Virginia Administrative Code
Title 1 - ADMINISTRATION
Agency 55 - DEPARTMENT OF HUMAN RESOURCE MANAGEMENT
Chapter 20 - COMMONWEALTH OF VIRGINIA HEALTH BENEFITS PROGRAM
Part IV - Employee Participation
Section 1VAC55-20-320 - Eligible employees
Universal Citation: 1 VA Admin Code 55-20-320
Current through Register Vol. 41, No. 3, September 23, 2024
A. State employees.
1. Full-time salaried, classified
employees and faculty as defined in
1VAC55-20-20 are eligible for
membership in the health benefits program. A full-time salaried employee is one
who is scheduled to work at least 32 hours per week or carries a faculty
teaching load considered to be full time at his institution.
2. Certain full-time employees in auxiliary
enterprises (such as food services, bookstores, laundry services, etc.) at the
University of Virginia, Virginia Military Institute and the College of William
and Mary as well as other state institutions of higher learning are also
considered state employees even though they do not receive a salaried state
paycheck. The Athletic Department of Virginia Polytechnic Institute and State
University is an example of a local auxiliary whose members are eligible for
the program.
3. Certain full-time
employees of the Medical College of Virginia Hospital Authority are eligible
for the program as long as they are on the authority's payroll and were
enrolled in the program on November 1, 1996. They may have payroll deductions
for health benefits premiums even if they rotate to the Veterans'
Administration Hospital or other acute care facility.
4. Other employees identified in the Code of
Virginia as eligible for the program.
5. Classified positions include employees who
are fully covered by the Virginia Personnel Act, employees excluded from the
Virginia Personnel Act by subdivision 16 of § 2.2-2905 of the Code of Virginia,
and employees on a restricted appointment. A restricted appointment is a
classified appointment to a position that is funded at least 10% from gifts,
grants, donations, or other sources that are not identifiable as continuing in
nature. An employee on a restricted appointment must receive a state paycheck
in order to be eligible.
B. Local employees.
1. Full-time employees of participating local
employers are eligible to participate in the program. A full-time employee is
one who meets the definition set forth by the local employer in the employer
application.
2. Part-time employees
of local employers may participate in the plan if the local employer elects and
the election does not discriminate among part-time employees. In order for the
local employer to cover part-time employees, the local employer must provide to
the department a definition of what constitutes a part-time employee.
The department reserves the right to establish a separate plan for part-time employees.
C. Unavailability of employer-sponsored coverage.
1. Employees, officers, and
teachers without access to employer-sponsored health care coverage may
participate in the plan. The employers of such employees, officers, and
teachers must apply for participation and certify that other employer-sponsored
health care coverage is not available. The employers shall collect
contributions from such individuals and timely remit them to the department or
its designee, act as a channel of communication with the covered employee and
otherwise assist the department as may be necessary. The employer shall act as
fiduciary with respect to such contributions and shall be responsible for any
interest or other charges imposed by the department in accordance with these
regulations.
2. Local employees
living outside the service area of the plan offered by their local employer
shall not be considered as local employees whose local employers do not offer a
health benefits plan. For example, a local employee who lives in North Carolina
and works in Virginia may live outside the service area of the HMO offered by
his employer; however, he may not join the program individually.
3. Employer sponsorship of a health benefits
plan will be broadly construed. For example, an employer will be deemed to
sponsor health care coverage for purposes of this section and
1VAC55-20-260 if it utilizes § 125
of the Internal Revenue Code or any similar provision to allow employees,
officers, or teachers to contribute their portion of the health care
contribution on a pretax basis.
4.
Individual employees and dependents who are eligible to join the program under
the provisions of this subsection must meet all of the eligibility requirements
pertaining to state employees except the identity of the employer.
D. Retirees.
1. Retirees are not eligible to enroll in the
state retiree health benefits group outside of the opportunities provided in
this section.
2. Retirees are
eligible for membership in the state retiree group if a completed enrollment
form is received within 31 days of separation for retirement. Retirees who
remain in the health benefits group through a spouse's state employee
membership may enroll in the retiree group at one of three later times:
(i) future open enrollment,
(ii) within 31 days of a qualifying mid-year
event, or
(iii) within 31 days of
being removed from the active state employee spouse's membership.
3. Membership in the retiree group
may be provided to an employee's spouse or dependents who were covered in the
active employee group at the time of the employee's death in service.
4. Retirees who have attained the age of 65
or are otherwise covered or eligible for Medicare may enroll in certain plans
as determined by the department provided that they apply for such coverage
within 31 days of their separation from active service for retirement. Medicare
will be the primary payor and the program shall serve as a supplement to
Medicare's coverage.
5. Retirees
who are ineligible for Medicare must apply for coverage within 31 days of their
separation from active service for retirement. In order to receive coverage,
the individual must meet the retirement requirements of his employer and
receive an immediate annuity.
6.
Local employers may offer retiree coverage at their option.
E. Dependents.
1. The following family members may be
covered if the employee elects:
a. The
employee's spouse.
The marriage must be recognized as legal in the Commonwealth of Virginia.
b. Children. Under the health benefits
program, the following eligible children may be covered to the end of the year
in which they turn age 26 (age requirement is waived for adult incapacitated
children):
(1) Natural children, adopted
children, or children placed for adoption.
(2) Stepchildren. A stepchild is the natural
or legally adopted child of the participant's legal spouse. Such marriage must
be recognized by the Commonwealth of Virginia.
(3) Incapacitated children. Adult children
who are incapacitated due to a physical or mental health condition, as long as
the child was covered by the plan and the incapacitation existed prior to the
termination of coverage due to the child attaining the limiting age. The
employee must make written application, along with proof of incapacitation,
prior to the child reaching the limiting age. Such extension of coverage must
be approved by the plan and is subject to periodic review. Should the plan find
that the child no longer meets the criteria for coverage as an incapacitated
child, the child's coverage will be terminated at the end of the month
following notification from the plan to the enrollee. The child must live with
the employee as a member of the employee's household and be dependent upon the
employee for financial support. In the case of a divorce, living with the
spouse will satisfy the condition of living with the employee. Furthermore, the
support test is met if either the employee or spouse or combination of the
employee and spouse provide over one half of the child's financial support.
Adult incapacitated children of new employees may also be covered, provided that:
(a) The
enrollment form is submitted within 31 days of hire;
(b) The child has been covered continuously
by group employer coverage since the disability first occurred; and
(c) The disability commenced prior to the
child attaining the limiting age of the plan.
The enrollment form must be accompanied by a letter from a physician explaining the nature of the incapacitation, date of onset and certifying that the dependent is not capable of self-support. This extension of coverage must be approved by the plan in which the employee is enrolled.
(4) Other children. A
child in which a court has ordered the employee to assume sole permanent
custody.
Additionally, if the employee or spouse shares custody with the minor child who is the parent of the "other child," then the other child may be covered.
When a child loses eligibility, coverage terminates at the end of the month in which the event that causes the loss of eligibility occurs.
There are certain categories of persons who may not be covered as dependents under the program. These include dependent siblings, grandchildren, nieces, and nephews except where the criteria for "other children" are satisfied. Parents, grandparents, aunts, and uncles are not eligible for coverage regardless of dependency status.
Statutory Authority: § 2.2-2818 of the Code of Virginia.
Disclaimer: These regulations may not be the most recent version. Virginia may have more current or accurate information. We make no warranties or guarantees about the accuracy, completeness, or adequacy of the information contained on this site or the information linked to on the state site. Please check official sources.
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