Oregon Health Authority
Oregon Educators Benefit Board - Chapter 111
Division 40
ENROLLMENT
111-040-0050
Declination of Coverage
(1) As used in this section:
(a) “Opting out of coverage” means that an otherwise Eligible Employee elects not to enroll in a medical plan and is eligible to receive a portion of the cash contribution or other type of remuneration as provided for under a collective bargaining agreement, documented Entity policy, or employment contract.
(b) “Waiving benefits” means that an otherwise Eligible Employee elects not to enroll in any one of the benefit plans available under the OEBB-sponsored benefits program and is not eligible to receive any portion of a cash contribution or other type of remuneration.
(2) Unless otherwise specified in a collective bargaining agreement, documented Entity policy or employment contract in effect on July 1, 2008, an Eligible Employee may opt out of the OEBB-sponsored medical benefit plans. Eligible Employees electing to opt-out must:
(a) Maintain minimum essential medical coverage for themselves and all other individuals for whom the employee can reasonably expect to claim a personal tax exemption deduction for. The medical coverage must be another employer-sponsored group medical benefit plan. The employee must attest to the coverage at initial enrollment and annually thereafter, or
(b) Be enrolled in Medicare or TRICARE coverage and be employed by an Entity that administers their benefits program in compliance with the requirements of Section 125 of the Federal Internal Revenue Code (IRC);
(c) Meet the requirements of the Entity opt-out program in which they are participating;
(d) Submit their election to opt-out through the OEBB benefit management system; and
(e) If requested, provide proof of current coverage under another employer-sponsored group medical benefit plan.
(3) An Eligible Employee participating with or enrolled in coverage bought on the individual market, the Oregon Health Plan/Medicaid, Veterans’ Administration Health Benefit Program, Student Health Insurance market may not elect to opt-out of OEBB-sponsored medical benefit plans. The Eligible Employee may elect to waive benefits or enroll in an OEBB-sponsored medical benefit plan.
(4) Eligible Employees electing to opt-out of the OEBB-sponsored medical benefit plans may enroll in the dental benefit plans, vision benefit plans, and optional benefit plans.
(5) The level and type of funds and allowances retained by Eligible Employees and Entities as a result of opt-out programs are determined through collective bargaining agreements and documented Entity policies.
(6) An Entity will provide OEBB with a written description of its opt-out program upon request.
(7) An otherwise Eligible Employee may opt-out of medical if the criteria above are met, decline dental and/or vision, or elect any combination of benefits provided under the OEBB-sponsored benefits program, unless otherwise stated in a collective bargaining agreement or documented Entity policy.
(8) Elections to opt out of the medical benefit plans or waive benefits must be made at the time of hire, when initially meeting eligibility, during an open enrollment period, or following a QSC event whereby the OEBB QSC Matrix allows this as an option.
(a) Coverage for previously OEBB-eligible employees or previously OEBB-eligible dependents enrolling in a dental plan during an open enrollment period will be limited to routine and preventive care for the first 12 months and subject to a 12-month waiting period for orthodontia coverage.
(b) An Eligible Employee who enrolls in a dental plan, or adds previously OEBB-eligible dependents to their dental plan following and consistent with a QSC event will not be subject to the 12 month waiting period.
(9) An Eligible Employee electing to not enroll when initially eligible for optional insurance plans, or enrolling for more than the guarantee issue amount, will have to go through a medical review. Failure to remit a medical history statement or complete other requirements will result in a declination of requested amounts, or the amount above the guaranteed amount, if applicable.
(10) An Eligible Employee electing to not enroll when initially eligible for optional short term disability will be subject to a late enrollment penalty upon enrollment.
Statutory/Other Authority: ORS 243.860 - 243.886
Statutes/Other Implemented: ORS 243.864(1)(a)
History:
OEBB 5-2017, amend filed 11/07/2017, effective 11/07/2017
OEBB 2-2014, f. & cert. ef. 3-7-14
OEBB 23-2013(Temp), f. & cert. ef. 12-27-13 thru 6-25-14
OEBB 9-2012, f. & cert. ef. 10-9-12
OEBB 4-2012(Temp), f. & cert. ef. 4-20-12 thru 10-16-12
OEBB 3-2011, f. & cert. ef. 2-11-11
Reverted to OEBB 21-2009, f. & cert. ef. 12-17-09
OEBB 9-2010(Temp), f. & cert. ef. 8-3-10 thru 1-29-11
OEBB 21-2009, f. & cert. ef. 12-17-09
OEBB 14-2009(Temp), f. & cert. ef. 7-31-09 thru 1-26-10
OEBB 9-2008, f. 6-25-08, cert. ef. 6-26-08