reglab/statecodes huggingface dataset:
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 260:50-3-20 - Withdrawal from plan; termination or loss of coverage

Current through Vol. 41, No. 20, July 1, 2024
(a)
Withdrawal from plan.
Those
				eligible entities participating on a voluntary basis that elect to withdraw
				cannot re-enter the Plan for one [1] year following the date of withdrawal
				except for extraordinary circumstances. Notice of the election to withdraw must
				be provided to EGID thirty [30] days prior to the actual withdrawal
				date.
(b)
Termination of
				coverage due to insolvency of carrier.
Any eligible entities who have
				withdrawn and purchased other coverage, then have been notified by their other
				health and/or group dental insurance carrier that coverage is being terminated
				due to insolvency of the carrier may re-enroll in the corresponding coverages
				within thirty [30] days after the loss of coverage by submitting a completed
				application form which must be approved by EGID prior to enrollment. Excepted
				Benefits do not qualify as other health coverage for purposes of this
				rule.
(c)
Individual member
				withdrawal and re-enrollment.
An individual employee who discontinues
				coverage on himself cannot re-enroll in any coverage for himself or his
				dependents for a period of twelve [12] months. Subsequent to the end of this
				twelve [12] month period, he may reapply for coverage offered by EGID provided
				that he is eligible through a participating entity. The orthodontic limitations
				will apply.
(d)
Loss of other
				health, group dental or group life insurance coverage.
The twelve [12]
				month requirement does not apply when the individual member has lost other
				health, group dental and/or group life insurance coverage and is seeking
				reinstatement pursuant to Rule 260:50-3-20(c). Excepted Benefits do not qualify
				as other health coverage for purposes of this rule.
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 260:50-3-22 - Mid-year benefit election changes

Current through Vol. 41, No. 20, July 1, 2024
(a)
				Mid-year elections will be allowed in accordance with and under those
				circumstances stated within Title 26 Treasury Regulations, Section 125 of the
				Internal Revenue Code. The determination of Title 26 Treasury Regulations,
				Section 125 of the Internal Revenue Code compliance for the current employee
				will be through certification from the employer.
(b) EGID will accept any change for any
				current employee certified as being compliant by the employer of that current
				employee so long as the notification of change is received by EGID within
				thirty [30] days of the employee's mid-year plan election. The employer must
				further certify that the documentation supporting compliances is available to
				EGID and will be provided upon written request. An employer's cafeteria plan
				may permit an employee to revoke an election during a period of coverage and to
				make a new election only as provided in Title 26 Treasury Regulations 1.125-4.
				This is discretionary with the employer. Employees should be aware that Title
				26 Treasury Regulations, Section 125 of the Internal Revenue Code does not
				require a cafeteria plan to permit any of these changes.
(c) For all other members not on current
				employee status or whose employer does not operate his employee benefit plan
				under a Section 125 plan, the rules for mid-year changes will be subject to the
				Section 125 guidelines as detailed in Title 26 Treasury Regulations 1.125-4.
(d) In all cases, mid-year
				election changes will only be considered in the event of a qualifying status
				change as described within Title 26 Treasury Regulations, Section 125 of the
				Internal Revenue Code and other federally required mandates. All other changes
				not in conjunction with a qualifying event can only be made during the annual
				Option Period.
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 260:50-3-23 - Corrections to benefit elections

Current through Vol. 41, No. 20, July 1, 2024
Members shall review their confirmation of coverage statement
				  to ensure that the coverage elected is correct. Any corrections shall be
				  submitted to the member's Insurance/Benefits Coordinator and EGID within sixty
				  [60] days of the election. Errors reported after the sixty [60] days shall be
				  effective the first [1st ] day of the month
				  following the notification of the error.
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 260:50-3-24 - Double coverage prohibited

Current through Vol. 41, No. 20, July 1, 2024
An eligible person shall not be insured as a primary insured
				  and also as a dependent for any benefit options except dependent life, nor can
				  any dependent be covered simultaneously by more than one primary insured,
				  except for dependent life. Double enrollment, whether it occurs intentionally
				  or by error, shall be deemed void from the inception, and EGID reserves the
				  right to decide which form of single enrollment coverage to allow, whether
				  primary or dependent.
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 260:50-3-25 - Basic disclosure plan for HealthChoice Medicare beneficiaries

Current through Vol. 41, No. 20, July 1, 2024
(a) The following words and terms as defined
				by EGID, when used in this section, shall have the following meaning: "Medicare
				beneficiary" means individuals eligible for HealthChoice Medicare plan coverage
				who are also entitled to Medicare benefits as designated by the United States
				Social Security Administration.
(b)
				In order to assure Medicare beneficiaries with an understanding of the medical
				and pharmacy benefits provided by, and the operation of, the HealthChoice
				Medicare plans; EGID shall maintain, adopt, and implement a basic disclosure
				plan for Medicare beneficiaries. This basic disclosure plan includes but is not
				limited to informational materials such as:
(1) A Medicare beneficiary benefits handbook
				providing a summary of medical and pharmacy benefits available under EGID's
				Medicare HealthChoice plan. Such handbooks shall be updated when material
				benefits or covered services change, or when reductions occur. A separate
				notification of material changes will be sent to all Medicare beneficiaries in
				a timely fashion prior to the updating of the Medicare beneficiary benefits
				handbook.
(2) A pre-enrollment
				package which shall be provided to all plan eligible Medicare beneficiaries.
				The pre-enrollment package shall, within a reasonable person's determination,
				be written in clear and understandable language providing the Medicare
				beneficiary detailed and necessary information upon which to make a selection
				of coverage for an upcoming plan year.
(3) A confirmation of benefit coverage form
				which will be distributed in a timely fashion after enrollment of a Medicare
				beneficiary, and by which HealthChoice shall notify the Medicare beneficiary of
				the plan coverage for the upcoming year.
(4) An explanation of benefit determination
				letter explaining the outcome of each medical or pharmacy claim processed for
				payment or denial. In the case of denial the explanation of benefit
				determination letter shall provide information of the appeals process available
				to the Medicare beneficiary.
(5)
				Material which provides all Medicare beneficiaries with basic disclosure
				information on special enrollment rights, medical child support orders, and any
				Medicare service or benefit that EGID by law has been directed to
				provide.
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 260:50-3-26 - Termination of benefits

Current through Vol. 41, No. 20, July 1, 2024
(a)
Termination of coverage.
The coverage under this plan will
				terminate at the earliest time stated below:
(1) On the last day of the calendar month in
				which employment terminates.
(2)
				When the plan is discontinued.
(3)
				When any required premiums cease to be paid.
(4) The individual does not begin or continue
				coverage as an eligible participating former employee and/or
				dependent.
(5) For a dependent when
				said dependent becomes ineligible for coverage.
(6) A participating entity ceases to
				participate in this plan.
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 260:50-3-27 - Procedures and implementation

Current through Vol. 41, No. 20, July 1, 2024
Notice of right to continue coverage.
EGID shall
				  advise each covered employee of his right to continue coverage under Federal
				  COBRA provisions. COBRA coverage applies only to health, dental, and vision
				  benefits. Life and disability coverage are not available through
				  COBRA.
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 260:50-3-28 - COBRA administration

Current through Vol. 41, No. 20, July 1, 2024
(a)
COBRA
				coverage is identical to coverage provided at date of the qualifying
				event.
The coverage elected shall be identical to the coverage provided
				at the date of the qualifying event. Should a beneficiary move out of the
				service area of their current plan, the beneficiary will be allowed to change
				to a plan whose service area covers the beneficiary's new location.
(b)
Payment of back premiums.
All back premiums from the termination of coverage to the election and approval
				of continuation must be paid before coverage is effective. Coverage will then
				be retroactive to provide continuous coverage. All time limits are mandatory
				and cannot be waived under any circumstances.
(c)
Responsibility of qualified
				beneficiary to inform EGID of ineligibility.
It is the responsibility of
				the qualified beneficiary to provide timely notice if he is not eligible for
				any reason. Failure to do so will result in cancellation of COBRA insurance
				coverage, retroactive to the time of ineligibility.
(d)
Primary member premium.
For
				any benefit continued under COBRA, one person must pay the primary member
				premium. In cases where a spouse, child, or children are insured for a
				particular benefit where the primary member did not retain coverage, one person
				will be billed at the primary member rate.
(e)
Federal regulations.
Federal
				regulations regarding COBRA extension of coverage shall be controlling in all
				situations where applicable.
Oklahoma Administrative Code › Title 260 - Office of Management and Enterprise Services › Chapter 50 - Employees Group Insurance Division - Health, Dental, Vision and Life Plans › Subchapter 5 - Coverage and Limitations › Part 1 - POLICY PROVISIONS › Section 260:50-5-1 - Selection of health plans

Current through Vol. 41, No. 20, July 1, 2024
(a)
Requirements for selection of HMO.
Eligible employees may select
				  either the state's comprehensive health plan (HealthChoice) or an HMO option.
				  In order to select an HMO option, the employee must reside or be employed
				  within the selected HMO's service area. The HMO election will apply not only to
				  the employee, but also to all covered dependents. Eligible retirees, vested,
				  non-vested, COBRA or survivor members and eligible dependents must reside
				  within the selected HMO's service area to participate in the HMO.
(b)
Selection of HMO during enrollment
				  period.
A choice of comprehensive benefits or the HMO may be made on an
				  annual basis by the member during the enrollment period as set by EGID. The
				  eligibility requirements set by EGID as applied to the comprehensive health
				  plan will apply to the HMO. Eligible members in all cases will retain
				  eligibility for dental, basic life and AD&D. Selection of the comprehensive
				  health plan or the HMO option will not affect eligibility for life and
				  AD&D, dependent dental, or dependent Life.
Oklahoma Administrative Code › Title 260 - Office of Management and Enterprise Services › Chapter 50 - Employees Group Insurance Division - Health, Dental, Vision and Life Plans › Subchapter 5 - Coverage and Limitations › Part 3 - HEALTHCHOICE PLANS › Section 260:50-5-2 - Schedule of benefits and benefit administration procedures or guidelines as adopted by EGID

Current through Vol. 41, No. 20, July 1, 2024
All benefits for HealthChoice plans offered through EGID
					 as described in the rules in this title shall be paid according to the
					 handbooks, schedule of benefits and benefit administration procedures or
					 guidelines as adopted by EGID. The schedule of benefits and benefit
					 administration procedures or guidelines as adopted by EGID shall be available
					 for inspection by the public during regular office hours at OMES EGID, 2401 N.
					 Lincoln Boulevard, Suite 300, Oklahoma City, OK 73105.
Oklahoma Administrative Code › Title 260 - Office of Management and Enterprise Services › Chapter 50 - Employees Group Insurance Division - Health, Dental, Vision and Life Plans › Subchapter 5 - Coverage and Limitations › Part 3 - HEALTHCHOICE PLANS › Section 260:50-5-3 - HealthChoice approval for emergency treatment by non-Network providers [REVOKED]

Current through Vol. 41, No. 20, July 1, 2024
Oklahoma Administrative Code › Title 260 - Office of Management and Enterprise Services › Chapter 50 - Employees Group Insurance Division - Health, Dental, Vision and Life Plans › Subchapter 5 - Coverage and Limitations › Part 3 - HEALTHCHOICE PLANS › Section 260:50-5-10 - Plan limits

Current through Vol. 41, No. 20, July 1, 2024
EGID will adopt handbooks, policies and procedures for the
					 implementation of the HealthChoice benefit plans. These documents shall clearly
					 describe any limits associated with:
(1) Individual and family deductibles;
(2) Network and Non-Network
				  out-of-pocket maximums; and
(3)
				  Charges associated with Non-Network providers.
Oklahoma Administrative Code › Title 260 - Office of Management and Enterprise Services › Chapter 50 - Employees Group Insurance Division - Health, Dental, Vision and Life Plans › Subchapter 5 - Coverage and Limitations › Part 3 - HEALTHCHOICE PLANS › Section 260:50-5-11 - Covered charges

Current through Vol. 41, No. 20, July 1, 2024
Items which will be considered for payment under
					 HealthChoice will be referred to as covered charges that are medically
					 necessary. Specific criteria and limitations apply. Covered charges may
					 include:
(1)
Hospital
				  services;
(2)
Provider's services;
(3)
Skilled Nurse facility
				  expense;
(4)
Skilled
				  nurse care;
(5)
Dentist's or oral surgeon's services;
(6)
Oral surgery;
(7)
Rehabilitative care;
(8)
Outpatient
				  expense;
and
(9)
Hospice care.
(10)
Approval of exceptional claims
(A) EGID's Health Care Management Unit may
				  recommend exceptions to the benefits provided by HealthChoice for situations
				  which would otherwise be denied or subject to limited coverage.
(B) Each request for exception must first be
				  reviewed by the Health Care Management Unit on an individual basis. All
				  responsibility for providing the documentation necessary to complete the review
				  falls to the member. Recommendations will then be given to the Medical Director
				  and Administrator both of whom must review all requested exceptions. Exceptions
				  that have been reviewed but not approved in writing by the Medical Director and
				  Administrator are deemed not approved. Approval of exceptions shall not
				  establish precedent for other requests. All requests shall confirm that the
				  requested exception is:
(i) medically
				  necessary, and
(ii) within
				  medically-accepted standards of care, and
(iii) cost effective, and/or
(iv) in compliance with all criteria as
				  established by the Medical Director or designee.
(C) Requests conforming with all listed
				  criteria shall remain subject to approval or denial at the discretion of the
				  Medical Director or designee.
Oklahoma Administrative Code › Title 260 - Office of Management and Enterprise Services › Chapter 50 - Employees Group Insurance Division - Health, Dental, Vision and Life Plans › Subchapter 5 - Coverage and Limitations › Part 3 - HEALTHCHOICE PLANS › Section 260:50-5-12 - HealthChoice plan limitations and exclusions

Current through Vol. 41, No. 20, July 1, 2024
For the health plans provided by EGID, there is no
					 coverage for expenses incurred for or in connection with conditions, services,
					 procedures, treatments, expenses, items, and supplies excluded by EGID's
					 benefit guidelines. There is no coverage or reimbursement for services or
					 supplies provided by ineligible providers. [260:50-1-2
					 ]
Oklahoma Administrative Code › Title 260 - Office of Management and Enterprise Services › Chapter 50 - Employees Group Insurance Division - Health, Dental, Vision and Life Plans › Subchapter 5 - Coverage and Limitations › Part 3 - HEALTHCHOICE PLANS › Section 260:50-5-13 - Payment of HealthChoice health, dental and life benefits

Current through Vol. 41, No. 20, July 1, 2024
(a) Life insurance benefits are payable to
				  the beneficiary designated by the employee. Premiums and overpaid disability
				  benefits due and payable to EGID at the time of the insured's death may be
				  withheld from life insurance benefits before payment of the remainder to the
				  beneficiary or estate. Life proceeds are not assignable, except a beneficiary
				  may assign proceeds in an amount equal to the decedent's burial expenses. If no
				  beneficiary form is on file with EGID, benefits will be paid to the decedent's
				  estate.
(b) Health and dental
				  benefits are payable to the employee or the provider. If any health or dental
				  benefits remain unpaid at the employee's death, EGID, may at its option, pay
				  the benefits to the employee's estate or to any one or more relatives such as
				  follows: spouse, father, mother, children, brothers or sisters. Any such
				  payment will constitute complete discharge of EGID's obligation to the extent
				  of the amount paid.
(c) If a minor
				  or person otherwise legally incapable of giving a valid receipt of discharge of
				  any payment is selected as a beneficiary, a guardian must be appointed by a
				  court of competent jurisdiction before benefits shall be paid.
Oklahoma Administrative Code › Title 260 - Office of Management and Enterprise Services › Chapter 50 - Employees Group Insurance Division - Health, Dental, Vision and Life Plans › Subchapter 5 - Coverage and Limitations › Part 3 - HEALTHCHOICE PLANS › Section 260:50-5-14 - Timely filing of HealthChoice health and dental claims

Current through Vol. 41, No. 20, July 1, 2024
Proof of health and dental claims for services received
					 (bill/receipt) must be furnished per the Plan policy. If such proof is not
					 furnished within the time allowed, at EGID's discretion the claim will still be
					 considered if the Insured or Provider shows that it was not reasonably possible
					 to furnish the notice of proof within the specified time and that the notice of
					 proof was furnished as soon as reasonably possible.
Oklahoma Administrative Code › Title 260 - Office of Management and Enterprise Services › Chapter 50 - Employees Group Insurance Division - Health, Dental, Vision and Life Plans › Subchapter 5 - Coverage and Limitations › Part 3 - HEALTHCHOICE PLANS › Section 260:50-5-15 - HealthChoice examination

Current through Vol. 41, No. 20, July 1, 2024
EGID reserves the right and opportunity to order the
					 examination of the person whose injury or sickness is the basis of a claim as
					 often as may be reasonable during the pending of the claim.
Oklahoma Administrative Code › Title 260 - Office of Management and Enterprise Services › Chapter 50 - Employees Group Insurance Division - Health, Dental, Vision and Life Plans › Subchapter 5 - Coverage and Limitations › Part 3 - HEALTHCHOICE PLANS › Section 260:50-5-16 - Action to recover

Current through Vol. 41, No. 20, July 1, 2024
No action at law or in equity shall be brought to recover
					 on this Plan unless brought pursuant to the Administrative Procedures Act, nor
					 shall such action be brought at all unless brought within three [3] years from
					 the expiration of the time within which proof of loss is required by the
					 policy.
Oklahoma Administrative Code › Title 260 - Office of Management and Enterprise Services › Chapter 50 - Employees Group Insurance Division - Health, Dental, Vision and Life Plans › Subchapter 5 - Coverage and Limitations › Part 3 - HEALTHCHOICE PLANS › Section 260:50-5-17 - Program integrity

Current through Vol. 41, No. 20, July 1, 2024
EGID may have a Program Integrity Initiative. The purpose
					 is to identify, recover, and prevent inappropriate provider billings and
					 payments through provider audits. The provider shall furnish any and all claims
					 information and medical documentation, upon request and at no cost, to EGID.
					 The requested documentation will be verified to substantiate the provision of
					 medical, dental, or durable medical equipment/supplies, and the charges for
					 such services, if the member and the provider are seeking reimbursement through
					 EGID. EGID will ensure appropriate payment to providers and recovery of
					 misspent funds, while providers shall ensure they only provide appropriate
					 services and exercise appropriate billing practices. EGID may implement
					 additional procedures and processes to effectuate this section.
Oklahoma Administrative Code › Title 260 - Office of Management and Enterprise Services › Chapter 50 - Employees Group Insurance Division - Health, Dental, Vision and Life Plans › Subchapter 5 - Coverage and Limitations › Part 5 - HEALTHCHOICE LIFE BENEFITS › Section 260:50-5-20 - Term life coverage

Current through Vol. 41, No. 20, July 1, 2024
(a)
Group
				  Term Life Benefits.
A former employee who is reemployed by a
				  participating employer within twenty-four [24] months after the date of
				  termination of previous employment shall not be enrolled for a greater amount
				  of life insurance than the individual had at the time of termination of
				  previous employment with the employer, unless the individual provides
				  satisfactory evidence of insurability or the guaranteed issue based on the
				  employee's current salary exceeds his or her prior coverage. Any life insurance
				  amount requested exceeding both prior coverage and the guarantee issue based on
				  the employee's current salary would require the individual to provide
				  satisfactory evidence of insurability. The amount of coverage provided by the
				  employer is specified in the benefit administration procedures or guidelines as
				  adopted by EGID. However, to elect this benefit, the member must be either a)
				  enrolled in one of the group health plans offered through EGID or b) be
				  enrolled in other qualified health coverage. In the event of death, the
				  proceeds of this coverage are payable to the beneficiary listed on the most
				  recently signed beneficiary designation subject to the limitations in Title 15.
				  [15 O.S. §
										178 ] If no beneficiary form is on
				  file at EGID, benefits will be paid to the decedent's estate.
(b)
Unlimited contestability
				  period.
There shall be no time limitation imposed upon EGID, during
				  which coverage based on evidence of insurability submitted to EGID can be
				  contested, if it is found that materially erroneous, false, inaccurate, or
				  misleading information was provided in order to obtain optional or supplemental
				  coverage in excess of any guaranteed amounts of coverage. In the event EGID
				  determines coverage was granted based upon erroneous, false, inaccurate or
				  misleading information, and that such information was material to EGID
				  providing any optional or supplemental coverage, EGID shall extinguish its
				  liability by tendering a refund of premiums paid to the insured or the
				  beneficiary.
Oklahoma Administrative Code › Title 260 - Office of Management and Enterprise Services › Chapter 50 - Employees Group Insurance Division - Health, Dental, Vision and Life Plans › Subchapter 5 - Coverage and Limitations › Part 5 - HEALTHCHOICE LIFE BENEFITS › Section 260:50-5-21 - Optional dependent life coverage

Current through Vol. 41, No. 20, July 1, 2024
(a)
Current employees.
Current employees may select life insurance
				  coverage for eligible dependents if the employee is enrolled in basic life.
				  This coverage does not include accidental death or dismemberment benefits. This
				  benefit is available even if the dependent is a participating
				  employee.
(b)
Former
				  employees.
Former employees may continue this coverage if the member is
				  enrolled in basic life.
Oklahoma Administrative Code › Title 260 - Office of Management and Enterprise Services › Chapter 50 - Employees Group Insurance Division - Health, Dental, Vision and Life Plans › Subchapter 5 - Coverage and Limitations › Part 5 - HEALTHCHOICE LIFE BENEFITS › Section 260:50-5-23 - Rights of retired and vested employees to continue life insurance coverage

Current through Vol. 41, No. 20, July 1, 2024
(a) Continuation of
				  coverage. Any person who retires or who has elected to receive a vested benefit
				  under the provisions of the Oklahoma Public Employees Retirement System, the
				  Oklahoma Teachers Retirement System, the Uniform Retirement System for Justices
				  and Judges, or the Oklahoma Law Enforcement Retirement system or is eligible to
				  continue in force the life insurance coverage following retirement or
				  termination of employment with the required minimum years of service with a
				  participating employer, or who meets each and every requirement of the State
				  Employees Disability Plan, or the spouse or dependent of any such employee, may
				  continue in force life benefits purchased prior to severance in a face amount
				  of no less than one-fourth [1/4] of the basic life coverage amount in five
				  thousand dollar [$5,000.00] increments, and the full amount of any additional
				  life insurance that was in effect prior to the date of retirement. Said
				  individual shall pay actuarially determined cost of such coverage and shall
				  make such election within thirty [30] days following the date of severance.
				  Said election to continue coverage becomes effective on the first [1 
				  st ] day of the month following
				  termination of current employment. Eligible employees may continue in force the
				  dependent life coverage in effect at time of termination of employment in five
				  hundred dollar [$500] increments per dependent if the member is enrolled in
				  basic life coverage.
(b)
Decrease or termination of coverage.
Coverage may be decreased or
				  terminated after severance from current employment, but shall not be increased
				  or reinstated after severance, except as permitted by rule or
				  statute.
(c)
Unavailability
				  to retirees, vested or eligible non-vested members or dependents.
Accidental death and dismemberment and loss of sight benefits are not available
				  to retired, vested, or eligible non-vested members or dependents.
(d)
Retirees returning to active
				  employment.
When an individual has retired and then returns to active
				  employment, that individual may not retain any more life insurance upon
				  termination of active employment than the amount that was retained when the
				  individual initially retired, unless the period of active employment is for at
				  least three [3] years.
Oklahoma Administrative Code › Title 260 - Office of Management and Enterprise Services › Chapter 50 - Employees Group Insurance Division - Health, Dental, Vision and Life Plans › Subchapter 5 - Coverage and Limitations › Part 7 - LIMITATIONS AND EXCLUSIONS FOR HEALTHCHOICE LIFE PLAN › Section 260:50-5-24 - Limitations and exclusions for life plans

Current through Vol. 41, No. 20, July 1, 2024
For the life plans provided by EGID, there is no coverage
					 for expenses incurred for or in connection with any of the items listed
					 below:
(1) There is no coverage for
				  employee life or dependent life benefits during the first twenty-four [24]
				  months of coverage when death is the result of suicide. The twenty-four [24]
				  month exclusion for death by suicide will begin on the effective dates of all
				  elective increases in coverage, and will apply to all increased amounts of
				  coverage which have been in effect for less than twenty-four [24] months on the
				  date of the act causing the insured's death.
(2) There is no coverage for accidental death
				  and dismemberment benefits or loss of sight benefits when such occurs as a
				  result of the following:
(A) Suicide,
				  attempted suicide or intentional self destruction, or intentionally
				  self-inflicted injury while sane or insane,
(B) Committing an assault or felony,
				  including participation as an aggressor in a riot or insurrection,
(C) Wholly or partly, directly or indirectly,
				  by disease, physical or mental, or by medical or surgical treatment or the
				  diagnosis of any of the foregoing,
(D) Wholly or partly, directly or indirectly
				  by bacterial infection, other than septic infection of and through a visible
				  wound sustained solely through external and accidental means,
(E) Any narcotic, drug, poison, gas or fumes,
				  voluntarily taken, administered, absorbed or inhaled, unless prescribed for the
				  exclusive use of the deceased, or administered by a licensed provider for a
				  legal purpose,
(F) Hang gliding,
				  sky diving and flying experimental aircraft.
Oklahoma Administrative Code › Title 260 - Office of Management and Enterprise Services › Chapter 50 - Employees Group Insurance Division - Health, Dental, Vision and Life Plans › Subchapter 5 - Coverage and Limitations › Part 9 - HEALTHCHOICE DENTAL BENEFITS, LIMITATIONS, AND EXCLUSIONS › Section 260:50-5-30 - Scope of coverage

Current through Vol. 41, No. 20, July 1, 2024
The dental expense benefit applies to eligible covered
					 employees and dependents. This benefit provides payment for dental expenses
					 incurred in excess of any applicable deductible. However, to elect this
					 benefit, the member must either be a) enrolled in one of the group health plans
					 offered through EGID or b) be enrolled in other qualified health coverage. It
					 is not necessary for dependents to be covered by health benefits to receive the
					 benefits of this Plan.
Oklahoma Administrative Code › Title 260 - Office of Management and Enterprise Services › Chapter 50 - Employees Group Insurance Division - Health, Dental, Vision and Life Plans › Subchapter 5 - Coverage and Limitations › Part 9 - HEALTHCHOICE DENTAL BENEFITS, LIMITATIONS, AND EXCLUSIONS › Section 260:50-5-31 - Plan limits

Current through Vol. 41, No. 20, July 1, 2024
(a)
Deductible.
The deductible amounts are the out-of-pocket expenses
				  for a class of benefits incurred by the employee for himself or on behalf of a
				  covered dependent during each calendar year.
(b)
Family deductible.
During
				  any benefit period, EGID will pay a percentage of the covered charges incurred
				  which exceed the family deductible amount, if applicable.
(c)
Maximum benefits.
The dental
				  plan has a maximum benefit on a calendar year basis as established by
				  EGID.
Oklahoma Administrative Code › Title 260 - Office of Management and Enterprise Services › Chapter 50 - Employees Group Insurance Division - Health, Dental, Vision and Life Plans › Subchapter 5 - Coverage and Limitations › Part 9 - HEALTHCHOICE DENTAL BENEFITS, LIMITATIONS, AND EXCLUSIONS › Section 260:50-5-32 - HealthChoice Dental limitations and exclusions

Current through Vol. 41, No. 20, July 1, 2024
For the dental plans provided by EGID, there is no
					 coverage for expenses incurred for or in connection with conditions, services,
					 procedures, treatments, expenses, items, and supplies excluded by EGID's
					 benefit guidelines.
Oklahoma Administrative Code › Title 260 - Office of Management and Enterprise Services › Chapter 50 - Employees Group Insurance Division - Health, Dental, Vision and Life Plans › Subchapter 5 - Coverage and Limitations › Part 11 - HEALTHCHOICE MEDICARE SUPPLEMENT › Section 260:50-5-40 - Medicare Supplement and Medicare Part D Prescription Drug Plan (PDP)

Current through Vol. 41, No. 20, July 1, 2024
Members who are eligible for Medicare will be assumed to be
					 enrolled in both Parts A and B of Medicare. Benefits payable under the Medicare
					 Supplement will be determined in accordance with this assumption. The Medicare
					 Supplement is either connected with a Medicare Part D Prescription Drug Plan or
					 contains pharmacy benefits that are considered creditable coverage by
					 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 5 - Coverage and Limitations › Part 11 - HEALTHCHOICE MEDICARE SUPPLEMENT › Section 260:50-5-41 - Primary insurer of current employees

Current through Vol. 41, No. 20, July 1, 2024
The health plan(s) offered through EGID may be primary for
					 current employees eligible for Medicare and their eligible covered dependents
					 as set forth in the Federal statutes governing 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 5 - Coverage and Limitations › Part 11 - HEALTHCHOICE MEDICARE SUPPLEMENT › Section 260:50-5-42 - Limitations of Medicare Supplement

Current through Vol. 41, No. 20, July 1, 2024
The Medicare Supplement health coverage is a supplement to
					 the coverage provided by Medicare.
(1)
				  This Supplement applies only after Medicare benefits are determined.
(2) Coverage is limited to Medicare's
				  scheduled amount.
Oklahoma Administrative Code › Title 260 - Office of Management and Enterprise Services › Chapter 50 - Employees Group Insurance Division - Health, Dental, Vision and Life Plans › Subchapter 5 - Coverage and Limitations › Part 11 - HEALTHCHOICE MEDICARE SUPPLEMENT › Section 260:50-5-43 - Enrollment in Medicare Supplement [REVOKED]

Current through Vol. 41, No. 20, July 1, 2024
Oklahoma Administrative Code › Title 260 - Office of Management and Enterprise Services › Chapter 50 - Employees Group Insurance Division - Health, Dental, Vision and Life Plans › Subchapter 5 - Coverage and Limitations › Part 15 - HEALTHCHOICE SUBROGATION › Section 260:50-5-49 - Right of subrogation

Current through Vol. 41, No. 20, July 1, 2024
(a) EGID
				  reserves the right to recover funds from members, dependents, tortfeasors,
				  liability policies, underinsured/uninsured motorist policies, medical payments
				  policies and/or other identifiable sources of funds, in amounts equal to any
				  and all claim payments made on behalf of a member or dependent for injury
				  caused by a third party's wrongful act or negligence.
(b) EGID has the right to recover any sums
				  collected by or on behalf of a member or dependent even if the member or
				  dependent has not been made whole. EGID is entitled to reimbursement from any
				  recovery even if the recovery does not fully compensate the member or dependent
				  for their injury. The make-whole doctrine shall not apply. The sole exception
				  to this paragraph exists only to the limited extent that EGID voluntarily
				  elects to invoke its exclusive statutory authority to waive or reduce EGID's
				  subrogation interest in an individual case.
(c) The act of submitting claims by or on
				  behalf of a member or dependent constitutes notice and acceptance of EGID's
				  right of recovery against the third party and creates a lien upon any
				  identifiable funds referenced in (a) above.
(d) A member or dependent will not take any
				  action to prejudice EGID's right of subrogation, such as settlement of the
				  claim without first giving notice of EGID's subrogation rights to the
				  responsible party and any and all known liability or other insurers.
(e) The member or dependent will cooperate in
				  doing what is reasonably necessary to assist EGID in any recovery, including
				  but not limited to promptly providing all information requested by
				  EGID.
(f) Subrogation will exist
				  only to the extent of plan benefits paid.
(g) Claims submitted after a member or
				  dependent has released the responsible party may be denied at the option of
				  EGID, by the issuance of routine written notice to the member, dependent, or
				  their attorney.
(h) If claims
				  relating to a specified injury are paid by EGID after the member or dependent
				  has released the responsible party, when the member or dependent has failed to
				  inform EGID in a timely manner prior to executing a release, EGID at its
				  option, may require reimbursement from the member, dependent or
				  provider.
(i) Claims submitted will
				  initially be pended as incomplete and subsequently denied if information
				  regarding possible third party responsibility is not voluntarily provided to
				  EGID within a reasonable time period [not less than ninety (90) days] after the
				  date the information was first requested in writing by or on behalf of
				  EGID.
Added at 31 Ok Reg
					 1390, eff 9-12-14
Oklahoma Administrative Code › Title 260 - Office of Management and Enterprise Services › Chapter 50 - Employees Group Insurance Division - Health, Dental, Vision and Life Plans › Subchapter 13 - Coordination of Health and Dental Benefits › Section 260:50-5-44 - Application of retiree benefit allowance

Current through Vol. 41, No. 20, July 1, 2024
When calculating premium rates for the retired population,
				  EGID shall first apply in whole or in part, benefit allowances funded by the
				  retirement systems to offset costs projected for the pharmacy portion of the
				  health insurance plan. Remaining amounts, if any, will then be applied toward
				  the medical coverage premium.
Revoked by
				  Oklahoma
				  Register, Volume 36, Issue 24, September 3, 2019, eff.
				  1/20/2020
Oklahoma Administrative Code › Title 260 - Office of Management and Enterprise Services › Chapter 50 - Employees Group Insurance Division - Health, Dental, Vision and Life Plans › Subchapter 13 - Coordination of Health and Dental Benefits › Section 260:50-5-46 - Effect on benefits

Current through Vol. 41, No. 20, July 1, 2024
(a)
Determining benefits.
This section shall apply in determining the
				benefits as to a person covered under the plan for any claim determination
				period if, for the allowable expense incurred as to such person during such
				period, the sum of:
(1) the benefits that
				would be payable under this plan in the absence of this provision,
				and
(2) the benefits that would be
				payable under all other plans in the absence therein of provisions of similar
				purpose to this provision would exceed such allowable expenses.
Oklahoma Administrative Code › Title 260 - Office of Management and Enterprise Services › Chapter 50 - Employees Group Insurance Division - Health, Dental, Vision and Life Plans › Subchapter 13 - Coordination of Health and Dental Benefits › Section 260:50-5-47 - Facility of benefit payment

Current through Vol. 41, No. 20, July 1, 2024
Whenever payments which should have been made under this plan
				  in accordance with this section have been made under any other plans, EGID
				  shall have the right, exercisable alone and in its sole discretion, to pay over
				  to any organizations making such other payments any amounts it shall determine
				  to be warranted in order to satisfy the intent of this section, and amounts so
				  paid shall be deemed to be benefits paid under this plan and, to the extent of
				  such payments, EGID shall be fully discharged from liability under this
				  plan.
Revoked by
				  Oklahoma
				  Register, Volume 36, Issue 24, September 3, 2019, eff.
				  1/20/2020
Oklahoma Administrative Code › Title 260 - Office of Management and Enterprise Services › Chapter 50 - Employees Group Insurance Division - Health, Dental, Vision and Life Plans › Subchapter 13 - Coordination of Health and Dental Benefits › Section 260:50-5-48 - Right of recovery

Current through Vol. 41, No. 20, July 1, 2024
Whenever payment has 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 that time to satisfy the intent of this section,
				  EGID shall have the right to recover such payments, to the extent of such
				  excess, from among one or more of the following, as EGID shall
				  determine:
(1) any persons to or for
				or with respect to whom such payments were made;
(2) any other insurers; or
(3) service plans or any other
				organizations.
Revoked by
				  Oklahoma
				  Register, Volume 36, Issue 24, September 3, 2019, eff.
				  1/20/2020
Oklahoma Administrative Code › Title 260 - Office of Management and Enterprise Services › Chapter 50 - Employees Group Insurance Division - Health, Dental, Vision and Life Plans › Subchapter 13 - Coordination of Health and Dental Benefits › Part 15 - SUBROGATION › Section 260:50-5-49 - Right of subrogation

Current through Vol. 41, No. 20, July 1, 2024
(a) EGID
				  reserves the right to recover funds from members, dependents, tortfeasors,
				  liability policies, underinsured/uninsured motorist policies, medical payments
				  policies and/or other identifiable sources of funds, in amounts equal to any
				  and all claim payments made on behalf of a member or dependent for injury
				  caused by a third party's wrongful act or negligence.
(b) EGID has the right to recover any sums
				  collected by or on behalf of a member or dependent even if the member or
				  dependent has not been made whole. EGID is entitled to reimbursement from any
				  recovery even if the recovery does not fully compensate the member or dependent
				  for their injury. The make-whole doctrine shall not apply. The sole exception
				  to this paragraph exists only to the limited extent that EGID voluntarily
				  elects to invoke its exclusive statutory authority to waive or reduce EGID's
				  subrogation interest in an individual case.
(c) The act of submitting claims by or on
				  behalf of a member or dependent constitutes notice and acceptance of EGID's
				  right of recovery against the third party and creates a lien upon any
				  identifiable funds referenced in (a) above.
(d) A member or dependent will not take any
				  action to prejudice EGID's right of subrogation, such as settlement of the
				  claim without first giving notice of EGID's subrogation rights to the
				  responsible party and any and all known liability or other insurers.
(e) The member or dependent will cooperate in
				  doing what is reasonably necessary to assist EGID in any recovery, including
				  but not limited to promptly providing all information requested by
				  EGID.
(f) Subrogation will exist
				  only to the extent of plan benefits paid.
(g) Claims submitted after a member or
				  dependent has released the responsible party may be denied at the option of
				  EGID, by the issuance of routine written notice to the member, dependent, or
				  their attorney.
(h) If claims
				  relating to a specified injury are paid by EGID after the member or dependent
				  has released the responsible party, when the member or dependent has failed to
				  inform EGID in a timely manner prior to executing a release, EGID at its
				  option, may require reimbursement from the member, dependent or
				  provider.
(i) Claims submitted will
				  initially be pended as incomplete and subsequently denied if information
				  regarding possible third party responsibility is not voluntarily provided to
				  EGID within a reasonable time period [not less than ninety (90) days] after the
				  date the information was first requested in writing by or on behalf of
				  EGID.
Oklahoma Administrative Code › Title 260 - Office of Management and Enterprise Services › Chapter 55 - Employees Group Insurance Division - Healthchoice Disability Plan › Section 260:55-1-1 - Purpose

Current through Vol. 41, No. 20, July 1, 2024
All terms of the HealthChoice Disability plan shall be set
				forth in handbooks and administrative procedures. These shall describe program
				and coverage eligibility, what constitutes disability, maximum length of
				coverage, maximum and minimum benefits for short-term disability and long-term
				disability, the calculation of disability income benefits, and the suspension
				or termination of benefits.
Oklahoma Administrative Code › Title 260 - Office of Management and Enterprise Services › Chapter 60 - Facilities Management › Subchapter 1 - General Provisions › Section 260:60-1-1 - Purpose

Current through Vol. 41, No. 20, July 1, 2024
This Chapter provides information and establishes procedures
				  for the Director of the Office of Management and Enterprise Services to
				  administer the operations of all buildings or property owned, used or occupied
				  by or on behalf of the State and controlled by the Office of Management and
				  Enterprise Services, including the Capitol, Capitol plazas, and the State
				  Capitol Park.
Oklahoma Administrative Code › Title 260 - Office of Management and Enterprise Services › Chapter 60 - Facilities Management › Subchapter 1 - General Provisions › Section 260:60-1-3 - Waiver

Current through Vol. 41, No. 20, July 1, 2024
The Director may waive any requirement of this chapter unless
				  statutes mandate the requirement.
(1)
				All requests for waivers shall be in writing and must include justification for
				the waiver request.
(2) The Office
				shall respond in writing as to the approval, conditional approval, or denial of
				a waiver request.
Oklahoma Administrative Code › Title 260 - Office of Management and Enterprise Services › Chapter 60 - Facilities Management › Subchapter 3 - Use of Public Areas of Capitol and Plazas › Section 260:60-3-1 - Purpose

Current through Vol. 41, No. 20, July 1, 2024
The provisions of this Subchapter prescribe conditions and
				  procedures for Capitol access and use of designated public areas of the Capitol
				  or Plazas for exhibits, art exhibits and events to ensure the safety of persons
				  visiting the Capitol, employees, the building and the building
				  contents.