Compilation of Rules and Regulations of the State of Georgia › Department 111 - RULES OF DEPARTMENT OF COMMUNITY HEALTH › Chapter 111-4 - STATE HEALTH BENEFIT PLAN › Subject 111-4-1 - STATE HEALTH BENEFIT PLAN › Rule 111-4-1-.03 - General Provisions

Current through Rules and Regulations filed through June 27, 2024
(1)
Applicability.
All Members
				who become eligible for Coverage under the SHBP shall be enrolled or permitted
				to change Coverage election only in accordance with these regulations. All
				Employing Entities covered by the Acts shall administer the SHBP in accordance
				with these regulations. All Annuitants or Extended
				Beneficiaries shall be enrolled or permitted to change Coverage election only
				in accordance with these regulations.
(2)
Extension of SHBP to Eligible
				Groups.
The Board shall review and approve provisions for extending
				Coverage to eligible Groups as required by law. The special provisions may
				include allowing Members or Beneficiaries to reenroll in the SHBP.
(3)
Conformity with Federal
				Requirements.
When federal law is enacted requiring public employers to
				comply with certain requirements for continued receipt of public health or
				other grant funds, the Commissioner shall submit proposed regulations to the
				Board for approval.
(4)
Records.
The Plan records shall be maintained in accordance with
				applicable State and federal law and regulations, including, but not limited
				to, Chapter 33 of Title 31 of the Georgia Code and the privacy regulations
				promulgated under the Health Insurance Portability and Accountability Act of
				1996 (HIPAA). Records which are not private, confidential or otherwise excluded
				from disclosure shall be available for public inspection and copying, in
				accordance with the Georgia Open Records Act. Any medical records and other
				individually identifying health information presented to the Administrator or
				to any of the Third Party Administrators in the Claim adjudication process or
				medical review process shall be confidential and shall be accessible only in
				accordance with applicable State and federal law and regulations.
(5)
Member Responsibility.
The
				Member has responsibility for notifying the Employer and the Plan of
				discrepancies in the Member's Coverage records. Notwithstanding the foregoing,
				the requirements of this provision do not negate the Employer's responsibility.
				The Employing Entity must still fulfill notification and all other requirements
				set forth under these regulations.
(a) The
				Enrolled Member is responsible for assuring that the proper Premium payments
				are deducted or reduced from the Enrolled Member's salary or retirement benefit
				for the Coverage that the Enrolled Member selected. Premiums of Enrolled
				Members that are paid through direct pay are to be paid in accordance with
				their Coverage selection.
(b) The
				Enrolled Member is responsible for submitting such documentation as the Plan
				requires to verify the eligibility of Dependents to be added to Coverage within
				the timeframe allotted by the Plan. Any Dependents not verified within the
				Plan's allotted time shall not be eligible for Coverage until the next annual
				Open Enrollment period or subsequent Qualifying Event as described in these
				regulations.
(c) The Enrolled
				Member is responsible for updating Spouse and Dependent information and
				requesting appropriate changes in Coverage as the circumstances may warrant.
				The Enrolled Member shall reimburse the Plan in full for Claim liability and
				expenditures incurred by the Plan on behalf of a Dependent who does not meet
				the definition of an eligible Dependent under these regulations. Any refunds of
				Premiums (for reasons other than administrative error) will be limited to
				twelve (12) calendar months from the date that the Administrator receives
				evidence from the Enrolled Member that the Plan had no liability for additional
				covered persons.
(d) When the
				Enrolled Member desires to reduce the period under the insurance Options of
				limited Coverage for Pre-existing conditions which may apply to himself/herself
				or any Covered Dependent, the Enrolled Member shall provide the Administrator
				certification of prior Creditable Coverage from the appropriate health plan
				administrator.