Oregon Health Authority
Public Employees' Benefit Board - Chapter 101
Division 20
ENROLLMENT RULES
101-020-0050
Midyear Benefit Plan Changes
(1) Eligible employee plan elections are irrevocable for the plan year. There are limited exceptions to the irrevocability rule if certain conditions or events are met. These events fall into three broad groups:
(a) Qualified Status Changes (QSC), which include:
(A) Changes in the eligible employee's legal marital status, such as marriage or divorce;
(B) Changes in the eligible employee's number of dependents, such as birth or adoption of a child;
(C) Changes in the employment status of the eligible employee or family member, such as the start or end of employment, or a change from part-time to full time;
(D) Changes in the eligibility of a dependent, such as attaining a certain age;
(E) Changes in the residence of the eligible employee , or;
(F) Changes in the eligible employee's domestic partnership.
(b) Cost or coverage changes. For example:
(A) An increase in out-of-pocket premium cost imposed by the employer;
(B) A reduction or a loss in the spouse's or domestic partner's group plan benefits, or;
(C) A reduction or a loss of plan coverage.
(c) Other laws or court orders. For example: National Medical Support Notice, Medicare, or HIPAA related special enrollments.
(2) The eligible employee may request only those midyear plan change elections that are consistent with the event.
Example: In the middle of the plan year, John moves from his current medical plan’s service area and can no longer access the plan’s closed panel of providers. However, all of John’s other coverages (dental, life, etc.) remain active for his new address. John may request to change his medical plan, because it is consistent with the event due to a move from his current medical plan’s service area. John may not request to change or add any other elections at this time because that would not be consistent with the allowable midyear event occurrence.
(3) Eligible employees experiencing a qualified midyear event, and who request a change of enrollment elections must complete and submit to their agency the correct update forms and all required documentation within 30 days of the event. Agencies receiving employee midyear change requests can make only those changes that are consistent with the event. All election changes are effective the later of the first of the month after receiving all required update forms and documents or the event date. Agencies will not process enrollment request changes when enrollment and change request information is incomplete or missing required documentation.
(4) The tag-a-long rule applies when the eligible employee experiences a QSC addition of a new family member, domestic partner, or domestic partner’s child. The rule allows the employee to add another eligible family member, domestic partner, or domestic partner’s child who was previously eligible for PEBB plan coverage but never added to coverage, to be added to coverage.
Statutory/Other Authority: ORS 243.061 - 302
Statutes/Other Implemented: ORS 243.061 - 302, 659A.060 - 069, 743.600 - 602 & 743.707
History:
PEBB 2-2017, f. & cert. ef. 8-17-17
PEBB 7-2010, f. 12-10-10, cert. ef. 1-1-11
PEBB 2-2007, f. 9-28-07, cert. ef. 10-1-07