reglab/statecodes huggingface dataset:
Oregon Administrative Rules › Chapter 111 - OREGON HEALTH AUTHORITY, OREGON EDUCATORS BENEFIT BOARD › Division 50 - CONTINUATION OF COVERAGE › Section 111-050-0050 - Removing an Ineligible Individual from Benefit Plans

Current through Register Vol. 63, No. 7, July 1, 2024
(1) An Eligible Early Retiree who enrolls
			 themselves and/or an eligible person is responsible for removing ineligible
			 spouses, domestic partners and children from their OEBB-sponsored benefit plans
			 by submitting completed, applicable forms to their Entity benefits
			 administrator within 31 calendar days after the date the individual becomes
			 ineligible. Coverage ends on the date identified under OAR
			 111-050-0045.
(2) An Entity is
			 responsible for removing ineligible individuals from the OEBB benefits
			 management system. The Entity must complete such removal within 14 calendar
			 days after:
(a) An event resulting in loss of
			 the Early Retiree's eligibility, or
(b) The receipt of notification of an event
			 resulting in loss of eligibility of the Early Retiree's spouse, domestic
			 partner or child.
Oregon Administrative Rules › Chapter 111 - OREGON HEALTH AUTHORITY, OREGON EDUCATORS BENEFIT BOARD › Division 50 - CONTINUATION OF COVERAGE › Section 111-050-0060 - Continuation of Coverage for Eligible Employees Covered under the Federal Family Medical Leave Act

Current through Register Vol. 63, No. 7, July 1, 2024
OEBB will allow Entities to continue medical, dental and vision
				coverage for Active Eligible Employees when the employee is granted leave under
				the Federal Family Medical Leave Act (FMLA) as required under related federal
				rules and regulations.
Statutory/Other Authority: ORS
				  243.860 - 243.886
Statutes/Other Implemented: ORS
				  243.864(1)(a)
Oregon Administrative Rules › Chapter 111 - OREGON HEALTH AUTHORITY, OREGON EDUCATORS BENEFIT BOARD › Division 50 - CONTINUATION OF COVERAGE › Section 111-050-0065 - Continuation of Coverage for Eligible Employees Covered under the Oregon Family Leave Act

Current through Register Vol. 63, No. 7, July 1, 2024
OEBB will allow Entities to continue medical, dental and vision
				coverage for Active Eligible Employees when the employee is granted leave under
				the Oregon Family Leave Act (OFLA) as required under related state rules and
				regulations.
Statutory/Other Authority: ORS
				  243.860 - 243.886
Statutes/Other Implemented: ORS
				  243.864(1)(a)
Oregon Administrative Rules › Chapter 111 - OREGON HEALTH AUTHORITY, OREGON EDUCATORS BENEFIT BOARD › Division 50 - CONTINUATION OF COVERAGE › Section 111-050-0070 - Continuation of Coverage for Eligible Employees during an Approved Leave of Absence

Current through Register Vol. 63, No. 7, July 1, 2024
OEBB will allow Entities to continue medical, dental and vision
				coverage for Active Eligible Employees when the employee is granted a leave of
				absence based on collective bargaining agreements and/or documented entity
				policies in effect on or before October 1, 2008.
Statutory/Other Authority: ORS
				  243.860 - 243.886
Statutes/Other Implemented: ORS
				  243.864(1)(a)
Oregon Administrative Rules › Chapter 111 - OREGON HEALTH AUTHORITY, OREGON EDUCATORS BENEFIT BOARD › Division 50 - CONTINUATION OF COVERAGE › Section 111-050-0075 - Continuation of coverage for Eligible Employees on Active Military Service

Current through Register Vol. 63, No. 7, July 1, 2024
OEBB will allow Entities to continue medical, dental, and
				vision coverage for Active Eligible Employees as required under the Uniformed
				Services Employment and Reemployment Rights Act (USERRA) and related federal
				rules and regulations.
Statutory/Other Authority: ORS
				  243.860 - 243.886
Statutes/Other Implemented: ORS
				  243.864(1)(a)
Oregon Administrative Rules › Chapter 111 - OREGON HEALTH AUTHORITY, OREGON EDUCATORS BENEFIT BOARD › Division 50 - CONTINUATION OF COVERAGE › Section 111-050-0080 - Portability and Conversion of Coverage

Current through Register Vol. 63, No. 7, July 1, 2024
(1) OEBB medical, life and accidental death
			 and dismemberment carrier(s) will make portability plans available to members
			 in accordance with related state and federal laws, rules and regulations.
			 Eligibility criteria for this coverage can be found in carrier member
			 handbooks.
(2) OEBB life insurance
			 carrier(s) will make conversion plans available to members in accordance with
			 related state and federal laws, rules and regulations. Eligibility criteria for
			 this coverage can be found in the carrier's member handbook.
(3) OEBB long term care carrier(s) will
			 transfer the coverage from a Group Long Term Care to an Individual Long Term
			 Care policy and premiums will be paid directly to the carrier upon
			 request.
Stat. Auth.: ORS
				  243.860 -
				  243.886
Stats. Implemented: ORS
				  243.864(1)(a)
Oregon Administrative Rules › Chapter 111 - OREGON HEALTH AUTHORITY, OREGON EDUCATORS BENEFIT BOARD › Division 60 - INFORMATION REQUIREMENTS AND REQUESTS › Section 111-060-0001 - Use of Social Security Numbers

Current through Register Vol. 63, No. 7, July 1, 2024
(1) The Oregon Educators Benefit Board (OEBB)
			 will comply with the requirements of Section 7 of the Privacy Act of 1974 and
			 the Oregon Consumer Identity Theft Protection Act, ORS
			 646A.600 to
			 646A.628 when requesting or
			 requiring complete or partial disclosure of an eligible employee's or family
			 member's, as defined in ORS
			 243.860(4) and
			 (5) respectively, social security
			 number.
(2) OEBB may request
			 voluntary disclosure and consent to use the social security number of an
			 eligible employee or family member for the following reasons:
(a) OEBB's internal verification and
			 identification of enrollments or elections for participation in benefits
			 provided by OEBB.
(b) Medicare
			 Secondary Payer Mandatory Reporting Provisions in Section 111 of the Medicare,
			 Medi-caid, and SCHIP Extension Act of 2007 (Public Law
			 110-173).
Oregon Administrative Rules › Chapter 111 - OREGON HEALTH AUTHORITY, OREGON EDUCATORS BENEFIT BOARD › Division 65 - OEBB ADMINISTRATION OF EARLY RETIREE GROUPS › Section 111-065-0001 - Definitions

Current through Register Vol. 63, No. 7, July 1, 2024
For the purpose of this rule:
(1) "Direct Debit" for purposes of this OAR
			 refers to a payment through an Automated Clearing House (ACH) credit or ACH
			 debit that initiates the movement of funds electronically from the early
			 retiree's individual banking account within the United States to the OEBB
			 Treasury account.
(2) "OEBB
			 Administered Early Retiree" means an individual who meets the definition of
			 Eligible Early Retiree in OAR 111-010-0015  and whose benefits are administered
			 by OEBB.
(3) "Overpayment" means
			 the amount of the Early Retiree's monthly payment to OEBB that exceeded the
			 amount due.
(4) "Payment in full"
			 means payment received by OEBB which is equal to the current monthly amount due
			 for all benefit premiums which the early retiree is currently enrolled
			 in.
(5) "Underpayment" means a
			 payment submitted on or before the due date by the Early Retiree that is less
			 than the invoiced amount.
Statutory/Other Authority: 243.860 - 243.886
Statutes/Other Implemented: ORS
				  243.864(1)(a)
Oregon Administrative Rules › Chapter 111 - OREGON HEALTH AUTHORITY, OREGON EDUCATORS BENEFIT BOARD › Division 65 - OEBB ADMINISTRATION OF EARLY RETIREE GROUPS › Section 111-065-0005 - Untitled

Current through Register Vol. 63, No. 7, July 1, 2024
The following administrative rules in Division 65 apply to OEBB
				Administered Early Retirees in addition to OEBB's Division 50 rules which apply
				to all Early Retirees.
Statutory/Other Authority: 243.860 - 243.886
Statutes/Other Implemented: ORS
				  243.864(1)(a)
Oregon Administrative Rules › Chapter 111 - OREGON HEALTH AUTHORITY, OREGON EDUCATORS BENEFIT BOARD › Division 65 - OEBB ADMINISTRATION OF EARLY RETIREE GROUPS › Section 111-065-0010 - OEBB Early Retiree Invoicing

Current through Register Vol. 63, No. 7, July 1, 2024
(1) OEBB will enroll the Early Retiree after
			 OEBB has received the enrollment form and one of the following is completed:
(a) The required ACH Authorization for a
			 recurring Direct Debit Payment is received from the Early Retiree to initiate
			 the setup of automated payments via ACH; or
(b) An Exception Request Form is received
			 from the Early Retiree and reviewed and approved by OEBB.
Oregon Administrative Rules › Chapter 111 - OREGON HEALTH AUTHORITY, OREGON EDUCATORS BENEFIT BOARD › Division 65 - OEBB ADMINISTRATION OF EARLY RETIREE GROUPS › Section 111-065-0015 - Early Retiree Payment Methods and Due Dates

Current through Register Vol. 63, No. 7, July 1, 2024
(1) Premium payments will be made through
			 Direct Payment via ACH (ACH Debit) on the 2nd business day of the month unless
			 otherwise prior authorized by designated OEBB staff.
(2) As necessary, or upon written request of
			 a participating Early Retiree, OEBB staff will review and determine if an
			 alternative withdrawal date is warranted to avoid future payments being
			 returned for Non-sufficient Funds (NSF) on a recurring basis.
(3) OEBB will accept payment from early
			 retirees by methods other than SCH Debit when specific exceptions apply:
(a) The individual does not have an account
			 with a financial institution within the United States;
(b) The individual's special circumstances,
			 which OEBB will review on a case by case basis.
Oregon Administrative Rules › Chapter 111 - OREGON HEALTH AUTHORITY, OREGON EDUCATORS BENEFIT BOARD › Division 65 - OEBB ADMINISTRATION OF EARLY RETIREE GROUPS › Section 111-065-0020 - Early Retiree Overpayments

Current through Register Vol. 63, No. 7, July 1, 2024
(1) OEBB will include overpayment amounts on
			 the monthly invoice. The invoice will include the total payment received, the
			 date it was received, the amount of premium payment due, and any remaining
			 balance of additional premiums paid.
(2) OEBB will automatically apply any
			 overpayments to the next month's premium due. The Early Retiree may complete a
			 Request for Reimbursement form if a refund of an overpayment is desired. The
			 Early Retiree may be responsible for processing fees associated with refunds
			 less than $100. Reimbursements will be refunded via check.
(3) Remaining balances on coverage that has
			 ended will be refunded in full within 30 days of the coverage end date or the
			 date OEBB is notified that coverage should end, whichever occurs
			 later.
Statutory/Other Authority: 243.860 - 243.886
Statutes/Other Implemented: ORS
				  243.864(1)(a)
Oregon Administrative Rules › Chapter 111 - OREGON HEALTH AUTHORITY, OREGON EDUCATORS BENEFIT BOARD › Division 65 - OEBB ADMINISTRATION OF EARLY RETIREE GROUPS › Section 111-065-0025 - Early Retiree Underpayments

Current through Register Vol. 63, No. 7, July 1, 2024
(1) Premiums must be paid in full on or
			 before the 2nd business day of the month, unless otherwise pre-approved by OEBB
			 under OAR 111-065-0015(2).
(2)
(a) Early Retirees will be notified if their
			 coverage was terminated due to the premium not being paid in full on the
			 specified due date, including payments returned by the bank for Non-Sufficient
			 Funds (NSF), closed bank accounts, and frozen accounts.
(b) A check or ACH transaction that is
			 returned for NSF, closed bank account, or frozen account is considered
			 non-payment of premiums.
Oregon Administrative Rules › Chapter 111 - OREGON HEALTH AUTHORITY, OREGON EDUCATORS BENEFIT BOARD › Division 65 - OEBB ADMINISTRATION OF EARLY RETIREE GROUPS › Section 111-065-0030 - Termination

Current through Register Vol. 63, No. 7, July 1, 2024
(1) OEBB shall not
			 be responsible for any unpaid portion of premiums for coverage and will
			 terminate the early retiree and dependent coverage for non-payment or
			 underpayment of premiums due.
(2)
			 OEBB coverage will be terminated under the following circumstances:
(a) Premiums are not paid in full by the due
			 date. If the payment is not received in full on the 2nd business day of the
			 month unless otherwise preapproved by OEBB under OAR 111-065-0015(2), the early
			 retiree's coverage will be terminated on the last day of the month in which a
			 full premium payment was received; or
(b) As referenced in 111-050-0015.
Oregon Administrative Rules › Chapter 111 - OREGON HEALTH AUTHORITY, OREGON EDUCATORS BENEFIT BOARD › Division 65 - OEBB ADMINISTRATION OF EARLY RETIREE GROUPS › Section 111-065-0035 - Appeals

Current through Register Vol. 63, No. 7, July 1, 2024
Early Retirees have the right to use the OEBB Appeals and
				Administrative Review process as defined in OAR 111-080-0030.
(1) Early Retirees may appeal OEBB's
			 eligibility decision.
(2) Early
			 Retirees have the right to request a review of benefit and claim issues that
			 are not resolved following the completion of the carrier appeal process.
			 Administrative Review requests relating to denied benefits are limited to a
			 determination of whether or not a benefit was intended to be covered under the
			 current contract.
Statutory/Other Authority: 243.860 - 243.886
Statutes/Other Implemented: ORS
				  243.864(1)(a)
Oregon Administrative Rules › Chapter 111 - OREGON HEALTH AUTHORITY, OREGON EDUCATORS BENEFIT BOARD › Division 65 - OEBB ADMINISTRATION OF EARLY RETIREE GROUPS › Section 111-065-0040 - Continuation of Coverage

Current through Register Vol. 63, No. 7, July 1, 2024
(1) Early
			 Retirees and dependents have COBRA rights consistent with
			 111-050-0001.
(2) Loss of coverage
			 due to failure to make a premium payment is not a Qualified Status
			 Change.
Statutory/Other Authority: 243.860 - 243.886
Statutes/Other Implemented: ORS
				  243.864(1)(a)
Oregon Administrative Rules › Chapter 111 - OREGON HEALTH AUTHORITY, OREGON EDUCATORS BENEFIT BOARD › Division 70 - SB 551 › Section 111-070-0001

Current through Register Vol. 63, No. 7, July 1, 2024
Stat. Auth.: ORS
				  243.864, 2009 OL Ch. 351 (HB
				  2557)
Stats. Implemented: 2009 OL Ch. 351 (HB
				  2557)
Oregon Administrative Rules › Chapter 111 - OREGON HEALTH AUTHORITY, OREGON EDUCATORS BENEFIT BOARD › Division 70 - SB 551 › Section 111-070-0005

Current through Register Vol. 63, No. 7, July 1, 2024
Statutory/Other Authority: ORS
				  243.860  - 243.886
Statutes/Other Implemented: ORS
				  243.864(1)(a)
Oregon Administrative Rules › Chapter 111 - OREGON HEALTH AUTHORITY, OREGON EDUCATORS BENEFIT BOARD › Division 70 - SB 551 › Section 111-070-0020

Current through Register Vol. 63, No. 7, July 1, 2024
Stat. Auth.: ORS
				  243.864, 2009 OL Ch. 351 (HB
				  2557)
Stats. Implemented: 2009 OL Ch. 351 (HB
				  2557)
Oregon Administrative Rules › Chapter 111 - OREGON HEALTH AUTHORITY, OREGON EDUCATORS BENEFIT BOARD › Division 70 - SB 551 › Section 111-070-0030

Current through Register Vol. 63, No. 7, July 1, 2024
Stat. Auth.: ORS
				  243.860 -
				  243.886
Stats. Implemented: ORS
				  243.864(1)(a)
Oregon Administrative Rules › Chapter 111 - OREGON HEALTH AUTHORITY, OREGON EDUCATORS BENEFIT BOARD › Division 70 - SB 551 › Section 111-070-0040

Current through Register Vol. 63, No. 7, July 1, 2024
Stat. Auth.: ORS
				  243.860 - 243.886
Stats. Implemented: ORS
				  243.864(1)(a)
Oregon Administrative Rules › Chapter 111 - OREGON HEALTH AUTHORITY, OREGON EDUCATORS BENEFIT BOARD › Division 70 - SB 551 › Section 111-070-0060

Current through Register Vol. 63, No. 7, July 1, 2024
Stat. Auth.: ORS
				  243.864, 2009 OL Ch. 351 (HB
				  2557)
Stats. Implemented: 2009 OL Ch. 351 (HB
				  2557)
Oregon Administrative Rules › Chapter 111 - OREGON HEALTH AUTHORITY, OREGON EDUCATORS BENEFIT BOARD › Division 70 - SB 551 › Section 111-070-0070

Current through Register Vol. 63, No. 7, July 1, 2024
Stat. Auth.: ORS
				  243.864, 2009 OL Ch. 351 (HB
				  2557)
Stats. Implemented: 2009 OL Ch. 351 (HB
				  2557)
Oregon Administrative Rules › Chapter 111 - OREGON HEALTH AUTHORITY, OREGON EDUCATORS BENEFIT BOARD › Division 70 - SB 551 › Section 111-070-0075 - Administration of SB 551 Program

Current through Register Vol. 63, No. 7, July 1, 2024
(1)  For purposes of this rule:
(a)  "SB 551 eligible member" is a part-time faculty member who
				is deemed eligible to receive coverage through OEBB by an Oregon public
				institution of higher education based on the requirements of SB 551(2021). "SB
				551 eligible member" does not mean or include a part-time faculty member who is
				currently eligible for employer-paid benefits through the Public Employees
				Benefit Board (PEBB) or the Oregon Educators Benefit Board (OEBB).
(b)  "SB 551 program" is the benefits program established by SB
				551(2021) and codified in ORS 350.355.
(c)  "OEBB coverage" means coverage that is available to
				part-time faculty members who are eligible for employer-paid benefits.
Oregon Administrative Rules › Chapter 111 - OREGON HEALTH AUTHORITY, OREGON EDUCATORS BENEFIT BOARD › Division 80 - OPERATIONS › Section 111-080-0001 - Payment Methods and Dates

Current through Register Vol. 63, No. 7, July 1, 2024
(1) For the purpose of this rule:
(a) "ACH credit" means a payment initiated by
			 an Entity that is cleared through the Automated Clearing House (ACH) network
			 for deposit to the OEBB account;
(b) "ACH debit" means a payment initiated by
			 OEBB and cleared through the ACH network to debit an Entity's account and
			 credit the OEBB account;
(c) "Due
			 date" means the seventh business day into the current month of
			 coverage;
(d) "Electronic funds
			 transfer" refers to a payment through ACH credit or ACH debit;
(e) "Entity Payment" means the monthly entity
			 payment to OEBB that includes the contributions of both the Entity and members
			 required to pay the monthly premiums for selected OEBB benefit plans;
(f) "Entity Payment Invoice" means
			 a monthly itemized statement provided by OEBB that includes the contributions
			 of both the entity and members required to pay the monthly premiums for
			 selected OEBB benefit plans;
Oregon Administrative Rules › Chapter 111 - OREGON HEALTH AUTHORITY, OREGON EDUCATORS BENEFIT BOARD › Division 80 - OPERATIONS › Section 111-080-0005 - Overpayments and Underpayments

Current through Register Vol. 63, No. 7, July 1, 2024
(1) For the purpose of this rule:
(a) "Overpayment" means the amount of an
			 Entity's monthly payment to OEBB that exceeded the amount due.
(b) "Underpayment" means a payment submitted
			 by an Entity that is less than the invoiced amount.
Oregon Administrative Rules › Chapter 111 - OREGON HEALTH AUTHORITY, OREGON EDUCATORS BENEFIT BOARD › Division 80 - OPERATIONS › Section 111-080-0040 - Eligibility and Policy Term Violations - Definitions

Current through Register Vol. 63, No. 7, July 1, 2024
For the purposes of OAR 111-080-0045  and 111-080-0050, the
				following definitions will apply:
(1)
			 "Eligibility or Enrollment Violations" means and includes a violation of the
			 OEBB's eligibility or enrollment rules or policies including fraud or material
			 misrepresentation. Misstatements, misrepresentations, omissions or concealments
			 on the part of the OEBB member are not fraudulent unless they are made with
			 intent to knowingly defraud. OEBB has primary responsibly in investigating such
			 violations. If an Eligibility Violation is considered a violation of the
			 insurance carrier's policy, then the violation may also be considered a Policy
			 Term Violation, and OAR 111-080-0050  would also apply.
(a) "Intentional Violation" is a violation
			 that has occurred in which OEBB has electronic or written documentation that
			 the eligible employee took action resulting in a non-eligible member being
			 enrolled in OEBB benefits.
(b)
			 "Unintentional Violation" is a violation that has occurred in which the
			 eligible employee was not aware that such violation had occurred and there is
			 no evidence of the eligible employee completing a paper form or logging in and
			 enrolling an ineligible member in OEBB benefits.
Oregon Administrative Rules › Chapter 111 - OREGON HEALTH AUTHORITY, OREGON EDUCATORS BENEFIT BOARD › Division 80 - OPERATIONS › Section 111-080-0045 - Eligibility Violations

Current through Register Vol. 63, No. 7, July 1, 2024
(1)
			 Unintentional Violation:
(A) OEBB will remove
			 from coverage an ineligible OEBB member due to eligibility or enrollment
			 violations. Removal from all benefit plans will be retroactive to the date the
			 individual is determined to have no longer been eligible, or the effective date
			 of coverage if eligibility criteria was never met unless in conflict with
			 federal healthcare reform.
(B) When
			 an eligibility or enrollment violation has been discovered and investigated,
			 OEBB will notify the member and the Educational Entity with the outcome. If the
			 outcome includes rescission of coverage, OEBB will give a 30 day notice of such
			 rescission prior to terminating coverage retroactively to the date the member
			 was no longer eligible for benefits.
(C) The member may be responsible for any
			 claims paid during the period of time the member was enrolled
			 inappropriately.
Oregon Administrative Rules › Chapter 111 - OREGON HEALTH AUTHORITY, OREGON EDUCATORS BENEFIT BOARD › Division 80 - OPERATIONS › Section 111-080-0050 - Policy Term Violations

Current through Register Vol. 63, No. 7, July 1, 2024
(1) An
			 OEBB-contracted insurance carrier may remove from coverage and/or deny the
			 claims of an OEBB member due to policy term violations. Removal from coverage
			 for policy term violations is at the discretion of the insurance carrier.
(A) If a policy term violation results in a
			 termination from the plan or carrier that the violation was committed, it will
			 not prevent the member from continuing enrollment in other OEBB types of
			 coverages (e.g., medical, dental, vision, life, etc.), as long as they remain
			 an employee and eligible for these benefits.
(B) If an eligible employee commits a policy
			 term violation and loses coverage, OEBB will remove the entire family from the
			 insurance plan since the benefits are extended to his or her dependents through
			 the eligible employee. If the eligible employee chooses to, and it is offered,
			 they can enroll in a different carrier plan (if applicable) during open
			 enrollment and cover themselves and dependents during the upcoming plan
			 year.
(C) If a dependent commits a
			 policy term violation, OEBB will remove only the dependent from the insurance
			 plan. If the eligible employee chooses to and it is offered, they can enroll in
			 a different carrier plan (if applicable) during open enrollment and cover the
			 dependent during the upcoming plan year, or as defined by the
			 carrier.
(D) The OEBB member who is
			 removed from an OEBB sponsored insurance plan may appeal the decision through
			 the carrier that terminated coverage.
(E) When a policy term violation has been
			 discovered and investigated, the applicable insurance carrier will notify OEBB
			 and the member with the outcome.
Oregon Administrative Rules › Chapter 111 - OREGON HEALTH AUTHORITY, OREGON EDUCATORS BENEFIT BOARD › Division 80 - OPERATIONS › Section 111-080-0055 - Eligibility Verifications and Reviews

Current through Register Vol. 63, No. 7, July 1, 2024
(1) OEBB shall plan and conduct eligibility
			 verifications and reviews to monitor compliance with OEBB administrative rules.
			 Reviews shall include, but are not be limited to the following:
(a) Dependent eligibility;
(b) Employee eligibility;
(c) Election change limitations;
			 and
(c) Plan enrollment
			 limitations.
Oregon Administrative Rules › Chapter 111 - OREGON HEALTH AUTHORITY, OREGON EDUCATORS BENEFIT BOARD › Division 80 - OPERATIONS › Section 111-080-0060 - Dependent Eligibility Verifications and Review Appeals

Current through Register Vol. 63, No. 7, July 1, 2024
(1) Following the termination of dependents
			 due to a dependent eligibility verification review, Eligible Employees,
			 Eligible Early Retirees, or COBRA participants may file an appeal and submit
			 requested documentation within 60 days from the date coverage ended. If
			 approved, coverage will be reinstated retroactively with no lapse in
			 coverage.
(2) For Eligible
			 Employees, if the appeal and submitted requested documentation is received by
			 OEBB after 60 days from the date the coverage ended, and dependents are
			 verified, OEBB will unlock the dependent records in the MyOEBB benefit
			 management system. Coverage can be added back following and consistent with a
			 Qualified Status Change (QSC) during the current plan year, or during the next
			 open enrollment period. Adding a dependent to dental or vision coverage at open
			 enrollment will result in the 12 month waiting period being applied where only
			 preventive and routine services will be covered for the first 12 months of
			 coverage.
(3) For Eligible Early
			 Retirees, if the appeal and submitted documentation is received by OEBB after
			 60 days from the date the coverage ended, and dependents are verified, OEBB
			 will unlock the dependent records in the MyOEBB benefit management system.
			 Coverage can be added back following and consistent with a Qualified Status
			 Change (QSC) during the current plan year, or during the next open enrollment
			 to the plans that they were previously enrolled in.
Statutory/Other Authority: ORS
				  243.860 to
				  243.886
Statutes/Other Implemented: ORS
				  243.864(1)(a)
Oregon Administrative Rules › Chapter 111 - OREGON HEALTH AUTHORITY, OREGON EDUCATORS BENEFIT BOARD › Division 80 - OPERATIONS › Section 111-080-0065 - Hospital Payments

Current through Register Vol. 63, No. 7, July 1, 2024
(1)
			 Except as provided in section (10), the maximum reimbursement amount for each
			 claim subject to ORS
			 243.879 and these rules shall be determined by the carrier applying the applicable
			 percentage of the Medicare rate, or the Medicare rate for similar services or
			 supplies, as of the date of service of the claim.
(2) The actual reimbursement amount for each
			 claim subject to ORS
			 243.879 and these rules shall be based on the lesser of billed charges, the carrier's
			 contracted rate for the provider, or the maximum reimbursement amount
			 established in ORS
			 243.879 and these rules.
(3) The carrier
			 shall determine the OEBB member's cost sharing based on the actual
			 reimbursement amount as determined in section (2) above.
(4) Any actions taken by the Centers for
			 Medicare and Medicaid Services (CMS) that result in retroactive adjustment of
			 the maximum reimbursement amount for an inpatient or outpatient hospital
			 service or supply shall not result in retroactive increases to member cost
			 sharing.
(5) The following payments
			 shall not be included under ORS
			 243.879(1)
			 or these rules:
(a) services or supplies that
			 are not covered by Medicare
(b)
			 services or supplies provided at Ambulatory Surgery Centers
(c) professional services provided in a
			 Hospital
(d) services or supplies
			 provided at CMS designated children's hospitals that are not reimbursed via the
			 Inpatient Prospective Payment System (IPPS).
Oregon Administrative Rules › Chapter 111 - OREGON HEALTH AUTHORITY, OREGON EDUCATORS BENEFIT BOARD › Division 80 - OPERATIONS › Section 111-080-0070 - Exempt Hospitals

Current through Register Vol. 63, No. 7, July 1, 2024
(1) As
			 specified in ORS
			 243.879,
			 these payment limits do not apply to reimbursements paid by a carrier or
			 third-party administrator to:
(a) Type A or
			 type B hospitals (defined in ORS
			 442.470);
(b) Rural critical access hospitals (defined
			 in ORS
			 315.613);
			 or
(c) Hospitals that are located
			 in a county with a population of less than 70,000 on August 15, 2017,
			 classified as a sole community hospital by the Centers for Medicare and
			 Medicaid Services, and have Medicare payments composing at least 40 percent of
			 the hospital's total annual patient revenue.
Oregon Administrative Rules › Chapter 114 - LONG TERM CARE OMBUDSMAN › Division 1 - PROCEDURAL RULES › Section 114-001-0000 - Notice to Interested Persons

Current through Register Vol. 63, No. 7, July 1, 2024
Except as permitted by ORS
				183.335(5), prior
				to adoption, amendment, or repeal of any rule, the Long Term Care Ombudsman shall
				give notice of the intended action:
(1)
			 In the Secretary of State's Bulletin referred to in ORS
			 183.360 at least 15 days prior to
			 the effective date.
(2) By mailing a
			 copy of the notice to persons on the Long Term Care Ombudsman's mailing list
			 established pursuant to ORS 183.33(7).
(3) By mailing a copy of the notice to the
			 following persons, organizations, or publications:
(a) United Press International;
(b) The Associated Press;
(c) Capitol Press Room;
(d) Oregon Registered Care Providers;
(e) Long Term Care Ombudsman Screening
			 Committees;
(f) Oregon Association of
			 Health Care;
(g) Oregon Association
			 of Homes for the Aging;
(h) Oregon
			 Area Agencies on Aging;
(i)
			 Governor's Commission on Senior Services;
(j) Senior Services Division;
(k) United Seniors;
(l) Oregon State Council;
(m) Oregon Citizens for Better Nursing
			 Care;
(n) American Association of
			 Retired Persons.
Oregon Administrative Rules › Chapter 114 - LONG TERM CARE OMBUDSMAN › Division 1 - PROCEDURAL RULES › Section 114-001-0005 - Model Rules of Procedure

Current through Register Vol. 63, No. 7, July 1, 2024
Pursuant to ORS
				183.341, the Long Term Care
				Ombudsman adopts the Attorney General's Model Rules of Procedure under the
				Administrative Procedure Act as amended and effective March 3,
				1988.
The full text of the Attorney General's Model Rules of
				  Procedures is available from the office of the Attorney General or the Long Term
				  Care Ombudsman.
Stat. Auth.: ORS 441 & ORS 183
Stats. Implemented:
Oregon Administrative Rules › Chapter 114 - LONG TERM CARE OMBUDSMAN › Division 1 - PROCEDURAL RULES › Section 114-001-0010 - Fee for Copies of Public Records

Current through Register Vol. 63, No. 7, July 1, 2024
The Ombudsman shall provide within a reasonable time copies of
				any public records in its files upon written request from any person and may
				charge a fee reasonably calculated to cover its costs.
Stat. Auth.: ORS 441
Stats. Implemented:
Oregon Administrative Rules › Chapter 114 - LONG TERM CARE OMBUDSMAN › Division 2 - GOALS AND DEFINITIONS › Section 114-002-0000 - Goals

Current through Register Vol. 63, No. 7, July 1, 2024
The goals of the Ombudsman Program are to identify and be
				responsive to citizen needs and concerns with respect to all aspects of Oregon's
				Long Term Care System, including but not necessarily limited to the sufficient
				quality of provider service, government rules and regulations, and any
				administrative or other actions impacting Long Term Care residents; to cause or
				promote such change in the Long Term Care System that would be of benefit to Long
				Term Care Residents.
Stat. Auth.: ORS 441
Stats. Implemented:
Oregon Administrative Rules › Chapter 114 - LONG TERM CARE OMBUDSMAN › Division 2 - GOALS AND DEFINITIONS › Section 114-002-0010 - Definitions

Current through Register Vol. 63, No. 7, July 1, 2024
The following definitions apply to all rules in chapter
				114:
(1) "Administrative Action" means
			 any action which may adversely affect a resident's health, safety, welfare or
			 rights.
(2) "Area Planning District"
			 means the geographical areas designated by the Office of the Long Term Care
			 Ombudsman for the purpose of local program development.
(3) "Certified Ombudsman" means a
			 designee.
(4) "Conflict of Interest
			 with the Ombudsman Program" means that a situation exists where an individual's
			 personal interests may adversely influence the individual's decisions relating to
			 the Ombudsman Program, except that a person presently residing in a long term
			 care facility shall not have a conflict of interest with the Ombudsman Program. A
			 conflict of interest with the Ombudsman Program exists when:
(a) A person or a member of the person's
			 immediate family has any financial or ownership interests in a long term care
			 facility or is employed by a long term care facility;
(b) A person is an employee, agent, or officer
			 of an Area Agency on Aging, type B, or the local state office of the Senior and
			 Disabled Services Division;
(c) A
			 person has been employed by a long term care facility within the last two
			 years.
Oregon Administrative Rules › Chapter 114 - LONG TERM CARE OMBUDSMAN › Division 3 - APPOINTMENT AND DUTIES OF LOCAL SCREENING COMMITTEES › Section 114-003-0000 - Appointment of Screening Committee Members

Current through Register Vol. 63, No. 7, July 1, 2024
(1) All screening committee members shall be
			 appointed by the Ombudsman.
(2) There
			 shall be at least one local screening committee in each area planning
			 district.
(3) Except for individuals
			 already appointed by the Ombudsman as screening committee members as of August
			 30, 1988, screening committee members shall be individuals who are concerned with
			 the provisions of quality care in long term care facilities and who do not have a
			 conflict of interest with the Ombudsman Program.
(4) Each local screening committee shall elect
			 a chairman, vice-chairman, secretary and treasurer and shall meet, at a minimum,
			 once a month. The chairman of the local screening committee may appoint a
			 subcommittee to serve at the chairman's pleasure which is responsible for
			 screening and approving potential designees.
Stat. Auth.: ORS 441
Stats. Implemented:
Oregon Administrative Rules › Chapter 114 - LONG TERM CARE OMBUDSMAN › Division 3 - APPOINTMENT AND DUTIES OF LOCAL SCREENING COMMITTEES › Section 114-003-0010 - Duties of the Local Screening Committee

Current through Register Vol. 63, No. 7, July 1, 2024
(1) Duties of the local screening committee
			 shall consist of the following:
(a) Publicizing
			 the Ombudsman Program's goals, needs and benefits;
(b) Recruiting potential designees;
(c) Screening potential designees, including
			 checking references;
(d) Referring
			 approved applicants for designees to the Ombudsman within seven days of approval
			 by the local screening committee;
(e)
			 Filing an annual report with the Ombudsman which includes, but is not limited to:
(A) General activities conducted by the local
			 screening committee;
(B) The number
			 of designee applicants screened;
(C)
			 The number of designee applicants approved;
(D) The number of designees certified, assigned
			 or serving as back up designees in the local screening committee's
			 area;
(E) Problems or concerns of the
			 local screening committee and recommendations to bring about resolution;
			 and
(F) Any other activities which
			 have been approved by the Ombudsman and which promote the goals of the Ombudsman
			 Program.
Oregon Administrative Rules › Chapter 114 - LONG TERM CARE OMBUDSMAN › Division 4 - DESIGNEES › Section 114-004-0000 - Appointment of Designees

Current through Register Vol. 63, No. 7, July 1, 2024
(1) The
			 Ombudsman shall review each designee applicant approved by a local screening
			 committee. The Ombudsman shall approve the applicant if the applicant meets the
			 qualifications of a designee as set forth in OAR
			 114-004-0010.
(2) Once the Ombudsman approves the applicant,
			 the applicant must meet the requirements set forth in OAR
			 114-004-0020(1).
(3) Upon successful completion of the
			 requirements set forth in OAR
			 114-004-0020(1)
 
			 by the designee applicant, the Ombudsman shall appoint the applicant as a
			 designee.
Stat. Auth.: ORS 441
Stats. Implemented:
Oregon Administrative Rules › Chapter 114 - LONG TERM CARE OMBUDSMAN › Division 4 - DESIGNEES › Section 114-004-0010 - Designee Qualifications

Current through Register Vol. 63, No. 7, July 1, 2024
(1) Designees
			 shall not have a conflict of interest with the Ombudsman Program.
(2) Designees shall have experience with long
			 term care facilities or residents thereof or elderly individuals at risk of
			 institutionalization or requiring assistance with the activities of daily living
			 including the ability to communicate well with the elderly as well as long term
			 care facility staff, to understand laws, rules and regulations, and to be
			 assertive, yet objective.
(3)
			 Designees with experience in either social service, gerontology, nursing or
			 paralegal work shall be preferred.
(4) Designees must be willing to donate 16
			 hours of their time per month to perform the duties of a designee.
Stat. Auth.: ORS 441
Stats. Implemented:
Oregon Administrative Rules › Chapter 114 - LONG TERM CARE OMBUDSMAN › Division 4 - DESIGNEES › Section 114-004-0020 - Designee Training

Current through Register Vol. 63, No. 7, July 1, 2024
(1) A designee
			 applicant who has been approved by the local screening committee and by the
			 Ombudsman shall, before being appointed as a designee by the Ombudsman:
(a) Complete 48 hours of training provided,
			 sponsored or approved by the Ombudsman Program;
(b) Maintain a log of all training hours
			 completed including but not limited to:
(A)
			 Training hours provided by the Ombudsman Program;
(B) Approved home study hours; and
(C) Approved training relating to Long Term
			 Care issues, but not directly provided by the Ombudsman Program such as community
			 workshops, seminars and association meetings.
(c) Take a certification assessment examination
			 covering training areas upon completion of the 48 hours of training;
			 and
(d) Receive a passing score of at
			 least 70 percent on the certification assessment examination.
Oregon Administrative Rules › Chapter 114 - LONG TERM CARE OMBUDSMAN › Division 4 - DESIGNEES › Section 114-004-0030 - Designee Contracts

Current through Register Vol. 63, No. 7, July 1, 2024
(1) Prior to being
			 assigned to a long term care facility, a designee shall sign a contract with the
			 Ombudsman Program which meets the requirements of ORS
			 441.131(3) and
			 (6).
(2) Noncompliance with the terms of the
			 contract is cause for immediate termination of the contract.
(3) Termination of a designee's contract may be
			 initiated by the Ombudsman or the designee in writing for any or no cause,
			 without prior notice.
(4) Upon
			 termination of a designee's contract, the designee must return all designee
			 identification, manuals, confidential material and reports to the
			 Ombudsman.
(5) Each designee's job
			 performance may be reviewed at any time by the Ombudsman Program for the
			 following purposes:
(a) To assure designee
			 compliance with contractual commitment;
(b) To assess and review job performance;
			 and
(c) To assure compliance with the
			 rules and Ombudsman Program goals and philosophy.
Oregon Administrative Rules › Chapter 114 - LONG TERM CARE OMBUDSMAN › Division 4 - DESIGNEES › Section 114-004-0040 - Designee Assignments

Current through Register Vol. 63, No. 7, July 1, 2024
(1) The
			 Ombudsman shall assign a designee to particular long term care facilities or to
			 act as a back-up designee. Designees shall not be assigned to a long term care
			 facility where an immediate family member is a resident.
(2) Each designee's contract shall identify the
			 long term care facility or facilities specifically assigned to that designee,
			 unless the designee is assigned as a back-up designee. A designee shall not have
			 access, as a designee, to any long term care facility other than the ones
			 specifically named in the designee's contract, unless the designee is requested
			 to enter another long term care facility by that facility's assigned designee,
			 the District Facilitator or the Office of the Long Term Care Ombudsman.
(3) A back-up designee's contract shall allow
			 the designee access, as a designee, to any long term care facility when requested
			 to by the assigned designee, the District Facilitator or the Office of the Long
			 Term Care Ombudsman.
Stat. Auth.: ORS 441
Stats. Implemented:
Oregon Administrative Rules › Chapter 114 - LONG TERM CARE OMBUDSMAN › Division 4 - DESIGNEES › Section 114-004-0050 - Duties of Designees

Current through Register Vol. 63, No. 7, July 1, 2024
A designee shall:
(1)
			 Visit each assigned long term care facility on a regular basis:
(a) Upon arrival and departure, inform a
			 specified staff member;
(b) Review
			 any problems or concerns relating to the assigned long term care facility with
			 administrators or persons in charge or their representatives provided that
			 confidentiality requirements are met; and
(c) Visit individual residents and resident
			 councils.
Oregon Administrative Rules › Chapter 114 - LONG TERM CARE OMBUDSMAN › Division 4 - DESIGNEES › Section 114-004-0060 - Complaints Against Designees and Rights of Designees

Current through Register Vol. 63, No. 7, July 1, 2024
(1) Any complaints regarding inappropriate
			 actions or inactions relating to the official conduct of designees shall be
			 referred to the Ombudsman.
(2) The
			 ombudsman shall investigate any complaint concerning designees. If the Ombudsman
			 finds reasonable cause to believe that a designee has acted inappropriately or
			 contrary to law and rule, the Ombudsman shall take appropriate action.
			 Appropriate action may include a reprimand, requiring additional training,
			 temporary suspension, or termination of the designee.
(3) A designee, who is not satisfied with any
			 action taken against the designee by the Ombudsman as a result of a complaint
			 against the designee, may request, in writing, an informal conference with the
			 Ombudsman to discuss and refute the complaint, findings and action taken by the
			 Ombudsman. An informal conference shall be held within 14 days of receipt of the
			 written request made by the designee to the Ombudsman. After considering the
			 information submitted at the informal conference the Ombudsman may affirm, modify
			 or rescind the initial action taken against the designee.
Stat. Auth.: ORS 441
Stats. Implemented:
Oregon Administrative Rules › Chapter 114 - LONG TERM CARE OMBUDSMAN › Division 5 - ACCESS, INVESTIGATION AND REPORTING PROCEDURES › Section 114-005-0000 - Access to Long Term Care Facilities

Current through Register Vol. 63, No. 7, July 1, 2024
(1) Upon entering a long term care facility,
			 the Ombudsman or designee shall present identification provided by the Ombudsman
			 Program to the specified staff person and request that the Ombudsman or designee
			 be directed to the person in charge. The Ombudsman or designee shall show I.D. to
			 the person in charge. If the person in charge is not available, the Ombudsman or
			 designee may proceed to fulfill the Ombudsman or designee's duties.
(2) The Ombudsman or designee is not required
			 to inform the long term care facility of the specific nature of the visit. The
			 Ombudsman or designee may generally inform the long term care facility as to
			 whether or not the visit is a routine visit or complaint investigation, but shall
			 not offer any information that would enable a person to determine the name of the
			 complainant, witness or witnesses or alleged victims.
(3) The Ombudsman or designee is not required
			 to give prior notification before visiting a long term care facility.
(4) The Ombudsman or designee is not required
			 to conform to any policy of a long term care facility that in any way limits
			 access rights established by ORS
			 441.117 and this rule.
(5) During any visit to a long term care
			 facility, the Ombudsman or designee shall have access, without accompaniment of
			 long term care facility staff, to all public or common areas and to resident
			 rooms with the consent of the resident or the resident's legal guardian. For the
			 purpose of investigating or resolving complaints, the Ombudsman or designee shall
			 have access to laundry rooms, kitchens, linen closets, shower rooms and other
			 service areas of a long term care facility that are relevant to any matter under
			 investigation.
(6) The Ombudsman or
			 designee may obtain access to a long term care facility at any time considered
			 necessary and reasonable by the Ombudsman or designee for the purpose of
			 performing the duties of the Ombudsman or designee.
Stat. Auth.: ORS 441
Stats. Implemented:
Oregon Administrative Rules › Chapter 114 - LONG TERM CARE OMBUDSMAN › Division 5 - ACCESS, INVESTIGATION AND REPORTING PROCEDURES › Section 114-005-0010 - Access to Resident

Current through Register Vol. 63, No. 7, July 1, 2024
(1) The Ombudsman
			 or designee may communicate privately with any consenting resident. The Ombudsman
			 and designee shall have access to each resident in private to determine if the
			 resident wishes to communicate with the Ombudsman or designee. The resident's
			 refusal to communicate with the Ombudsman or designee shall not be relayed by an
			 intermediary. In a multi-bed room, a resident's refusal to communicate with the
			 Ombudsman or designee shall not keep the Ombudsman or designee from entering or
			 communicating with other residents. If the resident's room does not permit
			 private consultation to occur between the Ombudsman or designee and resident, or
			 if such consultation infringes upon the rights of roommates, then the facility
			 shall provide an appropriate private place for such meetings. The resident(s) and
			 the Ombudsman or designee may also meet in any common area of the facility unless
			 their presence there would infringe upon the privacy or other rights of other
			 residents.
(2) When encountering a
			 closed door the Ombudsman or designee shall knock and listen for a response. If
			 there is no response, the Ombudsman or designee may open the door and announce
			 his/her presence as entering. If residents are observed in a situation or
			 condition requiring privacy, the Ombudsman or designee shall excuse themselves
			 and close the door upon exiting.
(3)
			 When encountering a closed privacy curtain, the Ombudsman or designee shall
			 request permission from the resident to enter the curtained area. If the resident
			 does not respond, the Ombudsman or designee shall request that staff of the long
			 term care facility determine if the resident is asleep or receiving treatment or
			 services. If the resident is sleeping or receiving treatment or services, the
			 Ombudsman or designee may not enter the curtained area. If the resident is not
			 sleeping or receiving treatment or services, the Ombudsman or designee may enter
			 the curtained area to determine if the resident wishes to communicate with the
			 Ombudsman or designee.
Stat. Auth.: ORS 441
Stats. Implemented:
Oregon Administrative Rules › Chapter 114 - LONG TERM CARE OMBUDSMAN › Division 5 - ACCESS, INVESTIGATION AND REPORTING PROCEDURES › Section 114-005-0020 - Reporting the Investigation

Current through Register Vol. 63, No. 7, July 1, 2024
Upon completion of an investigation, the Ombudsman or designee
				shall report, either verbally or in writing, opinions or recommendations to the
				administrator or other staff in charge, his/her designated representative, and
				affected parties. Findings and conclusions from the investigation may be
				reported, verbally or in writing, provided the report complies with all
				confidentiality requirements and does not jeopardize the integrity of any related
				investigation.
Stat. Auth.: ORS 441
Stats. Implemented:
Oregon Administrative Rules › Chapter 114 - LONG TERM CARE OMBUDSMAN › Division 5 - ACCESS, INVESTIGATION AND REPORTING PROCEDURES › Section 114-005-0030 - Access to Records

Current through Register Vol. 63, No. 7, July 1, 2024
(1) The Ombudsman or
			 designees shall have access to any resident's records with the written
			 authorization of the resident or the resident's legal guardian. If the resident
			 has no legal guardian and is unable to consent, the Office of the Long Term Care
			 Ombudsman may subpoena the resident's records for the purpose of complaint
			 investigation and resolution.
(2) The
			 Ombudsman and designee shall have access to long term care facility records that
			 relate to an investigation. Such records include:
(a) Incident reports;
(b) Staff plans;
(c) Survey inspection reports;
(d) Time Cards;
(e) Facility licenses;
(f) Staff licenses; and
(g) Employee schedules.