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Delaware General AssemblyDelaware RegulationsMonthly Register of RegulationsApril 2013

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19 DE Admin. Code 2001
Pursuant to the authority vested in the State Employee Benefits Committee (SEBC) by 29 Del.C. §§5210(4), 9602(b)(4), the SEBC adopts these eligibility and coverage rules for the State of Delaware Group Health Insurance Program (“State Plan”). In the event of a conflict between these rules and the Delaware Code, the Delaware Code takes precedence over these rules.
1.3 Short term disability beneficiaries receiving benefits under 29 Del.C. §5253(b) will be treated as "regular officers and employees" under these regulations. Long term disability beneficiaries receiving benefits under 29 Del.C. §5253(c) will be treated as "eligible pensioners" under these regulations.
In compliance with the Civil Union and Equality Act of 2011, 13 Del.C., Chapter 2, effective January 1, 2012 at 10 A.M., regular officers, employees, and pensioners who are party to a civil union in the State of Delaware shall be included in any definition or use of the terms “dependent”, “family”, “husband and wife”, “immediate family”, “next of kin”, “spouse”, “stepparent”, “tenants by the entirety”, and other terms whether or not gender-specific, that denote a spousal relationship or a person in a spousal relationship as they appear in the Groups Health Eligibility and Enrollment Rules. The same proof of relation required of “dependent”, “family”, “husband and wife”, “immediate family”, “next of kin”, “spouse”, “stepparent”, “tenants by the entirety”, will be required of employees and pensioners who are party to a civil union.
IMPORTANT NOTE: Spousal Coordination of Benefits Policy has been in effect since 1/1/93 and revised 7-1-11. The policy applies to a spouse who is eligible for health coverage through his/her own employer or former employer (when spouse is retired). Spouses who work full-time or who are retired and are eligible for health coverage through their current or former employer, but do not enroll under that employer's health plan, will have a reduction in benefits under the State Plan. A new Spousal Coordination of Benefits form must be completed each year during Open Enrollment or anytime throughout the year the spouse's employment or health insurance status changes. Information on the Spousal Coordination of Benefits Policy, form and a Summary Plan Description (SPD) for each health care plan is available on the Statewide Benefit Office’s website at http://ben.omb.delaware.gov/
2.1.1.4 unmarried dependent child/ren who meet the criteria of sections 2.1.1.2 above, but who is age 26 or older and incapable of self-support because of a mental or physical disability which existed before the child reached age 26. The child/ren must have been covered under employee's contract immediately preceding age 26.
2.1.1.5 unmarried dependent child/ren who meet the criteria of section (c) above, but who is age 19 (age 24 if full-time student) or older and incapable of self-support because of a mental or physical disability which existed before the child reached age 19 (age 24 if full-time student). The child/ren must have been covered under employee's contract immediately preceding age 19 (age 24 if full-time student).
IMPORTANT NOTES: The Administration of Dependent Coverage to Age 26 policy became effective July 1, 2011 and provides for coverage of adult dependents until age 26 under the State Plan. As a "grandfathered" health care plan, the State Plan shall exclude adult dependents who are eligible to enroll in an employer-sponsored plan available through the adult dependent's employer until the plan year beginning July 1, 2014. The Adult Dependent Coordination of Benefits form must be completed by the regular officer, employee, or eligible pensioner on an annual basis at Open Enrollment or anytime throughout the year that the adult dependent's employment or health care status changes, except if enrolled in one of the non-grandfathered Consumer-Directed Health Plans.
2.4 In accordance with 29 Del.C., §5202(h) any spouse receiving a survivor’s pension benefit from the State Employee Pension Plan, the State Police Pension Plan(s) or the Judiciary Pension Plan may not include a new spouse in the State’s pension group health insurance plan effective June 1, 2012.
IMPORTANT NOTES: Spousal Coordination of Benefits Policy became effective 1/1/93 and revised 7/1/11 for a spouse who is eligible for health coverage through his or her own employer or former employer when spouse is retired. Spouses who work full time and are eligible for health coverage through their employer or spouses who are retired and eligible for health coverage through their former employer, but do not enroll under their former employer's health plan, will have a reduction in benefits under the State Plan. Information on the Spousal Coordination of Benefits Policy, form and a Summary Plan Description (SPD) for each health care plan is available on the Statewide Benefit Office’s website at http://ben.omb.delaware.gov/
IMPORTANT NOTES: Adult Dependent Coordination of Benefits form must be completed for each enrolled adult dependent between ages of 21 to 26 upon enrollment, any time coverage changes, or upon request by the Statewide Benefits Office, except if enrolled in a Consumer-Directed Health Plan.
5.14.1 An employee who has paid the State Share in order to insure continuation of health coverage and then later is found to have been eligible for receipt of State Share, is to be refunded the amount that was not paid by the State. The employee must make application for the refund within one calendar year of the date the employee paid the State Share to be refunded; A regular officer, employee or eligible pensioner who has paid the State Share in order to insure continuation of health coverage and then later is found to have been eligible for receipt of State Share, is to be refunded the amount that was not paid by the State. The employee or pensioner must make application for the refund within one calendar year of the date the employee first paid the State Share to be refunded as required under 10 Del.C. §8111.
5.14.2 An employee who has paid the employee share then later is found to have been eligible for receipt of DSS is to be refunded the amount paid for employee share for a period not to exceed one calendar year. The employee seeking a refund must make application for the refund within one year of the date the employee paid the employee share to be refunded; A regular officer, employee or eligible pensioner who has paid the employee or pensioner share then later is found to have been eligible for receipt of DSS is to be refunded the amount paid for employee or pensioner share for a period not to exceed one calendar year. The employee or pensioner seeking a refund must make application for the refund within one year of the date the employee or pensioner first paid the employee or pensioner share to be refunded as required under 10 Del.C. §8111.
5.14.3 An employee who has paid the employee share for an ineligible dependent (for example following a divorce, death or exceeding the dependent age limits) is to be refunded the amount paid for employee share for a period not to exceed 60 days, provided that the employee seeking a refund must make application for the refund within 60 days of the date the employee paid the employee share to be refunded and further that the employee shall be liable for any amounts paid by the State Plan on behalf of the ineligible dependent until the employee provides notice to the Statewide Benefits Office of the dependent's ineligibility; A regular officer, employee or pensioner who has paid the employee or pensioner share for an ineligible dependent (for example following divorce, death, or exceeding the dependent age limits) is to be refunded the amount paid for employee or pensioner share for a period not to exceed 60 days, provided that the employee or pensioner seeking a refund must make application for the refund within 60 days of the date the employee or pensioner paid the employee or pensioner share to be refunded and further that the employee or pensioner shall be liable for any amounts paid by the State Plan on behalf of the ineligible dependent until the employee or pensioner provides notice to the Statewide Benefits Office of the dependent's ineligibility.
5.14.5 In any event, rRefunds of less than $1.00 will not be made.
5.21 In the event that the State has paid the employee share or any co-pays, coinsurance, deductibles or other amounts that OMB determines should have been paid by the regular officer or employee or covered spouse or dependent of the regular officer or employee upon prior written notice to such regular officer or employee (which shall not be less than sixty (60) days), the State, to the extent permissible under applicable law, may recover such amounts from such regular officer or employee by deducting the amount paid by the State from the after tax pay due to the regular officer or employee In the event that the State Plan has paid the employee or pensioner share or any co-pays, coinsurance, deductibles or other amounts that OMB determines should have been paid by the regular officer, employee or pensioner or covered spouse or dependent of the regular officer, employee or pensioner after deducting premiums paid during the applicable period and upon prior written notice to such regular officer, employee or pensioner (which shall not be less than sixty (60 days), the State Plan, to the extent permissible under applicable law, may recover such amounts from such regular officer, employee or pensioner by deducting the amount paid by the State Plan from the after tax pay due to the regular officer or employee or by invoicing the regular officer, employee or pensioner,
5.21.1 the regular officer or employee shall be provided an opportunity to dispute such amounts owed to the State to the Statewide Benefits Office and the regular officer, employee or pensioner shall be provided an opportunity to dispute such amounts owed to the State Plan to the Statewide Benefits Office and
5.21.2 if the amount owed by the regular officer or employee exceeds $1,000 then the regular officer or employee shall be provided an opportunity to have the amount owed deducted in monthly installments over a period of time not less than twelve (12) months. if the amount owed by the regular officer, employee or pensioner exceeds $500.00 then the regular officer, employee or pensioner shall be provided an opportunity to have the amount owed deducted or invoiced in monthly installments over a period of time not less than twelve (12) months. In accordance with 10 Del.C. §8106(a), payment which the State Plan has made for the employee or pensioner share or any co-pays, coinsurance, deductible or other amounts that OMB determines should have been paid by the regular officer, employee or pensioners or covered spouse or dependent of the regular officer, employee or pensioner for a period of up to one year may be collected from the regular officer, employee or pensioner after deducting premiums paid during the applicable period and provided the State Plan shall provide such officer, employee or pensioner an opportunity to repay the amount due in a period of time not less than the total number of months being collected by the State Plan or not less than twelve (12) months if the amount owed exceeds $500.00.
January 2nd through February 1st
February 2nd through March 1st
March 2nd through April 1st
April 2nd through May 1st
May 2nd through June 1st
June 2nd through July 1st
July 2nd through August 1st
August 2nd through September 1st
September 2nd though October 1st
October 2nd through November 1st
November 2nd through December 1st
December 2nd through January 1st
Last Updated: December 31 1969 19:00:00.
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