for a coverage period, and any unused portion of the
maximum dollar amount at the end of a coverage period is carried forward to
increase the maximum reimbursement amount in subsequent coverage periods. This
definition should be interpreted to comply with the guidelines established by
the IRS for treatment of HRAs on a tax-favored basis in Technical Release No.
2013-03, IRS Publication 969 and IRS Notice 2002-45. HRA includes, but is not
limited to, the following:
(a) "Integrated
General Purpose HRA" is an HRA that allows participants to be reimbursed for
all IRS qualified expenses and is available only to eligible employees who are
enrolled in an OEBB medical plan or opt out of an OEBB medical plan because
they are enrolled in another employer-sponsored group medical plan.
(b) "Integrated Post-Deductible HRA" is an
HRA that allows participants to be reimbursed for expenses up to a certain
amount, but only after the participants have met the annual deductible on an
OEBB medical plan in which the employee participant is enrolled as the primary
subscriber, or as an eligible dependent.
(c) "Limited Purpose HRA" is an HRA that
allows participants to be reimbursed for only standard dental, vision, and
orthodontia expenses and does not require the employee participant to be
enrolled in an OEBB medical plan as the primary subscriber, or as a
dependent.
(d) "Non-integrated HRA"
is an HRA that allows participants to be reimbursed for all IRS qualified
expenses when the employee participant is not enrolled in an OEBB medical plan
as the primary subscriber, or as an eligible dependent.
(e) "Post-Separation/Retiree HRA" is an HRA
that allows participants to be reimbursed for qualified expenses only after the
employee separates/retires and does not require the employee participant to be
enrolled in an OEBB medical plan as the primary subscriber, or as a
dependent.
(f) "Premium Only HRA"
is an HRA that allows participants to be reimbursed only for insurance premiums
paid on an after tax basis, where the employee participant has no ability to
pay the premium on a pre-tax basis and the HRA does not require the employee
participant to be enrolled in an OEBB medical plan as the primary subscriber,
or as a dependent.
(23)
"Health Savings Account (HSA)" means a tax-exempt trust or custodial account
that is set up with a qualified HSA trustee to pay or reimburse certain
incurred medical expenses, as defined in 26 U.S.C. Sec. 223(d) and IRS
Publication 969.
(24) "High
Deductible Health Plan (HDHP)" means a health plan that meets the criteria for
a "high deductible health plan" as outlined in 26 U.S.C. Sec. 223(c)(2).
Enrollment in an HDHP is one of the requirements that must be met in order to
qualify to contribute to a health savings account (HSA).
(25) "Local Government" means cities,
counties and special districts in Oregon.
(26) "Members" means and includes the
following:
(a) "Eligible employee" as defined
by OAR 111-010-0015(17).
(b)
"Child" as defined by OAR 111-010-0015(7).
(c) "Domestic Partner" as defined by OAR
111-010-0015(15).
(d) "Spouse" as
defined by OAR 111-010-0015(34).
(27) Newly-hired and newly-eligible employee
means a benefit-eligible employee who is being hired at an Entity and has not
been employed or eligible for benefits through the hiring Entity in the past
six months, or within the same benefit Plan Year.
(28) "Non-subject District" means a community
college not yet participating in benefit plans provided by the Oregon Educators
Benefit Board, or a charter school whose employees are not considered employees
of a school district.
(29) "Oregon
Educators Benefit Board or OEBB" means the program created under chapter 00007,
Oregon Laws 2007.
(30) "OEBB
participating organization" means a Subject District, Non-subject District, or
Provisional Non-subject District that participates in benefit plans provided by
the Oregon Educators Benefit Board (OEBB).
(31) "Provisional Non-subject District" means
a common school district, a union high school district, or an education service
district that:
(a) Was self-insured on
December 31, 2006;
(b) Had an
independent health insurance trust established and functioning on December 31,
2006; or
(c) Can provide comparable
plan designs at a comparable cost as defined by sections (8) and (10) of this
Rule.
(32) "Qualified
Status Change (QSC)" means a change in family or work status that allows
limited mid-year changes to benefit plans consistent with the individual event.
Outside of annual open enrollment, a QSC is the only time a change in
enrollments can occur.
(33)
"Special district" means any district listed in ORS chapter 198 "Special
Districts Generally," or as determined by the Board.
(34) "Spouse" means a person who is married
under the laws of the State of Oregon or under the laws of any other state or
country. The definition of spouse does not include a former spouse and a former
spouse does not qualify as a dependent.
(35) "Subject District" means a common school
district, a union high school district, or an education service district that:
(a) Did not self-insure on January 1,
2007;
(b) Did not have a health
trust in effect on January 1, 2007; or
(c) Does not provide comparable plan designs
at a comparable cost as defined by sections (8) and (10) of this
rule.
Statutory/Other Authority: ORS 243.860 - 243.886
Statutes/Other Implemented: ORS
243.864(1)(a)
