reglab/statecodes huggingface dataset:
Oklahoma Administrative Code › Title 260 - Office of Management and Enterprise Services › Chapter 40 - Employee Benefits Department › Subchapter 37 - Competitive Bidding Criteria and Procedures for Contracts Awarded for Flexible Benefits Plans › Section 260:40-37-12 - Administrative review

Current through Vol. 41, No. 20, July 1, 2024
(a) If the
				protesting Bidder does not agree with the Contracts Administrator's decision on
				the challenge of award, the protesting Bidder may request an administrative
				review. Any protesting Bidder may appeal a decision by the Contracts
				Administrator to the Director. In order for the claim to be eligible for
				administrative review, the appeal must have been through the challenge of award
				process as per OAC
				260:40-37-11.
(b) The protesting Bidder must file a notice
				of appeal with the Director within seven (7) business days of the date of the
				letter notifying the Bidder of the decision by the Contracts Administrator of
				the challenge of award by the protesting Bidder, or the postmark of such
				letter, whichever is later. The letter shall contain the following:
(1) The letter must state all the facts and
				arguments giving rise to the claim of controversy and the appeal.
(2) The letter must also state clearly and
				separately the alleged error by the Contracts Administrator or other EBD
				personnel and the relief sought with the appeal to the Director.
(3) The letter must clearly and separately
				state that the Bidder is requesting an opportunity to be heard in pursuit of
				the appeal.
Oklahoma Administrative Code › Title 260 - Office of Management and Enterprise Services › Chapter 40 - Employee Benefits Department › Subchapter 37 - Competitive Bidding Criteria and Procedures for Contracts Awarded for Flexible Benefits Plans › Section 260:40-37-13 - Confidentiality

Current through Vol. 41, No. 20, July 1, 2024
The EBD, with the cooperation of the Department of Central
				  Services, shall be authorized to retain as confidential, any proprietary
				  information submitted in response to the EBD's RFP; provided, however, that any
				  such information requested by the EBD from the Bidders shall only be subject to
				  the confidentiality provision of this paragraph if it is clearly designated in
				  the RFP as being protected under this provision.
Oklahoma Administrative Code › Title 260 - Office of Management and Enterprise Services › Chapter 40 - Employee Benefits Department › Subchapter 37 - Competitive Bidding Criteria and Procedures for Contracts Awarded for Flexible Benefits Plans › Section 260:40-37-14 - Vision Plan Participation

Current through Vol. 41, No. 20, July 1, 2024
(a) A
				Vision Plan must notify the EBD of its intention to participate in the flexible
				benefits plan no later than 4:45 p.m., Central Standard Time on the first day
				of July prior to the beginning of each Plan Year. Such notification must
				conform to the requirements this section. If the first day of July is a weekend
				day or other day when the offices of the EBD are closed, notification of Vision
				Plan participation is due by 4:45 p.m., Central Time, on the next day the EBD's
				offices are open.
(b) Notice of a
				vision plan's intent to participate in the flexible benefits plan is properly
				provided upon submission of all of the following:
(1) A statement from the Vision Plan
				indicating Vision Plan's intent to participate;
(2) A list of the providers in Vision Plan's
				network;
(3) A document(s)
				indicating Vision Plan has operated in Oklahoma for at least five (5)
				years;
(4) Either a license issued
				by the Oklahoma State Insurance Department, or a certificate issued by the
				Oklahoma State Department of Health;
(5) A list of the rates the Vision Plan will
				charge during the subsequent Plan Year. Rates must be listed independently for
				the following categories:
(A) Employee
				Only,
(B) Spouse Only,
(C) One Child, and
(D) Two or More Children;
(6) Accurate product information
				in a format not to exceed two pages.
Oklahoma Administrative Code › Title 260 - Office of Management and Enterprise Services › Chapter 40 - Employee Benefits Department › Subchapter 39 - Authorized Payroll Deduction Vendor Material › Section 260:40-39-1 - Purpose

Current through Vol. 41, No. 20, July 1, 2024
The purpose of this Chapter is to describe the rules
				  governing the process by which materials from vendors that have an authorized
				  payroll deduction pursuant to Section
				  7.10 of
				  Title 62 of the Oklahoma Statutes or Section
				  1701
				  of Title 74 of the Oklahoma Statutes shall be placed in the annual benefit
				  enrollment materials provided to state employees and their dependents. The
				  provisions of this Chapter do not apply to vendors who do not have authorized
				  payroll deduction pursuant to Section
				  7.10 of
				  Title 62 of the Oklahoma Statutes or Section
				  1701
				  of Title 74 of the Oklahoma Statutes.
Oklahoma Administrative Code › Title 260 - Office of Management and Enterprise Services › Chapter 40 - Employee Benefits Department › Subchapter 39 - Authorized Payroll Deduction Vendor Material › Section 260:40-39-2 - Definitions

Current through Vol. 41, No. 20, July 1, 2024
The following words and terms, when used in this Chapter,
				  shall have the following meaning, unless the context clearly indicates
				  otherwise:
"EBD"
means the State of Employee Benefits
				  Department
"Plan Year"
means the period of time,
				  established by the EBD, for which benefits are offered to State employees and
				  their eligible dependents.
"Vendor"
means a product vendor that has been
				  approved for an authorized payroll deduction pursuant to Section
				  7.10 of
				  Title 62 of the Oklahoma Statutes or Section
				  1701
				  of Title 74 of the Oklahoma Statutes on or before the last calendar day of July
				  prior to each Plan Year.
"Vendor Material"
means a one page, front and
				  back, eight and one-half inch by eleven inch document which, at a minimum,
				  identifies the vendor, describes the product being offered, includes the
				  vendor's contact information, and includes the premium or cost of the product.
				  Vendor material must be printed on white paper with a weight equal to 50#
				  offset or 20# bond copy paper.
Oklahoma Administrative Code › Title 260 - Office of Management and Enterprise Services › Chapter 40 - Employee Benefits Department › Subchapter 39 - Authorized Payroll Deduction Vendor Material › Section 260:40-39-3 - General provisions

Current through Vol. 41, No. 20, July 1, 2024
(a) A vendor must
				deliver its vendor material to the Employee Benefits Department no later than
				4:45 p.m., Central Time, on the second Friday in August prior to the beginning
				of the benefits enrollment period announced by the EBD.
(b) Vendor material must be designed,
				printed, and reproduced by the vendor at the vendor's expense.
(c) The EBD will determine the number of
				copies of vendor material each vendor must supply. The amount will be
				communicated to vendors each year.
(d) The EBD will bind and distribute all
				timely and properly submitted vendor material at its own expense.
(e) The EBD may create forms to standardize
				and simplify the information required by this section. If a form(s) has been
				created, a vendor must complete the form(s) to provide proper
				delivery.
Oklahoma Administrative Code › Title 260 - Office of Management and Enterprise Services › Chapter 45 - Employees Group Insurance Division - Administrative and General Provisions › Subchapter 1 - Purpose, Definitions, Rules and References › Section 260:45-1-1 - Purpose

Current through Vol. 41, No. 20, July 1, 2024
The purpose of this chapter is to outline the structure of
				  the Office of Management and Enterprise Services (OMES) Employees Group
				  Insurance Division (EGID), to outline the use and confidentiality of members'
				  personal health information and to identify the availability and procedures to
				  be used to access a grievance hearing.
Oklahoma Administrative Code › Title 260 - Office of Management and Enterprise Services › Chapter 45 - Employees Group Insurance Division - Administrative and General Provisions › Subchapter 1 - Purpose, Definitions, Rules and References › Section 260:45-1-2 - Definitions

Current through Vol. 41, No. 20, July 1, 2024
The following words and terms as defined by EGID shall have
				  the following meaning unless the content clearly indicates otherwise:
"Adverse determination"
means a determination by
				  or on behalf of EGID or its designee utilization review organization that an
				  admission, availability of care, continued stay or other healthcare service is
				  a covered benefit but, after review, based upon the information provided, does
				  not meet EGID's requirements for medical necessity, appropriateness, health
				  care setting, level of care or effectiveness, and the requested service is
				  therefore denied, reduced, or terminated.
"EGID"
means the Employees Group Insurance
				  Division of the Office of Management and Enterprise Services.
"Grievance Panel"
means EGID's independent
				  constitutionally created administrative court. [Const. Art. 7. §
				  1.]
"Independent review organization"
means a
				  properly accredited entity that conducts independent external reviews of
				  adverse determinations on behalf of EGID.
"OEIBB"
means the Oklahoma Employees Insurance
				  and Benefits Board.
Oklahoma Administrative Code › Title 260 - Office of Management and Enterprise Services › Chapter 45 - Employees Group Insurance Division - Administrative and General Provisions › Subchapter 1 - Purpose, Definitions, Rules and References › Section 260:45-1-3 - Rules, cumulative

Current through Vol. 41, No. 20, July 1, 2024
The Employees Group Insurance Division of the Office of
				  Management and Enterprise Services hereinafter "EGID" will, from time to time,
				  adopt handbooks, policies and procedures for the implementation of the rules
				  set forth herein. Nothing in this chapter shall be read, interpreted,
				  understood or applied so as to affect the validity and enforceability of any
				  additional requirements, statutes, rules or regulations of any other
				  governmental entity, public agency or instrumentality which may be otherwise
				  applicable to those transactions, conduct and facilities regulated herein. The
				  rules in this title shall not be deemed cumulative and supplemental but shall
				  replace all previously promulgated rules of this agency.
Oklahoma Administrative Code › Title 260 - Office of Management and Enterprise Services › Chapter 45 - Employees Group Insurance Division - Administrative and General Provisions › Subchapter 1 - Purpose, Definitions, Rules and References › Section 260:45-1-4 - Rules in this title and benefit administration procedures or guidelines as adopted by EGID are controlling in all situations

Current through Vol. 41, No. 20, July 1, 2024
The rules in this title and the benefit administration
				  procedures or guidelines as adopted by EGID shall be controlling in all
				  situations, without exception, and any and all written information contained in
				  any handbook, summary or other document prepared by or for EGID shall be
				  superseded and limited by the rules in this title and the benefit
				  administration procedures or guidelines as adopted by EGID.
Oklahoma Administrative Code › Title 260 - Office of Management and Enterprise Services › Chapter 45 - Employees Group Insurance Division - Administrative and General Provisions › Subchapter 1 - Purpose, Definitions, Rules and References › Section 260:45-1-5 - Disclaimer of conflicting information

Current through Vol. 41, No. 20, July 1, 2024
In the event there appears to be a conflict between
				  information contained in the rules in this title and the benefit administration
				  procedures or guidelines as adopted by EGID, and any information contained
				  within any handbook or any other written materials, including any letters,
				  bulletins, notices, or any other written document, or oral communication,
				  regardless of the source, such conflict shall always be resolved by a strict
				  application of the rules in this title or the benefit administration procedures
				  or guidelines as adopted by EGID, and no conflict will be resolved by
				  application of the erroneous information contained within the handbook or other
				  written document when the result would be contrary to the limitations set forth
				  in the rules in this title, and the benefit administration procedures or
				  guidelines as adopted by EGID. All erroneous, incorrect, misleading or obsolete
				  language contained within any handbook or any other written document or oral
				  communication, regardless of the source, shall be void from the inception, and
				  of no effect under any circumstances.
Oklahoma Administrative Code › Title 260 - Office of Management and Enterprise Services › Chapter 45 - Employees Group Insurance Division - Administrative and General Provisions › Subchapter 1 - Purpose, Definitions, Rules and References › Section 260:45-1-6 - Amending of rules

Current through Vol. 41, No. 20, July 1, 2024
This chapter may be amended or repealed from time to time and
				  new rules adopted by EGID pursuant to the Administrative Procedures
				  Act.
Oklahoma Administrative Code › Title 260 - Office of Management and Enterprise Services › Chapter 45 - Employees Group Insurance Division - Administrative and General Provisions › Subchapter 1 - Purpose, Definitions, Rules and References › Section 260:45-1-7 - Gender reference

Current through Vol. 41, No. 20, July 1, 2024
All references to "he" or "his" are not intended to be gender
				  related, but shall apply equally to both sexes.
Oklahoma Administrative Code › Title 260 - Office of Management and Enterprise Services › Chapter 45 - Employees Group Insurance Division - Administrative and General Provisions › Subchapter 3 - Records and Information › Section 260:45-3-1 - EGID records; release of information

Current through Vol. 41, No. 20, July 1, 2024
All official records of EGID shall be public records open to
				  public inspection under reasonable circumstances at any reasonable time during
				  business hours by any person, but such records shall not be taken from the EGID
				  office. Copies of public records may be obtained pursuant to the current fee
				  schedule as adopted by EGID.
Oklahoma Administrative Code › Title 260 - Office of Management and Enterprise Services › Chapter 45 - Employees Group Insurance Division - Administrative and General Provisions › Subchapter 3 - Records and Information › Section 260:45-3-2 - Confidentiality of medical records

Current through Vol. 41, No. 20, July 1, 2024
(a) All
				information, documents, medical reports and copies thereof contained in a
				member's insurance file held by EGID shall be confidential and shall not be
				reviewed by unauthorized parties, without permission of the individual or
				provider, or by court order. The confidentiality of a member's information is
				maintained when the member's information held by EGID is utilized for health
				management and communicated among:
(1)
				employees of EGID;
(2) EGID's
				contracted third party administrators and consultants;
(3) providers to the member and
(4) the member, according to statutory
				provisions for privilege and confidentiality or written agreements to protect
				the confidentiality and non-disclosure of the information.
Oklahoma Administrative Code › Title 260 - Office of Management and Enterprise Services › Chapter 45 - Employees Group Insurance Division - Administrative and General Provisions › Subchapter 3 - Records and Information › Section 260:45-3-3 - Participating entities/business associate protection of confidential health Information

Current through Vol. 41, No. 20, July 1, 2024
(a) The
				participating entity/business associate may only use and disclose the member's
				health information for the purposes of a member's treatment, to facilitate
				payment for Plan benefits or for participating entity/business associate
				business operations on behalf of the member. The participating entity/business
				associate may not use or further disclose a member's health information other
				than permitted by EGID rules or described in a written contract between EGID
				and the participating entity/business associate.
(b) Participating entities/business
				associates shall protect a member's confidential health information according
				to the following guidelines. Participating entity/business associate shall:
(1) not use or disclose a member's health
				information other than permitted in these rules; described in a written
				contract with EGID or required by law,
(2) ensure that subcontractors or agents of
				the participating entity/business associate maintain confidentiality of any
				health information provided to its subcontractors or agents,
(3) not use or disclose confidential health
				information for employment related actions concerning the member, unless
				required by law,
(4) notify EGID
				within five [5] working days when the participating entity/business associate
				becomes aware of any use or disclosure of a member's health information that is
				inconsistent with this rule and make an accounting of these disclosures
				available for EGID and each member,
(5) allow a member to access and review
				health information on file with the participating entity/business associate and
				submit amending statements for inclusion in their health information
				file,
(6) establish procedures to
				protect a member's health information and account for disclosures not
				authorized by these rules,
(7)
				identify the participating entity/business associate employees who may access a
				member's health information and restrict access to those persons,
(8) return to EGID or destroy a member's
				health information when no longer required by the participating entity/
				business associate, and if not feasible, limit the use or disclosure to the
				required purposes,
(9) ensure that
				proper security is in place to protect electronically stored health information
				and
(10) make internal practices,
				books and records concerning uses and disclosures of protected health
				information available for inspection by the appropriate authority. A written
				contract between EGID and participating entity/business associate shall not
				limit the participating entity/business associate protection of a member's
				health information to an extent less than described in this rule.
Oklahoma Administrative Code › Title 260 - Office of Management and Enterprise Services › Chapter 45 - Employees Group Insurance Division - Administrative and General Provisions › Subchapter 3 - Records and Information › Section 260:45-3-4 - HealthChoice authorization for release of medical records

Current through Vol. 41, No. 20, July 1, 2024
Through the submission of claims, each member for whom
				  coverage is applied authorizes, without further notice or consent, EGID to
				  obtain from any provider of medical services, all records and information
				  pertaining to that service which will aid in the proper payment of said claims.
				  EGID is further authorized to use and release to third party payers any
				  information and records so obtained. In all instances, the Rules of
				  Confidentiality shall be applied without regard to the requirements of
				  260:45-3-2.
Oklahoma Administrative Code › Title 260 - Office of Management and Enterprise Services › Chapter 45 - Employees Group Insurance Division - Administrative and General Provisions › Subchapter 3 - Records and Information › Section 260:45-3-5 - Right to receive and release necessary information

Current through Vol. 41, No. 20, July 1, 2024
For the purpose of determining applicability of and
				  implementing the terms in this Plan or any provision of similar purpose of any
				  other Plan, the Administrator may, without the consent of or notice of any
				  person, release to or obtain from any other insurance company or other
				  organization or person any information, with respect to any person, which the
				  Administrator deems to be necessary for such purposes. Any person claiming
				  benefits under this Plan shall furnish to the Administrator such information as
				  may be necessary to implement this section.
Oklahoma Administrative Code › Title 260 - Office of Management and Enterprise Services › Chapter 45 - Employees Group Insurance Division - Administrative and General Provisions › Subchapter 3 - Records and Information › Section 260:45-3-6 - Call monitoring for quality control

Current through Vol. 41, No. 20, July 1, 2024
The Administrator may institute procedures for monitoring of
				  telephone calls for purposes of providing quality control.
Oklahoma Administrative Code › Title 260 - Office of Management and Enterprise Services › Chapter 45 - Employees Group Insurance Division - Administrative and General Provisions › Subchapter 3 - Records and Information › Section 260:45-3-7 - Electronic records and facsimile, electronic or copies of signatures

Current through Vol. 41, No. 20, July 1, 2024
Use of electronic records, electronic signatures, facsimile
				  signatures and handwritten signatures executed to electronic records.
(1) Electronic records, electronic
				signatures, handwritten signatures executed to sign electronic records,
				handwritten signatures used to effectuate an electronic record for network
				contracting purposes, and facsimile or copies of signatures on EGID forms
				received from participating entities or members, may be used as an alternative
				or duplicate of paper records and handwritten signatures executed on paper to
				comply with any of the record and signature requirements of 12A O.S.
				§15-101 et seq. these rules or applicable Oklahoma law.
(2) Combinations of paper records and
				electronic records, electronic records and handwritten signatures executed on
				paper, or paper records and electronic signatures or handwritten signatures
				executed to sign electronic records, may be used to comply with any of the
				record and signature requirements of 12A O.S. §15-101 et seq., these rules
				or applicable Oklahoma law.
(3) The
				EGID Administrator or a Deputy Administrator may utilize a facsimile signature
				stamp to execute EGID contracts of any kind.
Oklahoma Administrative Code › Title 260 - Office of Management and Enterprise Services › Chapter 45 - Employees Group Insurance Division - Administrative and General Provisions › Subchapter 5 - Grievance Panel Procedures › Section 260:45-5-1 - Request for hearing

Current through Vol. 41, No. 20, July 1, 2024
(a)
Grievances.
EGID has established procedures by which:
(1) Independent Review Organizations shall
				act as an appeals body for complaints by insured members regarding adverse
				benefit determinations based on medical necessity, appropriateness, health care
				setting, level of care, or effectiveness of a covered benefit,
(2) A three [3] member Grievance Panel shall
				act as an appeals body for complaints by insured members regarding all other
				issues.
Oklahoma Administrative Code › Title 260 - Office of Management and Enterprise Services › Chapter 45 - Employees Group Insurance Division - Administrative and General Provisions › Subchapter 5 - Grievance Panel Procedures › Section 260:45-5-2 - Notice of hearing

Current through Vol. 41, No. 20, July 1, 2024
Upon receipt of a Grievance request, after a member has
				  exhausted EGID's applicable internal review procedures, a hearing number shall
				  be assigned in grievances involving the three [3] member Grievance Panel and
				  notice shall be forwarded to the claims administration contractor by email,
				  secure workflow, or by regular mail at its closest office. The employee shall
				  be notified of the hearing date by mail with delivery confirmation. A copy of
				  all rules pertinent to the hearing shall be forwarded with the Notice, along
				  with a statement of claimant's rights.
Oklahoma Administrative Code › Title 260 - Office of Management and Enterprise Services › Chapter 45 - Employees Group Insurance Division - Administrative and General Provisions › Subchapter 5 - Grievance Panel Procedures › Section 260:45-5-3 - Prehearing conference

Current through Vol. 41, No. 20, July 1, 2024
For grievance hearings conducted by the three [3] member
				  Grievance Panel theAttorney representing EGID, the claimant, or the claimant's
				  attorney may request a pre-hearing conference to determine legal or factual
				  issues. The Attorney representing EGID may conduct such a
				  conference.
Oklahoma Administrative Code › Title 260 - Office of Management and Enterprise Services › Chapter 45 - Employees Group Insurance Division - Administrative and General Provisions › Subchapter 5 - Grievance Panel Procedures › Section 260:45-5-5 - Continuance; disposition; Attorney representation

Current through Vol. 41, No. 20, July 1, 2024
Any request for continuance of a hearing conducted by the
				  three [3] member Grievance Panel may be granted by the Attorney representing
				  EGID or the Panel if requested for any of the following reasons: illness or
				  unavailability of the party requesting the hearing, unavailability or illness
				  of a material witness, unavoidable conflict of schedule, unavailability of
				  relevant documents, or other good cause. All parties to the hearing shall be
				  notified of the continuance as soon as possible.
(1) Unless precluded by law, informal
				disposition may be made of any individual proceedings by stipulation, agreed
				settlement, consent order, or default.
(2) Any party shall at all times have the
				right to be represented by counsel at their own expense, provided such counsel
				is licensed to practice law by the Supreme Court of Oklahoma.
Oklahoma Administrative Code › Title 260 - Office of Management and Enterprise Services › Chapter 45 - Employees Group Insurance Division - Administrative and General Provisions › Subchapter 5 - Grievance Panel Procedures › Section 260:45-5-6 - Certificate of mailing

Current through Vol. 41, No. 20, July 1, 2024
All filings, including Orders, Notices and Briefs,
				  considered or issued by the three [3] member Grievance Panel shall include a
				  Certificate of Mailing showing the names and mailing addresses of adverse
				  parties or their attorneys of record.
Oklahoma Administrative Code › Title 260 - Office of Management and Enterprise Services › Chapter 45 - Employees Group Insurance Division - Administrative and General Provisions › Subchapter 5 - Grievance Panel Procedures › Section 260:45-5-7 - Final order; appeals

Current through Vol. 41, No. 20, July 1, 2024
(a)
Final
				Order.
The Grievance Panel shall enter a Final Order within no more than
				forty-five [45] days after the date of the hearing in all cases in which
				evidence and testimony has been offered and admitted. The Final Order shall
				separately state all Findings of Fact, Conclusions of Law and an Order
				approving or denying the claim.
(b)
District Court appeals.
The Grievance Panel's Final Order shall be
				considered a final decision of EGID for purposes of appeal. Any party to the
				hearing has the right to appeal to District Court from Final Orders entered by
				the Panel. This appeal shall be governed by the Administrative Procedures Act,
				75 O.S. §
									301, et
				seq., and by other pertinent statutes such as 74 O.S. §
									1301, et
				seq.
Oklahoma Administrative Code › Title 260 - Office of Management and Enterprise Services › Chapter 45 - Employees Group Insurance Division - Administrative and General Provisions › Subchapter 5 - Grievance Panel Procedures › Section 260:45-5-8 - Scheduling of hearings

Current through Vol. 41, No. 20, July 1, 2024
All requests for hearings assigned to the three [3] member
				  Grievance Panel shall be placed on the Grievance Paneldocket to be heard in
				  open court following the receipt of a properly submitted Request For Grievance
				  Panel Hearing form.
Oklahoma Administrative Code › Title 260 - Office of Management and Enterprise Services › Chapter 50 - Employees Group Insurance Division - Health, Dental, Vision and Life Plans › Subchapter 1 - Purpose and Definitions › Section 260:50-1-1 - Purpose

Current through Vol. 41, No. 20, July 1, 2024
The purpose of this chapter is to outline definitions, plan
				  administration, coverage, and exclusions pertaining to health, dental, vision
				  and life benefits.
Oklahoma Administrative Code › Title 260 - Office of Management and Enterprise Services › Chapter 50 - Employees Group Insurance Division - Health, Dental, Vision and Life Plans › Subchapter 3 - Administration of Plans › Section 260:50-3-1 - Open enrollment period

Current through Vol. 41, No. 20, July 1, 2024
The Board or the Legislature may, at its discretion, declare
				  an open enrollment period during which time eligible individuals may enroll in
				  optional coverage on behalf of themselves or eligible
				  dependents.
Oklahoma Administrative Code › Title 260 - Office of Management and Enterprise Services › Chapter 50 - Employees Group Insurance Division - Health, Dental, Vision and Life Plans › Subchapter 3 - Administration of Plans › Section 260:50-3-2 - Approval of exceptional claims and eligibility matters

Current through Vol. 41, No. 20, July 1, 2024
The Administrator shall have the authority to approve
				  individual exceptional claims or eligibility matters when circumstances
				  require.
Oklahoma Administrative Code › Title 260 - Office of Management and Enterprise Services › Chapter 50 - Employees Group Insurance Division - Health, Dental, Vision and Life Plans › Subchapter 3 - Administration of Plans › Section 260:50-3-3 - Insurance/Benefits Coordinator for Education, Local Government, and State Employees

Current through Vol. 41, No. 20, July 1, 2024
The appointing authority or governing body of each
				  participating entity shall designate an Insurance/Benefits Coordinator and at
				  least one [1] Alternate to properly enroll members of the entity. Any
				  information given by an Insurance/Benefits Coordinator shall not supersede or
				  modify the statutes, rules in this title or any Insurance/Benefits Coordinator
				  Guide governing the Group Insurance Plan. Insurance/Benefits Coordinator
				  representing retirees may be provided by the retirement system from which the
				  retiree is receiving benefits. It is the employee's duty to notify his
				  Insurance/Benefits Coordinator of a change in eligibility for himself, his
				  spouse or his dependents. It is the Coordinator's duty to notify EGID within
				  ten [10] working days of the employee's notice of change. EGID is not obligated
				  to accept untimely notifications of change, and may elect to refuse to permit
				  said changes.
Oklahoma Administrative Code › Title 260 - Office of Management and Enterprise Services › Chapter 50 - Employees Group Insurance Division - Health, Dental, Vision and Life Plans › Subchapter 3 - Administration of Plans › Section 260:50-3-4 - Right of recovery

Current through Vol. 41, No. 20, July 1, 2024
(a)
Error in
				payment.
Any benefits paid erroneously by EGID are fully recoverable
				from the recipient. No such erroneous payment shall constitute waiver or
				estoppel or result in any equitable obligation by EGID to pay any benefits
				which are not specifically payable according to the rules in this title and the
				benefit administration procedures or guidelines as adopted by the Board. [74
				O.S. §
									1321
				]
(b)
Excessive
				amounts.
Whenever payments have been made by EGID with respect to
				allowable expenses in a total amount, at any time, in excess of the maximum
				amount of payment necessary at the time to satisfy the intent of this part, the
				Administrator shall have the right to recover such excess, from any person,
				organization or company with respect to whom such payments were made.
(c)
Right to Audit.
EGID
				reserves the right to audit any enrollment or insurance change form and to
				require that supporting documentation showing the participant's eligibility,
				including (but not limited to) proof of a qualifying event, be provided. EGID
				may retroactively terminate coverage on any individual who was not eligible to
				be enrolled in the Plan and recover any claims paid on the individual's
				behalf.
Oklahoma Administrative Code › Title 260 - Office of Management and Enterprise Services › Chapter 50 - Employees Group Insurance Division - Health, Dental, Vision and Life Plans › Subchapter 3 - Administration of Plans › Section 260:50-3-5 - Responsibility for premium payment

Current through Vol. 41, No. 20, July 1, 2024
(a)
Participating entity premiums.
Employer and employee premiums for
				participating entities are due to EGID no later than the tenth [10 
				th ] day of each month following the
				month of coverage. The first payroll deductions for insurance premiums of
				individuals paid bi-weekly will be withheld from the first pay period that
				extends into the month during which insurance coverage begins. It is ultimately
				the employing agency's responsibility to check and verify that premiums paid to
				EGID are a true and accurate accounting of the member's approved coverage
				selections. If premium for coverage selected by the employee differs from the
				amount deducted from the member's check, then the participating entity is
				responsible for payment to EGID for any deficiencies in premium for the
				member's coverage. Any shortage of premiums due and payable will result in
				suspension of benefits for Plan participants.
(1) An employee may continue coverage while
				on approved leave without pay status for up to twenty-four [24] months as long
				as the entity continues to remit premiums with the entity's monthly payment.
				The twenty-four [24] month limitation shall be extended to eight [8] years for
				education employees who are absent from employment because of election or
				appointment as a local, state, or national education association officer.
				Except as protected by federal statute, employees on leave whose premiums are
				not remitted in a timely manner shall have their coverage terminated at the end
				of the month for which last payment was received. If coverage is terminated for
				non-payment all coverage is terminated. Upon return to work, the employee may
				re-enroll. All Plan limitations apply and evidence of insurability is required
				to re-enroll in any life coverage.
(2) Provided that if a State employee is on
				leave without pay due to an injury or illness arising out of the course of his
				employment, the employee may continue the insurance during the maximum period
				of the time allowed by law, and the employing agency shall pay the benefit
				allowance allowed by law.
(3) An
				employee may continue coverage while on suspension without pay for up to ninety
				[90] days following the date of suspension or the duration of the
				administrative appeals process, whichever is greater, as long as premiums are
				remitted by the entity for the coverage.
(4) Collecting any employee share from an
				employee on leave without pay or suspension without pay is the responsibility
				of the entity.
Oklahoma Administrative Code › Title 260 - Office of Management and Enterprise Services › Chapter 50 - Employees Group Insurance Division - Health, Dental, Vision and Life Plans › Subchapter 3 - Administration of Plans › Section 260:50-3-6 - Cancellation of coverage

Current through Vol. 41, No. 20, July 1, 2024
After notice and opportunity for a hearing according to the
				  Oklahoma Administrative Procedures Act and these rules, coverage may be
				  cancelled.
(1)
Cancellation of
				coverage due to non-payment of premium.
If payment is not received by
				the end of the month in which the payment is due, coverage shall be canceled
				effective the end of the month for which the last premium was received. EGID
				may reinstate coverage within sixty [60] days after the date EGID canceled
				coverage, if it is shown that the failure to pay premiums was not due to the
				member's negligence, subject to payment of any required premiums. The employee
				shall be notified in writing by EGID of cancellation of coverage and provided
				an opportunity for a hearing.
(2)
Cancellation of coverage due to insufficient funds.
In the event
				the member's payment is returned or refused due to insufficient funds or closed
				account, coverage may be cancelled unless the check is returned due to no fault
				of the member.
(3)
All
				coverage canceled.
If coverage is canceled for either of the reasons
				listed above all coverage will be terminated. When the employee is eligible to
				re-enroll, all Plan limitations apply and evidence of insurability is required
				to enroll in any life coverage.
(4)
Cancellation of coverage for Medicare members.
If payment is not
				received by the twentieth [20 th ] of the month,
				Medicare members will be notified of the delinquency and given thirty [30] days
				to make the payment. If payment is not made within the thirty [30] day grace
				period, coverage will be terminated effective the first
				[1st ] day of the following month.
Oklahoma Administrative Code › Title 260 - Office of Management and Enterprise Services › Chapter 50 - Employees Group Insurance Division - Health, Dental, Vision and Life Plans › Subchapter 3 - Administration of Plans › Section 260:50-3-7 - Underpaid premiums

Current through Vol. 41, No. 20, July 1, 2024
When premiums are underpaid for coverage which has been
				  selected and provided, future payments will first be applied to the shortage
				  and the shortage will be rolled forward. Employees may not choose to
				  retroactively cancel coverage that was selected. The full amount of the
				  underpaid premium shall be submitted within sixty [60] days after the date EGID
				  notifies the insured or the insured's employer of the error. When the
				  underpayment occurs because an employee has entered into a salary reduction
				  agreement pursuant to the Internal Revenue Code, and the insured's employer has
				  erroneously failed to withhold and submit the proper premiums to EGID, the
				  insured's employer shall be solely responsible for the payment of outstanding
				  underpaid premiums to EGID. Failure to submit premiums could result in loss of
				  coverage in accordance with
				  260:50-3-5(a)(3).
Oklahoma Administrative Code › Title 260 - Office of Management and Enterprise Services › Chapter 50 - Employees Group Insurance Division - Health, Dental, Vision and Life Plans › Subchapter 3 - Administration of Plans › Section 260:50-3-8 - Refunds

Current through Vol. 41, No. 20, July 1, 2024
(a)
Refunds of premium
				overpayments.
Any refund of payment for any premium overpayment shall be
				made only when EGID is notified in writing of the overpayment.
(b)
Administrative Error.
Refunds for overpayment due to administrative error, as limited and defined in
				the rules in this title, of the Insurance/Benefits Coordinator or the payroll
				clerk for EGID, shall be made at one hundred percent [100%].
(c)
Refunds on behalf of
				employees.
Refunds on behalf of employees shall be paid to the
				appropriate party. For an entity to receive a refund, the entity must have a
				credit balance.
(d)
Inaccurate or erroneous information.
If EGID finds that materially
				erroneous, false, inaccurate, or misleading information was intentionally
				submitted in order to obtain a specific coverage, then:
(1) For optional or supplemental life
				insurance coverage in excess of any guaranteed amounts of coverage, EGID shall
				extinguish its liability by tendering a refund of premiums paid to the insured
				or the beneficiary;
(2) Health or
				dental coverage would be canceled retroactive to the effective date of the
				coverage obtained by the misrepresentation. Refunded premiums would be reduced
				by any claims paid by HealthChoice.
Oklahoma Administrative Code › Title 260 - Office of Management and Enterprise Services › Chapter 50 - Employees Group Insurance Division - Health, Dental, Vision and Life Plans › Subchapter 3 - Administration of Plans › Section 260:50-3-13 - Rights of eligible former employees to continue in the Group Health, Dental, and Vision Insurance Plan

Current through Vol. 41, No. 20, July 1, 2024
(a) Health,
				dental and vision coverage may be elected as determined by State Statute or
				retained at the time of termination of employment from an employer who
				participates in that health, dental or vision coverage, if such election to
				continue in force or begin is made within thirty [30] days from the date of
				termination of service, and if the following conditions are met:
(1) The former employee either retires or has
				a vesting right with a State funded retirement plan, or has the requisite years
				of service with an employer participating in the Plan.
(2) The election must be received by EGID no
				later than thirty [30] days after the date of termination of service.
Oklahoma Administrative Code › Title 260 - Office of Management and Enterprise Services › Chapter 50 - Employees Group Insurance Division - Health, Dental, Vision and Life Plans › Subchapter 3 - Administration of Plans › Section 260:50-3-14 - Coverage for eligible non-vested employee

Current through Vol. 41, No. 20, July 1, 2024
A non-vested employee must apply for continuation of coverage
				  thirty [30] days after the date of termination of employment. Coverage must be
				  continuous and eligibility to continue must be based upon the length of service
				  required by statute. [74 O.S. §
									1316.2;
				  74 O.S. §
									1316.3
				  ]
Oklahoma Administrative Code › Title 260 - Office of Management and Enterprise Services › Chapter 50 - Employees Group Insurance Division - Health, Dental, Vision and Life Plans › Subchapter 3 - Administration of Plans › Section 260:50-3-16 - Participating entities

Current through Vol. 41, No. 20, July 1, 2024
(a)
Participation in plans offered by EGID.
Entities electing to
				participate in the dental, life, vision, or disability plans offered by EGID
				must participate in one of the authorized health plans, unless the
				Administrator grants a waiver. Coverage offered by EGID to eligible education
				employees will also be offered to all elected members of the school board for
				that entity.
(b)
Enrollment
				in group term life benefits.
An entity may elect to participate in the
				group term life coverage offered by EGID. This includes basic and optional
				supplemental life coverage for the employee and dependent life coverage.
				Entities electing to participate in the life plan offered by EGID must
				participate in the health plan, unless the Administrator grants a waiver.
(c)
Non-participating
				entities in other group plans.
The group plans offered by EGID shall not
				be offered to any entity which is participating in any other group insurance
				program, regardless of the percentage or number of employees eligible to
				enroll, unless the Administrator grants a waiver.
(d)
Right of Board to approve or deny
				applications for coverage.
EGID shall retain the right to approve or
				deny any employer group applications for coverage. Upon approval, coverage will
				become effective at 12:01 a.m. on the first [1 
				st ] day of the month following the
				month in which approval is granted unless a subsequent month is requested and
				approved in advance.
(e)
Coverage without preexisting conditions.
When an entity enrolls
				all employees of the new entity are covered without penalty for preexisting
				conditions.
(f)
Enrollment of
				all individuals presently insured.
Upon the group initial enrollment of
				an institution of higher education, all individuals presently insured by the
				institution's previous group health plan may become enrolled. If any such
				individual does not meet the eligibility requirements of this plan, they are
				eligible for coverage only for the remaining period of the institution's
				contractual liability. The institution must provide written proof of its
				contractual liability at the time of said individual's enrollment.
(g)
Attestation of continuous coverage
				for retirees.
Upon beginning or reinstating participation in health
				coverage offered by EGID, the entity must provide EGID with an attestation that
				retirees over age sixty-five [65] that will gain coverage through EGID have had
				continuous creditable coverage for prescription drugs (coverage that is at
				least as good as Medicare's) since the retirees became eligible for Medicare.
				The entity must provide an accurate list of any retiree over age sixty-five
				[65] that does not meet this requirement in order for EGID to properly report
				uncovered months to Medicare.
Oklahoma Administrative Code › Title 260 - Office of Management and Enterprise Services › Chapter 50 - Employees Group Insurance Division - Health, Dental, Vision and Life Plans › Subchapter 3 - Administration of Plans › Section 260:50-3-18 - Eligibility criteria for disabled dependent over the age of twenty-six [26]

Current through Vol. 41, No. 20, July 1, 2024
Eligibility criteria for covering a disabled dependent
				  beyond the age of twenty-six [26] pursuant to 74 O. S. §1303(14) are as
				  follows, provided all other eligibility requirements are also satisfied:
(1) It is intended that the following
				dependents beyond the age of twenty-six [26] are eligible for coverage under
				this provision:
(A) An individual who has
				been medically determined to be incapable of self-support because of mental or
				physical incapacity that currently exists and has continuously existed since
				before reaching the age of twenty-six [26] years; and
(B) The individual resides in the primary
				member's home at least six [6] months of the year, and is the primary member's
				natural child, foster child, adopted child, or a child of the primary member's
				spouse when the spouse has been ordered by a Court to provide health insurance
				for the child; and
(C) If the
				requirements of subsection (A) and (B) are met, eligibility through court
				appointed guardianship will be accepted for disabled children, foster children
				and grandchildren, but only when guardianship existed prior to the dependent
				reaching age nineteen [19]. The assessment/application for coverage must be
				submitted within thirty [30] days of obtaining legal guardianship. Power of
				attorney, including durable power of attorney, does not qualify as
				guardianship. Coverage ceases at the end of the month in which the primary
				member's appointment as guardian is terminated.
(D) An approved disabled dependent who has
				been medically determined to be incapable of self-support because of mental or
				physical incapacity that currently exists and has continuously existed since
				before reaching the age of twenty-six [26] years can only be added to coverage
				within thirty [30] days of a qualifying event. While changes to coverage
				(benefits or plan options) may be made during the annual Option Period,
				enrollment of a disabled dependent will not be considered without a qualifying
				event.
Oklahoma Administrative Code › Title 260 - Office of Management and Enterprise Services › Chapter 50 - Employees Group Insurance Division - Health, Dental, Vision and Life Plans › Subchapter 3 - Administration of Plans › Section 260:50-3-19 - Termination of dependent coverage

Current through Vol. 41, No. 20, July 1, 2024
Dependent reaches age twenty-six [26].
Coverage
				  will be terminated for dependents reaching age twenty-six [26] on the first [1 
				  st] day of the month following their
				  twenty-sixth [26 
				  th] birthday, except disabled
				  dependents who are incapable of self-support and who have been deemed eligible
				  for coverage by EGID.