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-.01 - Definitions

Current through Rules and Regulations filed through June 27, 2024
(1)
"Active"
means that the Employee is receiving compensation or is on Approved
				Leave of Absence Without Pay through a department, school system, Local
				Employer, agency, authority, board, commission, county department of family and
				children services, county department of health, community service board, or
				Contract Employer and for whom the Employee's cost of Coverage is stated as a
				payroll Deduction or Reduction.
(2)
"Acts"
or
"The Acts"
or
"The Health Insurance
				Acts"
mean the legislative Acts that establish the Health Insurance
				Plans for State Employees, Teachers, and Public School Employees and are
				designated in the Official Code of Georgia Annotated as Article 1 of Chapter 18
				of Title 45 and Articles 880 and 910 of Chapter 2 of Title 20.
(3)
"Administrator"
means the
				Department of Community Health or the Commissioner of the Department of
				Community Health.
(4)
"Administrative Services"
means the services that are provided by
				contract for a self-insured Health Benefit Plan.
(5)
"Approved Leave of Absence Without
				Pay"
means a period of time approved by the appropriate organizational
				official during which the Employee is absent from work and is not in pay
				status.
(6)
"Annual Required
				Contribution"
means an actuarially determined amount to pay for future
				OPEB liability over a period of years.
(7)
"Beneficiary"
means an
				Employee, Surviving Spouse, divorced or legally separated Spouse, or eligible
				Dependent child who loses Coverage under these regulations.
(8)
"Benefits"
mean the schedule
				of Benefits of health care services eligible for approval of payments under the
				Options approved by the Board.
(9)
"Board of Community Health"
or
"Board"
means the
				governing body authorized to exercise jurisdiction over the SHBP pursuant to
				O.C.G.A. §
									31-2-3.
(10)
"Cafeteria Plan"
means a
				plan which meets the requirements of the regulations of the Internal Revenue
				Service under Internal Revenue Code (IRC) 125.
(11)
"Certificated Capacity"
means the Employee holds valid certification; is not assigned to a
				position that requires certification as a qualification; the Employee's
				compensation is determined, at least in part, based upon the certificate; and
				the Employee is a member of the Teachers Retirement System or other Public
				School Teacher retirement system.
(12)
"Certificated Position"
means the Employee holds valid certification; is assigned to a position
				that requires certification as a qualification; the Employee's compensation is
				determined, at least in part, based upon the certificate; and the Employee is a
				member of the Teachers Retirement System or other Public School Teachers
				retirement system.
(13)
"Claim"
means any bill, invoice, or other written statement from a
				specific provider for health care services or supplies submitted in accordance
				with the requirements of the SHBP for a specific eligible Member.
(14)
"Commissioner"
means the
				Commissioner of the Department of Community Health as created by O.C.G.A.
				§
									31-2-6.
(15)
"Contract Employee"
means a
				person employed by one of the entities that contracts with the Board of
				Community Health to provide health benefit Coverage under the SHBP, and who is
				not considered to be an independent contractor.
(16)
"Contract Employer"
means
				one of the organizational entities that has elected to contract with the Board
				of Community Health for inclusion of their Employees in the SHBP.
(17)
"Contribution"
means the
				amount or percentage of salaries to be paid by an Employing Entity or State
				Department of Education for Employees and Retirees for health benefit
				Coverage.
(18)
"Coverage"
means the type, Tier, and Option of contract offered to an Enrolled
				Member pursuant to the Health Insurance Acts. "Coverage" does not include
				TRICARE Supplemental Coverage.
(19)
"Covered Dependent"
means any individual eligible under these
				regulations and for whom the Premium has been paid by the Employee, Retiree, or
				Extended Beneficiary.
(20)
"Creditable Coverage"
means health insurance that may serve to
				reduce a Pre-existing Condition limitation period. Creditable Coverage shall
				include health plan offerings under the following type plans: group health
				plans; individual health policies; Health Maintenance Organizations (HMOs);
				Medicaid; Medicare; or other governmental health programs. Disease specific
				policies (i.e., cancer insurance), disability insurance, and insurance that
				provides incidental health insurance (i.e., auto insurance) is not Creditable
				Coverage.
(21)
"Deduction"
or
"Reduction"
means the Premium amount to be remitted to
				the Administrator as the Employee's or Retiree's share of the cost of the
				elected Coverage.
(22)
"Dependent"
means any eligible Spouse, Dependent child, or Totally
				Disabled Child.
(23)
"Employee"
means any eligible, Active State Employee, Teacher, or
				Public School Employee.
(24)
"Employing Entity"
means any department, school system, Local
				Employer, Contract Employer, agency, authority, board, commission, county
				department of family and children services, county department of health,
				community service board or retirement system that employs or issues an annuity
				check to an Employee, Contract Employee or Retiree as defined in these
				regulations.
(25)
"Enrolled
				Member"
means the contract holder who may be the Employee, Retiree,
				Contract Employee, or Extended Beneficiary who is currently enrolled in
				Coverage and who has paid the necessary Deduction or Premium for such
				Coverage.
(26)
"Extended
				Beneficiary"
means the individual who was covered as an Active or
				Retired Employee, Employee on Approved Leave of Absence Without Pay or person
				who was covered as a Spouse or eligible Dependent of an Active or Retired
				Employee or Employee on Approved Leave of Absence Without Pay on the day SHBP
				Coverage was lost as a result of a Qualifying Event under the requirements of
				federal law and regulation known as the Consolidated Omnibus Budget
				Reconciliation Act (COBRA), as amended.
(27)
"Fund"
or
"Health
				Benefit Fund"
or
"Health Insurance Fund"
means the State
				Employees Health Insurance Fund, the Teachers Health Insurance Fund, and the
				Public School Employees Health Insurance Fund.
(28)
"Georgia Retiree Health Benefit
				Fund"
or
"GRHBF"
means the fund which provides for costs of
				retiree post employment health insurance benefits. The fund shall be a trust
				fund of public funds; the Board in its official capacity shall be the fund's
				trustee; and the Commissioner in his or her official capacity shall be its
				administrator.
(29)
"Group"
means all eligible Employees authorized under a specific chapter,
				article or part of the Official Code of Georgia Annotated for Coverage under
				the SHBP.
(30)
"Health
				Maintenance Organization"
or
"HMO"
means an organization
				authorized and certified to provide services under Chapter 21 of Title 33 of
				the Official Code of Georgia Annotated.
(31)
"Local Employer"
means a
				county or independent board of education, regional or county libraries of
				Georgia, the governing authority of the Georgia Military College, or Regional
				Educational Service Areas.
(32)
"Managed Care Plan"
means plans that provide health Coverage
				through a specified network of providers with benefit differentials in cost
				sharing between in-network and out-of-network providers.
(33)
"Medicare Advantage"
means
				an Option that is offered to Retirees and is approved through the Centers for
				Medicare and Medicaid Services (CMS) as a Medicare Advantage plan under the
				Medicare Prescription Drug, Improvement and Modernization Act of 2003 and
				federal regulations thereunder.
(34)
"Member"
means a benefit
				eligible or ineligible Employee, former Employee, Retiree, or Extended
				Beneficiary.
(35)
"Option"
means a type of benefit schedule or premium rating category that is
				offered to an eligible Member through the SHBP.
(36)
"Other Post Employment Benefits"
or
"OPEB"
means retiree post-employment health insurance
				benefits.
(37)
"Partial
				Disability"
means the Employee is unable to perform the normal,
				full-time duties of the individual's occupation or employment due to
				disability, but is certified by his/her physician to return to work on a
				part-time basis following a period of disability for a fixed period of time in
				that individual's occupation or in a modified work capacity.
(38)
"Payor, Primary"
means the
				entity which is required by contract or law to reimburse or pay for covered
				health services without regard to any other benefit entitlement or contractual
				provision.
(39)
"Payor,
				Secondary"
means the entity which does not have the primary liability
				for providing benefit reimbursement for covered health services.
(40)
"Plan"
or
"Health
				Insurance Plan"
means the insurance Options formed by the combination of
				Health Insurance Plans for State Employees, Teachers, and Public School
				Employees.
(41)
"Plan Year"
means the twelve-month period beginning on January 1, and ending on the
				following December 31. The Commissioner shall have the flexibility to modify
				the SHBP Plan Year.
(42)
"Pre-existing Condition"
is a term defined by the Health Insurance
				Portability and Accountability Act of 1996 and regulations thereunder. In
				general, it means a sickness, injury, or other condition (except for pregnancy)
				for which medical advice, diagnosis, care or treatment was recommended or
				received within the six (6) months immediately before Coverage began under the
				Plan.
(43)
"Premium"
means the Enrolled Member's cost as set by the Board of Community Health
				for the elected Coverage
(44)
"Public School Employee"
means a person who is employed by the
				local school system, meets the eligibility requirements under these regulations
				and is receiving a salary for services.
(45)
"Qualifying Event"
means an
				event as defined by federal law or regulation that authorizes:
(a) eligibility for Extended Coverageor
(b) change in coverage election
				under a health benefit plan. Qualifying Events include changes in employment or
				family status as outlined in Sections
				111-4-1-.06,
				111-4-1-.07, and
				111-4-1-.08 of these
				regulations.