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Delaware General AssemblyDelaware RegulationsMonthly Register of RegulationsJuly 2014

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19 DE Admin. Code 2001
Employees Eligible to Participate in the State Group Health Insurance Program
Effective on July 1, 2014, under the authority of Title 29, Section 9602(b)(4) of the Delaware Code, the State Employee Benefits Committee (SEBC) voted to amend the Group Health Insurance Program (GHIP) Eligibility and Enrollment Rules shown below. The amended rules are effective upon publication in the Register of Regulations in accordance with 147th General Assembly’s House Bill 75.
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 enrollment 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.
Effective July 1, 2013, the Civil Marriage Equality and Religious Freedom Act of 2013 repeals the prohibition on same-gender marriage that was enacted in Delaware in 1996. As of July 1, 2013, two individuals, whether of the same or different genders, are allowed to marry if otherwise eligible. After June 30, 2013, no new civil unions will be formed in Delaware. Both parties to a civil union that is not subject to a pending proceeding for dissolution, annulment or legal separation are permitted to convert their civil union to a marriage prior to July 1, 2014 by application for a marriage license to the clerk of the peace of the county in which their civil union license was issued, with or without further solemnization of such marriage. On July 1, 2014, all remaining civil unions not currently subject to a proceeding for dissolution, annulment or legal separation will automatically convert to marriages. In addition, with respect to legal unions other than marriages between two persons of the same gender established in another jurisdiction, both parties to such legal union will be afforded the same rights, benefits and protections, and will be subject to the same responsibilities, obligations and duties, as a marriage for purposes of Delaware law. In order for such recognition to apply, such union must be validly formed in such other jurisdiction, the parties thereto must meet the eligibility requirements to enter into a marriage in the State of Delaware, and such union must afford and impose on the parties thereto substantially the same rights, benefits, protections, responsibilities, obligations and duties of marriage. This Act provides for the equal application of all laws of the State of Delaware relating to marriage, married spouses or their children to same-gender or different-gender married spouses and their children.
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/
2.1.1.5 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.
A separate Dependent Coordination of Benefits (child/ren) form must be completed for each enrolled dependent regardless of age, upon enrollment in other health coverage, any time other health coverage changes, or upon request by the Statewide Benefits Office to determine if the dependent is covered by any other health plan or the State Plan administrator.
2.2 Eligible dependent child/ren covered under the health insurance plans of both parents (one of whom must be employed by a group not participating in the State Plan) will be primary to the parent's plan whose birthday is the first to occur during the calendar year. In the event the parents’ birth dates are the same, the dependent child will be primary to the parent with the longest employment service. In the event birth dates and length of service are the same, the dependent child will be primary to the mutual choice of the parents.
2.3 Eligible dependent child/ren whose parents are divorced or are not living together and not married will be primary to the plan of the parent with custody or primary to the plan of the spouse of the parent with custody unless a Court or Administrative Order defines one parent as responsible for the child/ren’s health care expenses or health care coverage and if so, that parent’s plan will be primary. If a Court or Administrative Order states that both parents are responsible for the child/ren’s health care expenses or health care coverage or that the parents have joint custody without specifying that one parent has responsibility for the health care expenses or health care coverage of the dependent child/ren the provisions of Eligibility and Enrollment Rule 2.2 shall apply. If there is no Court or Administrative Order allocating custody or responsibility for the child/ren’s health care expenses or health care coverage the provisions of Eligibility and Enrollment Rule 2.2 shall apply. Also see Eligibility and Enrollment Rule 4.10.
2.34 Employing agencies shall maintain files that include such documents as SEBC determines appropriate to administer the State Plan; files shall be subject to audit by the SEBC.
2.45 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.
3.1 Coverage of an eligible regular officer or employee (eligible for State Share) and his/her eligible dependents will become effective on the date of hire or on the first of the any month following date of hire up to the first of the month when eligible for State Share provided the employee submits a signed application within 30 days of the employee's date of hire or within 30 days of the employee becoming eligible for the State Share first of the month when coverage becomes effective. Refer to Eligibility Table for specific coverage date options for employees who elect coverage when eligible for State Share.
3.1.1 Coverage may become effective on date of hire provided the employee submits a signed application within 30 days of the employee's date of hire. Premiums are not pro-rated for employees who elect coverage on their date of hire which is not the first day of the calendar month.
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/
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.
A separate Dependent Coordination of Benefits (child/ren) form must be completed for each enrolled dependent regardless of age, upon enrollment in other health coverage, any time other health coverage changes, or upon request by the Statewide Benefits Office to determine if the dependent is covered by any other health plan or the State Plan administrator.
3.5 Eligible employees or pensioners who fail to submit a completed and signed application/enrollment form within 30 days of their date of hire or first of any month up to their date of eligibility for State Share (see 3.1) or their date of retirement may not join the State Plan until the next open enrollment period (usually May), unless the employee or pensioner meets the requirements of Eligibility and Enrollment Rule 3.6.
Each eligible regular officer, employee, or pensioner may elect to enroll under a separate contract, but no regular officer or employee or eligible pensioner may be enrolled more than once under the State Plan. Eligible dependents may be enrolled under either contract, but no dependent shall be enrolled more than once under the State Plan not be enrolled more than once under the State Plan and can be enrolled under either parent unless the parents cannot agree in which case enrollment shall meet the requirements of Eligibility and Enrollment Rules 2.2 and 2.3.
4.1 An eligible employee who elects to be covered on his/her EMPLOYMENT COVERAGE DATE date of hire or on the first of any one month prior to the employee’s eligibility for State Share may change health insurance (medical) coverage when the employee first becomes eligible for the State Share payment. (Examples: (1) An employee who at hire enrolls in the "First State Basic" plan may change to "Comprehensive PPO" (or another optional coverage) when beginning State Share contribution, without waiting for the next open enrollment period. (2) An employee who at hire enrolls for "Employee" coverage may change to "Employee and Child/ren", "Employee and Spouse", or "Family" coverage when he/she begins to receive State Share, without waiting for the next open enrollment period. The employee who elects coverage to dental and/or vision coverage on his/her EMPLOYMENT COVERAGE DATE may not make changes to dental and/or vision coverage until the next open enrollment period unless the employee meets the requirements of Eligibility and Enrollment Rule 3.6.
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.
A separate Dependent Coordination of Benefits (child/ren) form must be completed for each enrolled dependent regardless of age, upon enrollment in other health coverage, any time other health coverage changes, or upon request by the Statewide Benefits Office to determine if the dependent is covered by any other health plan or the State Plan Administrator.
5.21.2 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.
10.1.3 The Dental and Vision Plans’ effective date is always the first of the month and not on event date of hire or date of qualifying event as for the health plan;
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Last Updated: December 31 1969 19:00:00.
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