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Subject 111-4-1 STATE HEALTH BENEFIT PLAN

Rule 111-4-1-.01 Definitions

(1) "Active" means that the Employee is receiving compensation or is on Approved Leave of Absence Without Pay through a department, school system, Local Employer, agency, authority, board, commission, county department of family and children services, county department of health, community service board, or Contract Employer and for whom the Employee's cost of Coverage is stated as a payroll Deduction or Reduction.
(2) "Acts" or "The Acts" or "The Health Insurance Acts" mean the legislative Acts that establish the Health Insurance Plans for State Employees, Teachers, and Public School Employees and are designated in the Official Code of Georgia Annotated as Article 1 of Chapter 18 of Title 45 and Articles 880 and 910 of Chapter 2 of Title 20.
(3) "Administrator" means the Department of Community Health or the Commissioner of the Department of Community Health.
(4) "Administrative Services" means the services that are provided by contract for a self-insured Health Benefit Plan.
(5) "Approved Leave of Absence Without Pay" means a period of time approved by the appropriate organizational official during which the Employee is absent from work and is not in pay status.
(6) "Annual Required Contribution" means an actuarially determined amount to pay for future OPEB liability over a period of years.
(7) "Beneficiary" means an Employee, Surviving Spouse, divorced or legally separated Spouse, or eligible Dependent child who loses Coverage under these regulations.
(8) "Benefits" mean the schedule of Benefits of health care services eligible for approval of payments under the Options approved by the Board.
(9) "Board of Community Health" or "Board" means the governing body authorized to exercise jurisdiction over the SHBP pursuant to O.C.G.A. § 31-2-3.
(10) "Cafeteria Plan" means a plan which meets the requirements of the regulations of the Internal Revenue Service under Internal Revenue Code (IRC) 125.
(11) "Certificated Capacity" means the Employee holds valid certification; is not assigned to a position that requires certification as a qualification; the Employee's compensation is determined, at least in part, based upon the certificate; and the Employee is a member of the Teachers Retirement System or other Public School Teacher retirement system.
(12) "Certificated Position" means the Employee holds valid certification; is assigned to a position that requires certification as a qualification; the Employee's compensation is determined, at least in part, based upon the certificate; and the Employee is a member of the Teachers Retirement System or other Public School Teachers retirement system.
(13) "Claim" means any bill, invoice, or other written statement from a specific provider for health care services or supplies submitted in accordance with the requirements of the SHBP for a specific eligible Member.
(14) "Commissioner" means the Commissioner of the Department of Community Health as created by O.C.G.A. § 31-2-6.
(15) "Contract Employee" means a person employed by one of the entities that contracts with the Board of Community Health to provide health benefit Coverage under the SHBP, and who is not considered to be an independent contractor.
(16) "Contract Employer" means one of the organizational entities that has elected to contract with the Board of Community Health for inclusion of their Employees in the SHBP.
(17) "Contribution" means the amount or percentage of salaries to be paid by an Employing Entity or State Department of Education for Employees and Retirees for health benefit Coverage.
(18) "Coverage" means the type, Tier, and Option of contract offered to an Enrolled Member pursuant to the Health Insurance Acts. "Coverage" does not include TRICARE Supplemental Coverage.
(19) "Covered Dependent" means any individual eligible under these regulations and for whom the Premium has been paid by the Employee, Retiree, or Extended Beneficiary.
(20) "Creditable Coverage" means health insurance that may serve to reduce a Pre-existing Condition limitation period. Creditable Coverage shall include health plan offerings under the following type plans: group health plans; individual health policies; Health Maintenance Organizations (HMOs); Medicaid; Medicare; or other governmental health programs. Disease specific policies (i.e., cancer insurance), disability insurance, and insurance that provides incidental health insurance (i.e., auto insurance) is not Creditable Coverage.
(21) "Deduction" or "Reduction" means the Premium amount to be remitted to the Administrator as the Employee's or Retiree's share of the cost of the elected Coverage.
(22) "Dependent" means any eligible Spouse, Dependent child, or Totally Disabled Child.
(23) "Employee" means any eligible, Active State Employee, Teacher, or Public School Employee.
(24) "Employing Entity" means any department, school system, Local Employer, Contract Employer, agency, authority, board, commission, county department of family and children services, county department of health, community service board or retirement system that employs or issues an annuity check to an Employee, Contract Employee or Retiree as defined in these regulations.
(25) "Enrolled Member" means the contract holder who may be the Employee, Retiree, Contract Employee, or Extended Beneficiary who is currently enrolled in Coverage and who has paid the necessary Deduction or Premium for such Coverage.
(26) "Extended Beneficiary" means the individual who was covered as an Active or Retired Employee, Employee on Approved Leave of Absence Without Pay or person who was covered as a Spouse or eligible Dependent of an Active or Retired Employee or Employee on Approved Leave of Absence Without Pay on the day SHBP Coverage was lost as a result of a Qualifying Event under the requirements of federal law and regulation known as the Consolidated Omnibus Budget Reconciliation Act (COBRA), as amended.
(27) "Fund" or "Health Benefit Fund" or "Health Insurance Fund" means the State Employees Health Insurance Fund, the Teachers Health Insurance Fund, and the Public School Employees Health Insurance Fund.
(28) "Georgia Retiree Health Benefit Fund" or "GRHBF" means the fund which provides for costs of retiree post employment health insurance benefits. The fund shall be a trust fund of public funds; the Board in its official capacity shall be the fund's trustee; and the Commissioner in his or her official capacity shall be its administrator.
(29) "Group" means all eligible Employees authorized under a specific chapter, article or part of the Official Code of Georgia Annotated for Coverage under the SHBP.
(30) "Health Maintenance Organization" or "HMO" means an organization authorized and certified to provide services under Chapter 21 of Title 33 of the Official Code of Georgia Annotated.
(31) "Local Employer" means a county or independent board of education, regional or county libraries of Georgia, the governing authority of the Georgia Military College, or Regional Educational Service Areas.
(32) "Managed Care Plan" means plans that provide health Coverage through a specified network of providers with benefit differentials in cost sharing between in-network and out-of-network providers.
(33) "Medicare Advantage" means an Option that is offered to Retirees and is approved through the Centers for Medicare and Medicaid Services (CMS) as a Medicare Advantage plan under the Medicare Prescription Drug, Improvement and Modernization Act of 2003 and federal regulations thereunder.
(34) "Member" means a benefit eligible or ineligible Employee, former Employee, Retiree, or Extended Beneficiary.
(35) "Option" means a type of benefit schedule or premium rating category that is offered to an eligible Member through the SHBP.
(36) "Other Post Employment Benefits" or "OPEB" means retiree post-employment health insurance benefits.
(37) "Partial Disability" means the Employee is unable to perform the normal, full-time duties of the individual's occupation or employment due to disability, but is certified by his/her physician to return to work on a part-time basis following a period of disability for a fixed period of time in that individual's occupation or in a modified work capacity.
(38) "Payor, Primary" means the entity which is required by contract or law to reimburse or pay for covered health services without regard to any other benefit entitlement or contractual provision.
(39) "Payor, Secondary" means the entity which does not have the primary liability for providing benefit reimbursement for covered health services.
(40) "Plan" or "Health Insurance Plan" means the insurance Options formed by the combination of Health Insurance Plans for State Employees, Teachers, and Public School Employees.
(41) "Plan Year" means the twelve-month period beginning on January 1, and ending on the following December 31. The Commissioner shall have the flexibility to modify the SHBP Plan Year.
(42) "Pre-existing Condition" is a term defined by the Health Insurance Portability and Accountability Act of 1996 and regulations thereunder. In general, it means a sickness, injury, or other condition (except for pregnancy) for which medical advice, diagnosis, care or treatment was recommended or received within the six (6) months immediately before Coverage began under the Plan.
(43) "Premium" means the Enrolled Member's cost as set by the Board of Community Health for the elected Coverage
(44) "Public School Employee" means a person who is employed by the local school system, meets the eligibility requirements under these regulations and is receiving a salary for services.
(45) "Qualifying Event" means an event as defined by federal law or regulation that authorizes:
(a) eligibility for Extended Coverageor
(b) change in coverage election under a health benefit plan. Qualifying Events include changes in employment or family status as outlined in Sections 111-4-1-.06, 111-4-1-.07, and 111-4-1-.08 of these regulations.
(46) "Rate" means an amount set by the Board for the Enrolled Member Premium or an amount or percentage of salary set by the Board as the Employer's Contribution.
(47) "Regular Insurance" means Options that are not Medicare Advantage Options.
(48) "Retired Employee" or "Retiree" or "Annuitant" means a former State Employee, former Teacher, or former Public School Employee who met the eligibility criteria when Active or was included by specific legislation and who receives a monthly benefit from the Employees' Retirement System, Georgia Legislative Retirement System, Teachers Retirement System, Public School Employees Retirement System, Superior Court Judges Retirement System, District Attorneys' Retirement System, or local school system retirement system and an eligible and former Employee of a county department of family and children services or county department of health who receives a monthly benefit from the Fulton County Retirement System. In the case of a county health department Employee, the Employee must have been covered as an Active Enrolled Member and continued Coverage upon receiving an annuity from the Fulton County Retirement System. Retiree shall also include Enrolled Members who remit payment directly to the SHBP and who are eligible for Coverage as a Surviving Spouse of the eligible Employee or Retiree, and Extended Beneficiary who is eligible by virtue of State law, or an Annuitant whose monthly benefit from a retirement system is insufficient to pay the Premium for the Coverage in which enrolled.
(49) "Retiring Employee" means a Enrolled Member who is eligible to receive an immediate retirement benefit payment from the Employees' Retirement System, Georgia Legislative Retirement System, Teachers Retirement System, Public School Employees Retirement System, Superior Court Judges Retirement System, District Attorneys' Retirement System or local school system retirement system or an Enrolled Member of a county department of family and children services or county department of health who is eligible to receive an immediate retirement benefit payment from the Fulton County Retirement System.
(50) "Spouse" means an individual who is not legally separated, who is of the opposite sex to the Enrolled Member and who is legally married or who submits satisfactory evidence to the Administrator of common law marriage to the Employee or Retired Employee entered into prior to January 1, 1997 and is not legally separated.
(51) "State Employee" means a person employed by the State or a community service board and who meets the eligibility definitions of these regulations and who is receiving a salary or wage for services rendered.
(52) "State Health Benefit Plan" or "SHBP" means the health benefit plan administered by the Department of Community Health covering State Employees, Public School Teachers, Public School Employees, Retirees and their eligible Dependents, and other entities under The Acts for health insurance.
(53) "Summary Plan Description" is a booklet that describes the health benefits and other provisions of the State Health Benefit Plan (SHBP) specific to the Coverage elected by the Enrolled Member.
(54) "Surviving Spouse" means the living Spouse of a deceased Enrolled Member.
(55) "Teacher" or "Public School Teacher" means a person employed by a local school system in a Certificated Position and who meets the eligibility definitions of these regulations and who is receiving a salary or wage for services rendered.
(56) "Tier" means the number and relationship to the Enrolled Member of the persons enrolled under the Member's Coverage.
(57) "Total Disability" means that the Enrolled Member is not able to perform any and every duty of the individual's occupation or employment or that the Dependent is not able to perform the normal activities of a person of like age or sex.
(58) "TPA" or "Third-party Administrator" means an approved contractor for adjudicating paying Claims, and performing other administrative processes.
(59) "TRICARE Supplemental Coverage" means insurance made available to Members who are eligible for SHBP Coverage and entitled to health care benefits under the TRICARE program, and for which premiums are collected by the Administrator and transferred to the company that sells the TRICARE Supplemental Coverage. TRICARE Supplemental Coverage provides health care benefits that are supplementary to health care benefits under TRICARE. The purchase of TRICARE Supplemental Coverage by eligible Members is facilitated by the Administrator and Employing Entities in accordance with the John Warner National Defense Authorization Act for Fiscal Year 2007 and implementing regulations. TRICARE Supplemental Coverage is a voluntary, unsubsidized benefit and is not endorsed or subsidized by the Administrator or any Employing Entity. The Administrator and Employing Entities provide minimal administrative duties with regard to TRICARE Supplemental Coverage, which duties are limited to providing information about the TRICARE Supplemental Coverage to Members and facilitating the collection of premiums for such coverage and transmittal of the premiums to the company that sells the TRICARE Supplemental Coverage. Neither the Board, nor the Administrator nor any Employing Entity provides any incentive to Members to enroll in TRICARE Supplemental Coverage. Neither the Board, nor the Administrator, nor any Employing Entity receives any compensation or consideration for offering TRICARE Supplemental Coverage. TRICARE Supplemental Coverage is not considered SHBP Coverage.

Rule 111-4-1-.02 Organizations

(1) Functions, Duties and Responsibilities of the Board of Community Health. The Board shall provide policy direction for the operation of the State Health Benefit Plan. Other responsibilities as defined by law are:
(a) Establish and Design Plan. The Board is authorized to establish a Health Insurance Plan for group medical insurance against the financial costs of hospitalizations and medical care. The Plan may also include, but is not required to include, prescription drugs, prosthetic appliances, hospital inpatient and outpatient Benefits, dental Benefits, vision care Benefits, and other types of medical Benefits. The Plan shall be designed to:
1. Provide reasonable hospital, surgical, and medical benefits with cost sharing of expenses for each such type to be incurred by the Enrolled Members, Dependents and the Plan, and
2. Include reasonable controls, which may include deductible and reinsurance provisions applicable to some or all of the benefits, to reduce unnecessary utilization of the various hospital, surgical and medical services to be provided and to provide reasonable assurance of financial stability in future years of the Plan.
(b) Promulgate Regulations. The Board is authorized to adopt and promulgate rules and regulations for the effective administration of the SHBP; to adopt and promulgate regulations for defining the contract(s) for Retiring Employees and their Spouses and Dependent children; to adopt and promulgate regulations for prescribing the conditions under which an Employee or Retiring Employee may elect to participate in or withdraw from the SHBP; to adopt and promulgate regulations defining the conditions for covering the eligible Member's Spouse and Dependent children and for discontinuance and resumption by eligible Members of Coverage for the Spouse, Surviving Spouse, and Dependents; to adopt and promulgate regulations to establish and define terms and conditions for former and terminated eligible Member participation; adopt and promulgate rules and regulations which define the conditions under which eligible Members who originally rejected Coverage may acquire Coverage at a later date; and adopt and promulgate rules and regulations for withdrawing from the SHBP upon eligibility for the aged program of the Social Security Administration. Additionally, the Plan shall be required to establish the same eligibility requirements, unless either State or federal law, or regulations promulgated by the State of Georgia's Insurance Commissioner requires a modification.
(c) Establish Member Premium Rates. The Board shall establish Member Premium Rates for each Coverage Option. The Board shall consider the actuarial estimate of the SHBP costs and the funds appropriated to the various departments, boards, agencies, and school systems in establishing the Employee Deduction amount. Other Member Premium amounts shall be established in accordance with these regulations. All Enrolled Member Premium Rates shall be established by resolution and shall remain in effect until changed by resolution.
1. Tobacco Surcharge. An Enrolled Member may be charged a tobacco surcharge in an amount approved by the Board if either the Enrolled Member or any of his or her Covered Dependents have used tobacco products in the previous twelve (12) months. The surcharge amount will be added to the Enrolled Member's base monthly Premium. Any Enrolled Member who fails to answer any designated question(s) relating to the surcharge during Open Enrollment will automatically be charged a surcharge for the remainder of the Plan Year, unless the tobacco user successfully completes a tobacco cessation program, or other similar program, specifically designated by the SHBP.
2. Spousal Surcharge. An Enrolled Member may be charged a spousal surcharge in an amount approved by the Board if the Enrolled Member elects to cover his or her Spouse and the Spouse is eligible for health benefits through his or her employer but opts not to take those benefits. Notwithstanding the foregoing, if the Spouse is already eligible for Coverage with the SHBP through his or her employment, and the Spouse answered the surcharge question(s) on-line, the SHBP will not add the surcharge to the Premium amount. Any Enrolled Member who fails to answer any designated question(s) relating to the surcharge during Open Enrollment will automatically be charged the surcharge for the remainder of the Plan Year.
(d) Establish Employer Rates. The Board shall establish by Resolution, subject to the Governor's approval, Employer Contribution Rates. These rates may be a dollar amount for each Member, a dollar amount for each Enrolled Member, a percentage of Member salary or any other method permitted by law. If the rates are expressed as a percentage of Member salary, the requirements of (4) and (5) below apply. The Commissioner is authorized to establish necessary procedures to facilitate the receipt of Employer Contributions on a timely and accurate basis.
1. The Employer Contribution Rate for Teachers who retired prior to January 1, 1979 may be a dollar amount as identified in the Appropriations Act.
2. The State Department of Education Employer Contribution Rate for the Public School Employee Health Insurance Fund may be a dollar amount as identified in the Appropriations Act.
3. The local school system Employer Contribution Rate for the Public School Employee Health Insurance Fund may be a dollar amount per Enrolled Member and shall be remitted to the Administrator on a monthly basis. The Employer's Contribution amount shall be due to the Administrator on the first of the month coincident with the Employees' monthly Premium amounts.
4. The Employer Contribution Rate for the Teachers Health Insurance Fund may be a percentage of the salary approved by the State Board of Education under the Quality Basic Education Act for persons holding "Certificated Positions" or in a "Certificated Capacity". If it is expressed as a percentage of salary, the monthly Employer Contribution shall be a percentage of state based salaries. County or district libraries shall pay as the Employer Contribution the Board approved percentage of total salaries, exclusive of per diem and casual labor, which is defined as part-time Employees who work less than seventeen and a half (17 ½) hours per week. The Employer's contribution amount shall be due to the Administrator on the date coincident with the Employees' monthly Premium amounts.
5. The Employer Contribution Rate for the State Employees Health Insurance Fund may be a percentage of the total salaries of all Members. Total salaries include temporary salaries, overtime pay, terminal leave pay, and all types of supplemental pay. If it is expressed as a percentage of salary, the monthly Employer Contribution shall be based on salaries for the previous month and shall be due on the date coincident with the Employees' monthly Premium amounts.
6. The Employer Contribution Rate required for coverage of local school board members shall be based on the actual claims experience of all county officers, employees, and local school board members enrolled in the SHBP.
7. The Contributions required from Contract Employers shall be calculated in a manner designed to ensure that Contract Employers pay the full cost of coverage for Enrolled Members, plus an administration fee.
(e) Approve Contracts. The Board is authorized to approve contracts for insurance, reinsurance, health services, and administrative services for the operation of the Plan. The Board is authorized to approve contracts as authorized by law with governments, authorities, or other organizations for inclusion in the Plan.
1. Insurance. The Board may execute a contract or contracts to provide the Benefits under the Plan. Such contract or contracts may be executed with one or more corporations licensed to transact accident and health insurance business in Georgia. The Board shall invite proposals from qualified insurers who, in the opinion of the Board, would desire to accept any part of the health benefit Coverage. Any contracts that the Board executes with insurers shall require compliance with O.C.G.A. § 10-1-393(b)(30.1) relating to certain unfair practices in consumer transactions. The Board may reinsure portions of a contract for the Plan. At the end of any contract year, the Board may discontinue any contract or contracts it has executed with any corporation or corporations and substitute a contract or contracts with any other corporation or corporations licensed to transact accident and health insurance business in Georgia.
2. Self Insurance. The Board in its discretion may establish a self-insured Plan in whole or in part. The contract for Administrative Services in connection with a self-insured health benefit plan may be executed with an insurer authorized to transact accident and sickness insurance in Georgia; with a hospital service nonprofit corporation, nonprofit medical service corporation, or health care corporation; with a professional claim Administrator authorized or licensed to transact business in Georgia; or with an independent adjusting firm with Employees who are licensed as independent adjusters pursuant to Article 2 of Chapter 23 of Title 33.
3. Local Governments. The Board is authorized to contract with the various counties of Georgia, the County Officers Association of Georgia, the Georgia Cooperative Services for the Blind, public and private nonprofit sheltered employment centers which contract with or employ persons within the Division of Rehabilitation Services and the Division of Mental Health and Mental Retardation of the Department of Human Resources; and to contract with the Georgia Development Authority, the Georgia Agrirama Development Authority, the Peace Officer's Annuity and Benefit Fund, the Georgia Firefighters' Pension Fund, the Sheriffs' Retirement Fund of Georgia, the Georgia Housing and Financing Authority, the Georgia-Federal State Inspection Service for the inclusion of eligible Members, retiring Enrolled Members and Dependents in the SHBP. The Board is authorized to include the Georgia-Federal State Inspection Service Employees who retired under the Employees' Retirement System of Georgia on or before July 1, 2000. The term of these contracts shall be established by the Department in accordance with these regulations and Board resolutions. The Board is authorized to contract with local boards of education for inclusion of current board members and their Dependents in the SHBP. The terms of such contracts are established by these regulations once an election for inclusion has been submitted to the Department by the local board of education. Each Contract Employer shall deduct from the Enrolled Members salary the Member's cost of Coverage. In the case of the Georgia Development Authority, the Peace Officers' Annuity and Benefit Fund, the Georgia Firefighters' Pension Fund, the Sheriffs' Retirement Fund of Georgia, the Georgia Housing Authority, and the Georgia Agrirama Development Authority, the Retiree's cost of Coverage shall be deducted from the Retired Enrolled Member's annuity payment. In addition, each Contract Employer shall make the Employer Contribution required for inclusion in the Plan and remit such payments in accordance with procedures as the Administrator may require.
4. Consumer Driven Health Plans (CDHPs). The Board may contract with any CDHP qualified and licensed to conduct business in Georgia pursuant to Chapter 21 of Title 33 of the Official Code of Georgia Annotated.
5. Other Organizations. The Board is authorized to contract with other organizations, including any public or nonprofit critical access hospital, and any federally qualified health center as defined in 42 U.S.C.A. 1395x(aa)(4), that meets such requirements as the Administrator may establish for the inclusion of eligible Members and Dependents in the SHBP. Each Contract Employer shall deduct from the Enrolled Member's salary the Member's share of the cost of Coverage. Each Contract Employer shall remit the total Premium amount as established by the Administrator for inclusion of its Members in the Plan and in accordance with such procedures as the Administrator may require. The Board may require that specified Groups provide a bond to ensure payment performance before allowing SHBP Coverage.
6. Health Maintenance Organizations (HMOs). The Board may contract with any HMO qualified and licensed to conduct business in Georgia pursuant to Chapter 21 of Title 33, relating to Health Maintenance Organizations.
7. Local School Systems. When a school system has elected not to participate in the SHBP for Public School Employees, the Employees may petition the local school system to contract with the Board for an Employee-Pay-Group. The local system may contract with the Board after agreeing to:
(i) Collect the Enrolled Member Premium amounts for the Rates established by the Board; and
(ii) Enroll and maintain enrollment at 75% of the eligible Public School Employees as defined in these regulations.
(2) Functions, Duties and Responsibilities of the Commissioner. The Commissioner is the chief administrative officer of the Department of Community Health. The Commissioner and Administrator as used in these regulations are synonymous. The Commissioner shall employ such personnel as may be needed to administer the SHBP, to appoint and prescribe the duties of positions, all positions of which shall be included in the classified service except as otherwise provided in the law, and may delegate administrative functions and duties at the Commissioner's discretion.
(a) Administer Regulations and Policies. The Commissioner shall administer the SHBP consistent with applicable law, Board regulation and policy.
(b) Custodian of Funds. The Commissioner shall be the custodian of the health benefit Funds and shall be responsible under a properly approved bond for all monies coming into said Funds and paid out of said Funds.
1. All amounts contributed to the Funds by the Member and the Employers and all other income from any source shall be credited to and constitute a part of such trust Funds. Any amounts remaining in such Fund(s) after all expenses have been paid shall be retained in such Fund(s) as a special reserve for adverse fluctuation.
2. The Commissioner shall establish accounting procedures for maintaining trust Funds for the Premium income, interest earned on the income and expenses and benefits paid. Any amounts remaining in each trust Fund after all expenses have been paid shall be retained wholly for the benefit of the members who are eligible and who continue to participate in each health insurance trust.
3. The Commissioner shall submit to the Director of the Office of Treasury and Fiscal Services any amounts available for investment, an estimate of the date such Funds shall no longer be available for investment, and when Funds are to be withdrawn. The director of the Office of Treasury and Fiscal Services shall deposit the Funds in a trust account for credit only to the Plan and shall invest the Funds subject only to the terms, conditions, limitations and restrictions imposed by the laws of Georgia upon domestic life insurance companies.
4. The Commissioner may administratively discharge a debt or obligation not greater than $400.00 due the Health Insurance Fund or Funds.
5. Accurate and Timely Payment of Employer or Employee Contributions.
(i) Payroll System and Other Supporting Documentation Required. Employing Entities that pay Employer Contributions calculated based on salaries or state based salaries must submit the documentation set forth below, in the format required by the Administrator.
(I) Annually and upon request of the Administrator, the Employing Entity must submit documentation showing that the Employing Entity's payroll software is set up to correctly reflect the salary or state-based salary used to determine the required Employer Contribution for each month. This requirement may be satisfied by the State Accounting Office on behalf of all Employing Entities that use payroll software managed by the State Accounting Office.
(II) At the time of each payment of Contributions, the Employing Entity must submit the summary page from the payroll software that displays the total salary or state-based salary used to determine the required Employer Contribution for that month, documentation showing that Employee Contributions were properly calculated and remitted, and documentation showing that Employer and Employee Contributions required for employees on unpaid leave of absence were properly calculated and remitted.
(ii) Local Employers. When a required payment from a local Board of Education, RESA, library or charter school is not received by the deadline, the Administrator shall notify the appropriate superintendent or official and the State Board of Education of the delinquency. The State Board of Education is required by law to withhold all allotments to the local Board of Education, RESA, library or charter school until the full required payment is received.
(iii) Entities Included in the SHBP Pursuant to Contract. Upon providing written notice, the Commissioner may terminate Coverage for any Group that either contracts for SHBP Coverage or is designated by applicable state law as eligible for such Coverage for failure to remit either Employee or Employer Contributions. Upon remittance of the required contributions from any Group that either contracts for SHBP Coverage or is designated by applicable state law as eligible for such Coverage, the SHBP may reinstate Coverage that has been terminated previously for failure to remit Premiums.
(c) Regulations. The Commissioner shall recommend to the Board amendments to the regulations, submit the approved regulations to appropriate filing entities, cause all regulations to be published and provide a copy to the Employing Entities.
(d) Elicit and Evaluate Proposals from Health Care Contractors and/or Administrators. As required for the appropriate administration of the Plan, the Commissioner shall cause to be prepared requests for proposals for selection of health care contractors, vendors, or administrators. Upon receipt of the proposals, the Commissioner shall secure an evaluation of the proposals and submit recommendations for the selection of health care contractors, vendors, or administrators to the Board for approval.
(e) Calculate Employer Contribution Rates. The Commissioner shall cause to be calculated Employer Contribution Rates expressed in the manner specified in Section 111-4-1-.02(d)(1) - (5) of these regulations. These Employer Contribution Rates shall be calculated and presented to the board by such time as is required for the Commissioner to meet the notification deadline set forth in (h) below.
(f) Premium Payments to a Contractor. The Commissioner shall cause to be calculated the Premium amounts due to any underwriter of insurance or re-insurance and remit payments from the appropriate trust Funds for Member Coverage.
(g) Develop and Publish Enrollment Materials, Legal Notices, and Plan Documents.The Commissioner shall cause to be developed enrollment materials, legal notices, and plan documents for Coverage Options. Plan documents shall include, for each Option, a Summary Plan Description (SPD) or Certificate of Coverage which incorporates the approved schedule of Benefits, eligibility requirements, Termination of Coverage provisions, Extended Coverage provisions, to whom benefits will be payable, to whom claims should be submitted, and other administrative requirements. The Commissioner or designee shall publish enrollment materials, legal notices and plan documents on the portion of the Department Website dedicated to the State Health Benefit Plan, and shall provide electronic versions of the enrollment materials, legal notices and plan documents to each local and state Employer for distribution to eligible Members and Enrolled Members. The Commissioner or designee shall cause to distribute the enrollment materials, legal notices and plan documents to Retired Enrolled Members and Extended Beneficiaries at their last known address.
(h) Provide Notice of Employer Contribution. The Commissioner shall provide notice and certification of the required Employer Contribution Rate to each of the Employing Entities and the Department of Education no less than thirty (30) days prior to the commencement of the plan year. The Commissioner shall notify the Employing Entities before the Rate is effective of any Rate change which may be required at times other than the beginning of a fiscal year.
(i) Provide Notice of Eligibility. The Commissioner shall develop procedures for notifying Extended Beneficiaries of the Extended Coverage provisions of Section 111-4-1-.08 of these regulations upon notification by the Employing Entity of the Enrolled Member's employment termination, death, or reduced hours or upon notification by the Member of divorce, legal separation, or child no longer meeting the definition of Dependent.
(j) Provide Certification of Creditable Coverage. The Administrator shall establish procedures for providing a Certificate of Creditable Coverage to each Enrolled Member in compliance with federal law. In general, this Certificate of Creditable Coverage must be provided at the time Coverage cancels or upon request of the Member or Covered Dependent and for a period of twenty-four (24) months after coverage cancellation. The Member may use the certification to limit a subsequent plan's imposition of a Pre-existing Condition limitation or exclusion period.
(k) Correction for Administrative Error. An administrative error is defined as any clerical error in submitting pertinent records or a delay in making any changes by the Employing Entity or Administrator that affects the Coverage for a Member or Dependent who has followed all established procedures and met the time deadlines regarding enrollment or maintenance of Coverage. If the error has placed the Member or Dependent at a substantial financial risk or risk of loss of Coverage, the facts shall be reviewed and corrective action taken. If the Administrator concludes that the Member or Dependent was substantially harmed, the Member or Dependent shall be restored to the former position or shall be granted the request in whole or in part. Any determination of an administrative error shall be left to the discretion of the Administrator and is not subject to challenge.
(l) Perform Minimal Administrative Duties and Maintain Documentation Associated with Tricare Supplemental Insurance.Any TRICARE Supplemental Insurance made available to Members shall be made available in accordance with the John Warner National Defense Authorization Act for Fiscal Year 2007 (the "DAA") and implementing regulations. The Administrator shall not endorse or subsidize TRICARE Supplemental Insurance and shall ensure that it provides only administrative support associated with enabling Members to elect TRICARE Supplemental Insurance and pay for such Insurance through salary deductions or annuity payments. The Administrator shall maintain the certification required by the DAA on behalf of all Employing Entities and provide such certification to the Department of Defense upon request. The Administrator shall take such other actions are necessary to ensure compliance with the DAA.
(3) Duties and Responsibilities of Employing Entity. Each Employing Entity is responsible for complying with these regulations. Statements made by the staff of the Employing Entities or any third party representing the Employing Entity, that are in conflict with these regulations, the Schedule of Benefits, Decision Guide, or the Summary Plan Description (SPD) shall not be binding on the Administrator. Failure of the Employing Entities to fulfill the duties and responsibilities listed in these regulations does not negate the time requirements specified throughout these regulations.
(a) Enroll Eligible Employees. Each Employing Entity shall determine which of its employees meet the SHBP eligibility requirements, which are set forth in the regulations. Each Employing Entity is solely responsible for compliance with State and federal employment laws with respect to its own employees. Each Employing Entity is solely responsible for complying with State and federal obligations to verify eligibility for receipt of health benefits that meet the definition of "public benefits" under applicable immigration laws. Each Employing Entity is solely responsible for obtaining all documentation required under applicable immigration laws, and taking all actions necessary to verify the employee's eligibility to receive "public benefits." Each Employing Entity shall provide enrollment materials, legal notices and plan documents to eligible Members and Enrolled Members, and shall instruct and assist all persons who become eligible to become Enrolled Members under these regulations how to complete the SHBP enrollment or declination process. The Employing Entity shall require each eligible new Member to complete, within thirty-one (31) calendar days of reporting to work, a form for enrolling or declining SHBP Coverage. The Employing Entity shall be responsible for collecting any Premiums due for the selected Coverage. Any penalties or claim expenses resulting from the Employing Entity's enrollment of an ineligible Member, or from the Employing Entity's failure to timely obtain the completed enrollment or declination form, or from the Employing Entity's failure to provide Plan Documents, legal notices or enrollment information to an eligible Member, shall be assessed against the Employing Entity. By facilitating the enrollment of a Member in the SHBP or communicating that a Member is eligible for the SHBP, the Employing Entity is affirming that it has taken all actions required by law for the provision of "public benefits" to that individual. Any penalties arising from the Employing Entity's failure to take such actions shall be assessed against the Employing Entity. Neither the Board nor the Administrator nor the Commissioner shall be liable for the failure of an Employing Entity to comply with employment laws or properly verify SHBP eligibility in accordance with State and federal immigration laws.
(b) Deduct Enrolled Member Premium Amounts. The Employing Entity shall withhold the Enrolled Member Premium amount as approved by the Board, or the Premium amount authorized by the applicable Georgia Code sections from earned compensation as the Enrolled Member's share of the cost of Coverage under the Plan. Any retirement system under which retired or retiring Enrolled Members may continue Coverage under the SHBP as an Annuitant shall withhold the Premium amount as approved by the Board from the annuity as the Enrolled Member's share of the cost of Coverage under the Plan.
(c) Remit Enrolled Members' Premiums and Required Employer Contributions. Employing Entities shall remit the following within five business days of the SHBP billing invoice's coverage month effective date:
1. Enrolled Members' premiums paid through salary deductions or annuity deductions;
2. Premiums collected from employees who have continued their coverage during an Approved Leave of Absence without Pay; and
3. Required Employer Contributions, which include contributions separately calculated for employees on an Approved Leave of Absence without Pay.

For any contribution that is based on actual SHBP enrollment, each Employing Entity is responsible for reconciling any discrepancies between the billed amount and actual enrollment. All corrections to the employee coverage or deductions should be made prior to the coverage month's effective date. The Employing Entity shall follow the manner prescribed by the Administrator for both corrections and reconciliation. The amounts billed on the invoice will be considered final if reconciliations are not completed within 30 day of the billing invoice.

(d) Administer Leave Without Pay Provisions. Each Employing Entity shall administer Approved Leave of Absence Without Pay, Military Leave, and Family and Medical Leave Act Programs in compliance with the federal laws and shall provide information regarding the conditions for continuing Coverage under the SHBP to eligible Enrolled Members. Each Employing Entity shall also provide continuation of Coverage enrollment information to Members. Each Employing Entity shall insure Members on Approved Leave of Absence Without Pay are properly notified of the annual Open Enrollment period and afforded the opportunity to enroll or change Coverage. Each Employing Entity shall maintain procedures to ensure that Member Premiums are collected during these leave periods. If a Member fails to timely pay a Premium during the leave period, that failure causes a loss of eligibility for coverage unless federal law requires otherwise.
(e) Provide Member Loss of Eligibility Information to the Administrator. Each Employing Entity shall report to the Administrator the last date employed/eligible and the reason for the loss of employment/eligibility no later than thirty (30) days following the event leading to loss of eligibility to participate in the Plan. The reasons for loss of eligibility shall be limited to: failure of a Member to pay a required Premium during an approved leave of absence (unless federal law requires continuing coverage), resignation, transfer, retirement, termination of employment for gross misconduct, separation from employment for reasons other than gross misconduct, including, but not limited to loss of eligibility to work under applicable immigration laws, reduction in employment hours below the number of hours required for eligibility, lay-off, failure of an Enrolled Member to timely submit a required Premium during an approved leave of absence without pay, discontinuation, and death. Each Employing Entity is solely responsible for penalties or other liabilities arising from its failure to timely notify the Administrator of loss of eligibility for Coverage. Any claim expenses borne by the SHBP, and any penalties assessed upon the Administrator as a result of the Employing Entity's failure to timely notify the Administrator of a Member's loss of eligibility shall be billed to the respective Employing Entity. The Employing Entity shall reimburse the Administrator in full for claim liability and expenditures incurred by the Plan as a result of the Employing Entity's failure to comply with notification requirements.
(f) Protect the Privacy of Enrollment Information. The SHBP only shares enrollment information with designated employees of the Employing Entity who help with Plan enrollment. Each Employing Entity shall ensure that the SHBP is promptly notified whenever such an employee is no longer permitted to review and share enrollment information about Members with the SHBP. The Employing Entity shall ensure that designated employees are properly trained to protect the privacy and security of the enrollment information. The Employing Entity shall never use enrollment information for any purpose other than helping with enrollment in the Plan.
(g) Refrain from Endorsing TRICARE Supplemental Coverage or Providing Incentives for Members to Elect TRICARE Supplemental Coverage. If TRICARE Supplemental Insurance is made available, Employing Entities shall refrain from endorsing TRICARE Supplemental Insurance or providing any incentives to those who elect TRICARE Supplemental Insurance. Any TRICARE Supplemental Insurance is to be offered only in accordance with the requirements of the John Warner National Defense Authorization Act for Fiscal Year 2007 (the "DAA") and implementing regulations. Employing Entities shall not pay any portion of TRICARE Supplemental Coverage. Nor shall they provide any incentive to individuals who elect TRICARE Supplemental Coverage. Enrolled Members must elect TRICARE Supplemental Coverage by salary deduction or annuity deduction in the same manner they elect SHBP Coverage Options. Any penalties arising from impermissible incentives by the Employing Entity shall be assessed against the Employing Entity. Employing Entities shall provide certifications described in regulations to the Administrator or to the Department of Defense upon request.

Rule 111-4-1-.03 General Provisions

(1) Applicability. All Members who become eligible for Coverage under the SHBP shall be enrolled or permitted to change Coverage election only in accordance with these regulations. All Employing Entities covered by the Acts shall administer the SHBP in accordance with these regulations. All Annuitants or Extended Beneficiaries shall be enrolled or permitted to change Coverage election only in accordance with these regulations.
(2) Extension of SHBP to Eligible Groups. The Board shall review and approve provisions for extending Coverage to eligible Groups as required by law. The special provisions may include allowing Members or Beneficiaries to reenroll in the SHBP.
(3) Conformity with Federal Requirements. When federal law is enacted requiring public employers to comply with certain requirements for continued receipt of public health or other grant funds, the Commissioner shall submit proposed regulations to the Board for approval.
(4) Records. The Plan records shall be maintained in accordance with applicable State and federal law and regulations, including, but not limited to, Chapter 33 of Title 31 of the Georgia Code and the privacy regulations promulgated under the Health Insurance Portability and Accountability Act of 1996 (HIPAA). Records which are not private, confidential or otherwise excluded from disclosure shall be available for public inspection and copying, in accordance with the Georgia Open Records Act. Any medical records and other individually identifying health information presented to the Administrator or to any of the Third Party Administrators in the Claim adjudication process or medical review process shall be confidential and shall be accessible only in accordance with applicable State and federal law and regulations.
(5) Member Responsibility. The Member has responsibility for notifying the Employer and the Plan of discrepancies in the Member's Coverage records. Notwithstanding the foregoing, the requirements of this provision do not negate the Employer's responsibility. The Employing Entity must still fulfill notification and all other requirements set forth under these regulations.
(a) The Enrolled Member is responsible for assuring that the proper Premium payments are deducted or reduced from the Enrolled Member's salary or retirement benefit for the Coverage that the Enrolled Member selected. Premiums of Enrolled Members that are paid through direct pay are to be paid in accordance with their Coverage selection.
(b) The Enrolled Member is responsible for submitting such documentation as the Plan requires to verify the eligibility of Dependents to be added to Coverage within the timeframe allotted by the Plan. Any Dependents not verified within the Plan's allotted time shall not be eligible for Coverage until the next annual Open Enrollment period or subsequent Qualifying Event as described in these regulations.
(c) The Enrolled Member is responsible for updating Spouse and Dependent information and requesting appropriate changes in Coverage as the circumstances may warrant. The Enrolled Member shall reimburse the Plan in full for Claim liability and expenditures incurred by the Plan on behalf of a Dependent who does not meet the definition of an eligible Dependent under these regulations. Any refunds of Premiums (for reasons other than administrative error) will be limited to twelve (12) calendar months from the date that the Administrator receives evidence from the Enrolled Member that the Plan had no liability for additional covered persons.
(d) When the Enrolled Member desires to reduce the period under the insurance Options of limited Coverage for Pre-existing conditions which may apply to himself/herself or any Covered Dependent, the Enrolled Member shall provide the Administrator certification of prior Creditable Coverage from the appropriate health plan administrator.
(6) Gender and Number. Except when otherwise indicated by the context, any masculine terminology herein shall also include the feminine and the definition of any terms herein of the singular may also include the plural.

Rule 111-4-1-.04 Eligibility for Coverage

(1) Active Employees. Employees who are actively at work or on approved leave of absence and have not terminated their employment may participate in the SHBP if classified as the following:
(a) Full-Time.
1. State Employees who work a minimum of thirty (30) hours per weeks are considered full-time.
2. A regular full-time Employee who receives a salary or wage payment from a state department, board, agency, commission, the general assembly, a community service board, or a local government or other organization to which the Department of Community Health provides SHBP coverage through a contract authorized by the Board of Community Health; except contingent workers of the Labor Department, specially classified Employees of the Jekyll Island State Park Authority, Employees working as an independent contractor or on a temporary, seasonal, or intermittent basis and Employees whose duties are expected to require less than nine (9) months of service.
3. A regular full-time Employee who receives a salary or wage payment from a state authority that participates in the Employees' Retirement System;
4. Part-time Employees of the General Assembly who had coverage prior to January 1981, and Administrative and clerical personnel of the General Assembly;
5. A full-time district attorney, assistant district attorney who was appointed pursuant to O.C.G.A. § 15-18-14, or district attorneys' investigators appointed pursuant to O.C.G.A. § 15-18-14.1 of the superior courts of this state;
6. A full-time Employee who receives a salary or wage payment from a county board of health or a county board of family and children services that receives financial assistance from the Department of Human Resources; except for sheltered workshop Employees;
7. Full-time secretaries and law clerks who are employed by district attorneys and judges and are employed under O.C.G.A. §§ 15-6-25 through 15-6-28 and O.C.G.A. §§ 15-18-17 through 15-18-19.
(b) Teachers who are employed not less than half time, which must be at least seventeen and a half (17½) hours per week, in the public school systems of Georgia are eligible to participate under these regulations. An eligible teacher shall not include any independent contractor, emergency or temporary person and is further defined as:
1. A person employed in a professionally Certificated Capacity or Position in the public school systems of Georgia;
2. A person employed by a regional or county library of Georgia;
3. A person employed in a professionally Certificated Capacity or Position in the public vocational and technical schools operated by a local school system;
4. A person employed in a professionally Certificated Capacity or Position in the Regional Educational Service Areas of Georgia;
5. A person employed in a professionally Certificated Capacity or Position in the high school program of the Georgia Military College.
(c) Public School Employees who are employed by a local school system that have elected to participate in the Plan, and are not considered independent contractors, are eligible to enroll under the conditions of these regulations.
1. An Employee who is eligible to participate in the Public School Employees Retirement System as defined by Paragraph (20) of O.C.G.A. § 47-4-2 may enroll, provided the Employee works the greater of at least 60 percent of the time required to carry out the duties of such position or a minimum of fifteen (15) hours per week and is not employed on an emergency or temporary basis.
2. An Employee who holds a non-certificated public school position and who is eligible to participate in the Teachers Retirement System (or other independent local school retirement system), provided the Employee is not employed on an emergency or temporary basis and the Employee works at least 60 percent of the time required to carry out the duties of such position or a minimum of twenty (20) hours per week, whichever is greater may enroll.
(d) Local Boards of Education that elect to provide group medical insurance for members of the local board of education, their spouses, and dependents in accordance with O.C.G.A. § 45-18-5 are eligible to enroll under the conditions of these regulations. Collection and remittance of Enrolled Member premium and employer contribution amounts shall be in accordance with O.C.G.A. § 20-2-55 and these regulations.
(2) Retired Employees. Any Employee who was eligible to participate under 111-4-1-.04(1)(a), 111-4-1-.04(1)(b), or 111-4-1-.04(1)(c) and who was enrolled in the Plan at the time of retirement shall be eligible to continue coverage if:
(a) The Retired Employee is eligible to immediately receive an annuity from the Employees' Retirement System, Georgia Legislative Retirement System, Judicial Retirement System, Superior Court Judges or District Attorneys' Retirement System, Teachers Retirement System, Public School Employees Retirement System, any local school system teachers retirement system, or other retirement system with which the Board is authorized to contract; or
(b) The Retired Employee as an Employee of a county department of family and children services or a county department of health is eligible to receive an annuity from the Fulton County Retirement System.
(3) Eligibility for Coverage as an Enrolled Member and a Dependent. In the situation where both husband and wife are eligible to be covered under the SHBP as an Enrolled Member, each may enroll as a Member and enroll the eligible dependents. The benefits provided under the SHBP will be coordinated in accordance with the Coordination of Benefits or the Medicare Coordination of Benefits provisions of the Summary Plan Description. In no case shall the sum of the total benefits provided by the SHBP exceed the reasonable charges for covered services.
(4) Eligibility for Coverage as an Enrolled Member Limited. In the situation where the Enrolled Member is entitled to Coverage under the SHBP as an Active Employee under a health insurance act and Retired Employee under a different health insurance act, or any combination of provisions, the Member may choose among the Active Employee provisions under which the Member will be covered, but may not choose Coverage as a Retiree or Beneficiary of a Retiree as long as the Member is eligible for Coverage under one of the Active Employee provisions. In no circumstance shall the individual be an Enrolled Member under more than one provision of these regulations.
(5) Eligibility for Coverage as an Active Employee with Two (2) Employing Entities. Dual eligibility and overlapping Coverage shall be handled as follows:
(a) Dual Eligibility. In the situation where the Enrolled Member is eligible for Coverage under the SHBP as an Active Employee of two (2) separate Employing Entities, the Employee may, during the annual Open Enrollment period, elect which Employing Entity shall deduct the Employee Premium in the upcoming Plan Year. Each Employing Entity is responsible for remitting Employer Contribution amounts in accordance with 111-4-1-.02(3)(d) of these regulations.
(b) Overlapping Coverage. In the situation where the Enrolled Member experiences a period of overlapping Coverage as a result of transferring employment between two (2) separate Employing Entities, the Coverage effective date with the second Employer shall determine the Coverage termination date with the first Employer. The Employing Entities shall be responsible under this provision for deducting or refunding Employee Premiums as appropriate.
(6) Employees on Leave Without Pay. Active Employees who are Enrolled Members of the SHBP may continue the Coverage in which enrolled during a period of "Approved Leave of Absence Without Pay", subject to the conditions in these regulations. Enrolled Employees who are on suspension or Approved Leave of Absence Without Pay who did not continue Coverage shall not be eligible to enroll or re-enroll for Coverage while on Approved Leave of Absence Without Pay under any provision of these regulations except during the annual Open Enrollment period. Except for military leave Coverage shall not be extended for an Employee who is self employed or gainfully employed by another party during a period of Approved Leave of Absence Without Pay. A request to continue Coverage while on Approved Leave Without Pay must be received by the Employing Entity within thirty-one (31) calendar days of the termination of paid Coverage through payroll Deductions. Employees who qualify for continued Coverage under multiple leave types may continue Coverage under a combination of leave types; however, the total period of Coverage on Approved Leave of Absence Without Pay shall not exceed twelve (12) calendar months, unless otherwise noted in these provisions. Premium payments must be in an amount sufficient to provide continuous Coverage between termination of paid Coverage through payroll Deductions and the beginning of Approved Leave of Absence Without Pay Coverage. When an Employee on Approved Leave of Absence Without Pay enrolls during the annual Open Enrollment, Period the twelve (12) calendar month Coverage period shall be reduced by the number of prior months of Approved Leave of Absence Without Pay during which the Employee did not elect to participate in the SHBP. Employees on Leave Without Pay must timely submit required Premiums to the Employing Entity, and the Employing Entity must timely pay required Employer Contributions associated with such Employees. An Employee's failure to timely submit a required Premium to the Employing Entity causes a loss of eligibility for Coverage, and the Employing Entity must timely notify the Administrator of loss of eligibility in accordance with these regulations.
(a) Disability Leave. A disability leave is the period of time an Approved Leave of Absence Without Pay has been granted to the Employee due to personal illness, accident or disability. Coverage may be continued under this paragraph for the period of disability, but not longer than twelve (12) consecutive calendar months. Certification of the disability period by a licensed physician shall be required to continue coverage under this provision.
(b) Reduced Working Hours Due to Partial Disability. A Partial Disability leave is the period of time during which an Employer approves an Employee's return to work on a part-time basis from a period of disability leave or paid leave if the part-time work is part of a process to gradually return the Employee to full-time work. Coverage may be continued under this provision for the period of disability approved by a licensed physician, but not longer than twelve (12) consecutive calendar months, inclusive of any time from a period of disability leave without pay. Certification of the Partial Disability period shall be required to continue coverage under this provision.
(c) Leave of Absence for the Employer's Convenience. Employer's convenience leave is a period of time during which an Approved Leave of Absence Without Pay has been granted by the appropriate organizational official due to a regular programmatic plan for Employee absence and pursuant to appropriate regulation. The Employee may continue the Coverage such leave of absence, but not longer than twelve (12) consecutive calendar months.
(d) Educational Leave. Educational leave is the period of time during which an Approved Leave of Absence Without Pay has been granted by the appropriate organizational official for educational or training purposes. The Employee may continue the Coverage under such leave for the period of absence, but not longer than twelve (12) consecutive calendar months.
(e) Family Medical Leave. Family medical leave is the period of time during which an Approved Leave of Absence Without Pay has been granted to the Employee by the appropriate organizational official for personal illness, the care of the Employee's child after birth or placement for adoption or the care of an Employee's seriously ill Spouse, child, or parent. An Employee's personal illness, if properly certified and approved may be granted under the disability leave provisions. Coverage while on Approved Leave of Absence Without Pay for family medical leave may be continued for the period of approved leave, but not longer than twelve (12) weeks in any twelve (12) consecutive month period.
(f) Military Leave. Military leave is the period of time during which an Approved Leave of Absence Without Pay has been granted by the appropriate organization official when an Employee is ordered to military duty or the period, as provided by law, during which an Employee is attending military training. Military leave also applies to an Employee who qualifies for an exigency leave or service member care leave, as defined under Federal law. The Employee may continue the Coverage under such leave for the period of absence.
(g) Suspension or Other Leave of Absence. Suspension or other leave of absence is the period of time during which suspension is in effect or an Approved Leave of Absence Without Pay has been granted by the appropriate organization official for the Employee's convenience. The Employee may continue the Coverage for the period of suspension or approved leave, but not to exceed twelve (12) calendar consecutive months, provided the Employee is not self employed or gainfully employed by another party during such leave of absence.
(h) Extensions of Leave of Absence. If the Employee is unable to return to work at the expiration of the approved leave and the maximum period has not been exhausted, a request to extend the leave of absence may be filed. The Administrator must receive the Employee's request for extension no later than thirty-one (31) calendar days following expiration of Coverage under the leave of absence. The Employing Entity must certify approval of the extension. The attending physician must complete a new disability certification for an extension of a disability leave.
(i) Sequential Periods of Leave. Health benefits may be continued during sequential types of leave, provided that continuation of health benefits during continuous, sequential periods of time shall not exceed the time limitation of the most recently approved type of leave.
(j) Premiums. Premiums for continued Coverage during a period of Approved Leave of Absence Without Pay shall be paid monthly to the Employing Entity. When establishing the monthly Premium amount to be paid by the Employee, the Board may add a processing fee. The Premium Rate, excluding the processing fee, shall be based on the type of approved leave. The Premium Rate for disability, family leave or military leave of absence shall be the same as the Employee Deduction; the Premium Rate for all other types of leave shall be the total cost of coverage as set forth in Board resolution. Failure to pay the full Premium to the Employing Entity within the allotted time shall result in loss of eligibility for Coverage.
(7) Spouse. An Active Employee shall be entitled to enroll the Employee's Spouse upon employment, during Open Enrollment, or under conditions specified in Section 111-4-1-.06 of these regulations. A Retiree shall be entitled to continue Coverage for the Spouse upon retirement or may enroll the Spouse in accordance with Section 111-4-1-.06(5) or 111-4-1-.06(6). The Administrator shall require the Social Security Number for the Spouse as well as appropriate documentation from an Enrolled Member in order to verify a Spouse's eligibility for Coverage.
(8) Dependent Child. An Active Employee shall be entitled to enroll eligible Dependent children upon employment, during Open Enrollment, or under conditions specified in Section 111-4-1-.06 of these regulations. A Retiree shall be entitled to continue Coverage for eligible Dependent children upon retirement or may enroll eligible Dependent children in accordance with Section 111-4-1-.06(5). The Administrator shall require the Social Security Number for every child, starting at age two, as well as appropriate documentation from an Enrolled Member in order to verify a Dependent child's eligibility for Coverage. An eligible Dependent child must meet one of the following definitions;
(a) A natural child, for which the natural guardian has not relinquished all guardianship rights through a judicial decree. Eligibility begins at birth and ends at the end of the month in which the child reaches age twenty-six (26);
(b) An adopted child. Eligibility begins on the date of legal placement for adoption and ends at the end of the month in which the child reaches age twenty-six (26);
(c) A stepchild. Eligibility begins on the date of marriage to the natural parent and ends at the end of the month in which the child reaches age twenty-six (26), or at the end of the month in which he or she loses status as the stepchild of the Enrolled Member, whichever date is earlier; or
(d) Guardianship. A child for whom the Enrolled Member is the legal guardian. Eligibility begins on the date the legal guardianship is established and ends at the end of the month in which the child reaches age twenty-six (26), or at the end of the month in which the legal guardianship terminates, whichever is earlier. Certification documentation requirements are at the discretion of the Administrator. However, a judicial decree from a court of competent jurisdiction is required unless the Administrator concludes that documentation is satisfactory to establish legal guardianship and financial dependence and that other legal papers present undue hardship on the Member or living natural parent(s).
(9) Totally Disabled Child. An Enrolled Member shall be entitled to apply for Coverage of a natural child, legally adopted child or stepchild age twenty-six (26) or older if the child was physically or mentally disabled before age twenty-six (26), continues to be physically or mentally disabled, lives with the Enrolled Member or is institutionalized and depends primarily on the Enrolled Member for support and maintenance.
(a) Application Period. The Enrolled Member may apply for Coverage during Open Enrollment, as a New Hire, or as the result of a Qualifying Event. At all other times, an Enrolled Member whose Totally Disabled Child was a covered dependent on the Member's Family Plan prior to turning age twenty-six (26) must apply for continuation of Coverage and include all supporting documentation no later than thirty-one (31) calendar days following the end of the month in which the child reaches age twenty-six (26). If the Enrolled Member fails to complete the request within the allotted time, eligibility for Coverage until the next Open Enrollment is limited to the conditions outlined for Extended Beneficiaries.
(b) Documentation and Approval. The Administrator shall require documentation as necessary to provide certification that the child was physically or mentally incapable of sustaining, self-supporting employment because of the physical or mental disability before age twenty-six (26), continues to be physically or mentally incapable of sustaining, self-supporting employment because of the physical or mental disability, and lives at the Enrolled Member's home or is institutionalized. The documentation may include but is not limited to certification from a qualified medical practitioner that outlines the physical and psychological history, diagnosis, and provides an estimate of length of time for disability, and an estimate of the child's earning capacity. If the documentation is satisfactory to substantiate the physical or mental disability as required in these regulations, the Administrator may approve Coverage for the period of incapacitation. The Administrator may require periodic recertification of the disabling condition and circumstances, provided the recertification is not more frequent than each twelve (12) calendar months or at the end of the projected disability period if that date is less than twelve (12) calendar months.
(10) Surviving Beneficiary. An Enrolled Member's Surviving Spouse and eligible Dependent children, who were included in the Coverage by the Enrolled Member immediately before death, may continue Coverage provided an application for continuing Coverage is received by the Administrator within ninety (90) calendar days following Coverage termination as a result of the death of the Enrolled Member in the situations set forth below. In the application, the Surviving Spouse shall be required to list all eligible Covered Dependents who will continue Coverage and shall not be allowed to add any future spouse or children not listed. Surviving Covered Spouses and Dependent children are entitled by federal law to continue Coverage under the Extended Beneficiary provisions set forth in Section 111-4-1-.08. By electing to continue coverage under any of these Surviving Beneficiary provisions, the Surviving beneficiary waives rights to continuation coverage under the Extended Beneficiary provisions of Section 111-4-1-.08.
(a) The Surviving Spouse of an Active Employee may continue Coverage for him or herself and surviving eligible Covered Dependent children if the Spouse is eligible to immediately receive a monthly benefit payment from a state supported retirement system in an amount sufficient to pay the Premium established by the Board. The Spouse must elect to continue Coverage as a Surviving Spouse under this provision or as an Employee as a result of the Spouse's own employment, and cannot elect double or dual Coverage under separate provisions of the SHBP. Eligibility of Dependent children shall terminate in accordance with provisions for Dependent children of these regulations. An election to take a lump sum distribution rather than the monthly Annuity negates eligibility to continue Coverage as a Surviving Spouse
(b) The Surviving Spouse of an Annuitant may continue Coverage for him or herself and surviving eligible Covered Dependent children if the Spouse is eligible to immediately receive a monthly benefit payment from a state supported retirement system in amount sufficient to pay the Premium established by the Board. The Surviving Spouse must elect to continue Coverage as a Surviving Spouse under this provision or as an Employee as a result of the Spouse's own employment, and cannot elect double or dual Coverage under separate provisions of the SHBP Eligibility of Dependent children shall terminate in accordance with provisions for Dependent children. An election to take a lump sum distribution rather than the monthly Annuity negates eligibility to continue Coverage as a Surviving Spouse.
(c) Upon the death of an Active Employee, an eligible Covered Dependent child who is the principal Beneficiary under one of the state supported retirement systems may continue Coverage, provided the Dependent child is not covered as a Dependent child under another contract under the SHBP, and provided the monthly benefit payment from a state supported retirement system is in an amount sufficient to pay the Premium established by the Board. Eligibility to continue Coverage shall terminate in accordance with provisions for Dependent children. An election to take a lump sum distribution rather than the monthly Annuity negates eligibility to continue Coverage under this provision.
(d) Upon the death of a Retired Employee, an eligible Covered Dependent child who is the principal beneficiary under one of the state supported retirement systems may continue Coverage, provided the Dependent child is not covered as a Dependent child under another contract under the SHBP, and provided the monthly benefit payment from a state supported retirement system is in an amount sufficient to pay the Premium established by the Board. Eligibility to continue coverage shall terminate in accordance with provisions for Dependent children. An election to take a lump sum distribution rather than the monthly Annuity negates eligibility to continue Coverage under this provision.
(e) The Surviving Spouse of a Retired Employee who is included in Coverage at the time of death of the enrolled Retiree and who will not receive a monthly annuity payment from one of the state supported retirement systems shall be eligible to continue Coverage for him or herself and any of the Retiree's Dependent children who were Covered at the time of the Retiree's death, if the following conditions are met:
1. The Surviving Spouse must make written application no later than ninety (90) calendar days following Coverage termination as a result of the death of the Retired Employee; and
2. The parties must have been married at least one full year prior to the death of the Retired Employee; and
3. The Surviving Spouse agrees to pay the monthly premium payment established by the Board in accordance with the established requirements; and
4. Coverage under this provision shall terminate for the Surviving Spouse and any enrolled Dependent children in the event the Surviving Spouse remarries.
(f) The eligible Covered Spouse and Dependent children of a Covered Active State Employee who is killed or receives injury that results in death while acting in the scope of his or her employment may continue Coverage provided the deceased Enrolled Member's Coverage was continuous during the period between injury and death. The eligible Covered Dependents may elect Coverage as a surviving Dependent or as an Employee as a result of the person's own employment, but cannot elect double or dual Coverage under separate provisions of the SHBP. Surviving Covered Dependents must agree to pay the monthly Premium payment established by the Board for Active State Employees. The Surviving Spouse may elect to continue Coverage for eligible Covered Dependent children. Eligibility of Dependent children shall terminate in accordance with provisions for Dependent children.
(11) Dependent Eligibility Unverified. The Administrator shall define the supporting documentation requirements for verifying Dependent eligibility. Coverage for Dependents whose eligibility is unverified will pend awaiting receipt and review of the documentation. When the Administrator has verified eligibility of the Dependent, the Coverage will be activated in accordance with the provisions of this Section. If the Administrator cannot verify Dependent eligibility within the allotted time, the Dependent will be ineligible for Coverage. The next opportunity to enroll the Dependent and verify the Dependent's eligibility will be the annual Open Enrollment period or subsequent Qualifying Event. Changes to a different coverage tier will not be allowed based on unverified dependent eligibility.
(12) Retired Employees Having Intermittent Periods of Active Employment. Retired Employees who are eligible to continue Coverage under these regulations may elect to return to or continue Active employment with any of the Employing Entities. In such case, the retirement benefit may be suspended or continued; however, the federal Social Security Act requires the health benefit Coverage must be purchased as an Active Employee whenever the eligibility requirements of Section 111-4-1-.04 of these regulations are met. At the point the Employee discontinues Active employment, continuous health benefit Coverage shall be reinstated with the state supported retirement system which previously collected the Premium. In no case, however is an individual who retired prior to the initial legislated funding for that Group of Employees to be entitled to enroll as a Retiree, unless the final Active service period qualifies the Employee for a retirement benefit by one of the state supported retirement systems.
(13) Judicial Reinstatement of State Employees. State Employees who are reinstated to employment by the State Personnel Board or the judiciary shall have Coverage reinstated for themselves and any eligible Dependents. If employment reinstatement occurs within twelve (12) calendar months of discharge and back-pay for continuous employment is awarded, all retroactive Premiums must be collected and remitted to the Plan before and Claims incurred during the period may be filed for reimbursement. If back-pay to provide for continuous employment is not awarded, Coverage may be reinstated with the Employee's return to work. If reinstatement occurs following a period longer than twelve (12) calendar months after the discharge, Coverage for the Employee and previously Covered Dependents will be reinstated when the Employee returns to work or in accordance with the judicial review. In any case where the reinstatement overlaps an Open Enrollment period, the Employee will be given fifteen (15) calendar days after reinstatement to modify Coverage in compliance with Open Enrollment guidelines. Pre-existing condition limitations will be waived for the reinstated Employee and all previously enrolled Dependents. Employing Entities shall be responsible for collecting and remitting any Premiums due for the selected Coverage.
(14) Contract Employees. Employees who are on approved leave of absence and/or have not terminated their employment may participate in the Plan if their Employer has contracted with the Board to provide inclusion in the SHBP. The Employee will be eligible to participate in accordance with the provisions of the contract.

Rule 111-4-1-.05 Effective Date of Coverage

(1) Upon Employment. The Employee's Coverage under the SHBP shall become effective on the first of the month following employment for the full preceding calendar month if the Employee has not terminated employment on or before that date. Coverage for a transferring Employee shall be effective the first of the month following the end of Coverage under a previous Employing Entity. Coverage for eligible Dependents will become effective on the date the Employee's Coverage is effective.
(2) Upon Change in Coverage. If the Member changes Coverage to include eligible Dependents based upon acquisition of Dependent(s), Coverage for the Dependents shall become effective on the later of the first of the month following the request for Coverage, or subject to guidelines for acquisition of Dependent(s).
(3) Upon Open Enrollment Change or Enrollment. The effective date for enrollments or changes in Coverage election to add eligible dependents shall be January 1st unless the Member no longer meets the definition of an Active Employee on or before that date. The termination date for Open Enrollment discontinuation of Coverage shall be December 31st. Subject to the provisions of Section 111-4-1-.06 of these regulations, Coverage elections shall be binding upon the Member for the duration of the Plan Year.
(4) Upon Return from Leave Without Pay. The effective date for re-enrollments following an Approved Leave of Absence Without Pay shall be the first of the month following the return to work. The effective date for re-enrollments following a military leave without pay shall be the first of the month following the return to work or the date employment is reinstated. In all instances, the appropriate Premiums must be deducted and remitted by the Employing Entity.
(5) Upon Acquisition of a Dependent. The effective date of Coverage for acquired Dependents is subject to the requirements as outlined for the Member and shall be the later of the first of the month following the request for Coverage or:
(a) Legally Married Spouse. The effective date of Coverage shall be no earlier than the first of the month of marriage to the Member. The Plan is not responsible for payment of the Spouse's medical services incurred prior to the actual date of the marriage.
(b) Natural Children. The effective date of Coverage shall be the date of birth.
(c) Stepchildren. The effective date of Coverage shall be no earlier than the date of marriage of the Member and the natural parent of the children.
(d) Adopted Children. The effective date of Coverage shall be no earlier than the date of legal placement for adoption.
(e) Other Children. The effective date of Coverage shall be no earlier than the date that sole legal guardianship is established.
(6) Premium. The Administrator shall terminate Coverage of Enrolled Members and Covered Dependents for which the Plan has not received full payment of the required Premium prior to the first day of the Coverage month. Terminated Coverage will be reactivated upon receipt of full payment of the required monthly Premium.

Rule 111-4-1-.06 Changes in Coverage and Option

(1) Open Enrollment Period and Retiree Option Change Period. The Open Enrollment period and Retiree Option change period shall be a minimum period of fifteen (15) days and shall begin no earlier than October 1 and shall end no later than November 15 of each year. The Commissioner shall announce the dates of the periods each year. Eligible Employees, enrolled Retirees and Extended Beneficiaries shall be given an opportunity to make the changes in Coverage election as reflected in the following paragraphs.
(a) Active Employees. Eligible Active Employees, eligible Employees on Approved Leave of Absence Without Pay and Extended Beneficiaries shall be given an opportunity to enroll or change Coverage during the Open Enrollment period.
(b) Retirees. During the Retiree Option Change Period, enrolled Retirees shall be given an opportunity to change Coverage Option to any Option for which the Retiree is eligible.
(2) Returning Employee from an Approved Leave of Absence. An eligible Employee who did not continue Coverage during an Approved Leave of Absence Without Pay which included the Open Enrollment period shall be offered the opportunity to enroll, discontinue, or change Coverage within fifteen (15) calendar days of the date the Employee returns to work.
(3) Qualifying Event During a Period of Ineligibility. When an Employee loses eligibility for Coverage and subsequently resumes eligibility for Coverage within the same Plan Year, and a Qualifying Event under these regulations occurs during the period of ineligibility, the Employee shall have the opportunity to request a change in Coverage election for the remainder of the Plan Year that is consistent with that Qualifying Event. The request to change Coverage election must be received by the Administrator within thirty-one (31) calendar days following the date the Employee resumes eligibility through an Employing Entity. The effective date of the requested action shall be consistent with the new employment provisions of these regulations. The Administrator shall request supporting documentation to demonstrate the Qualifying Event has occurred. Failure to fully document the occurrence of the Qualifying Event within the allotted time shall result in reversal of the new Coverage election and restoration of the Employee's former Coverage election.
(4) Retired Employee's Discontinuation of Coverage. An Enrolled Retired Employee may discontinue Coverage for him or herself at any time. A discontinuation may be made by advance notice to the Administrator or by failing to timely pay required Premiums. Once a Retired Employee discontinues Coverage for him or herself, the discontinuation is permanent except as described below.
(a) TRICARE Supplemental Coverage. If a Retired Employee discontinues SHBP Coverage and elects TRICARE Supplemental Coverage, which is offered by the Administrator, the Retired Employee may re-enroll in SHBP Coverage during the next Retiree Option Change Period as long as he or she has maintained continuous coverage under either SHBP Coverage or TRICARE Supplemental Coverage.
(b) Termination of Medicare Advantage Coverage by CMS. If a Retired Employee's Medicare Advantage coverage is terminated by CMS due to enrollment in another plan or failure to pay Medicare Part B premiums, the Retired Employee will be automatically enrolled in another SHBP Option in accordance with the procedures of the Administrator, and will be charged the required Premiums.
(c) Employment as an Active Employee. If a Retired Employee who has discontinued Coverage becomes employed as an Active Employee, he or she may re-enroll in the SHBP as an Active Employee.

An Enrolled Retired Employee may discontinue Coverage for a Dependent at any time. A discontinuation of Coverage for a Dependent will be permanent except as described below.

(d) PeachCare for Kids Coverage. If a Retired Employee discontinues SHBP Coverage for a Dependent child and enrolls that Dependent child in PeachCare for Kids, the Retired Employee may re-enroll the Dependent child in SHBP Coverage during the next Retiree Option Change Period as long as the Dependent child has maintained continuous coverage under either SHBP Coverage or PeachCare for Kids.
(e) Qualifying Event. If an Enrolled Retired Employee discontinues Coverage for a Dependent and experiences a qualifying event described in Internal Revenue Service Regulation 1.125.4, subsection (6) below will apply and the Retired Employee may be able to re-enroll the Dependent.
(5) Reinstatement of Employee Across Plan Years. If an Employee was reinstated to employment for a period of time inclusive of the applicable Open Enrollment period, the Employee shall be offered the opportunity to enroll or change Coverage within fifteen (15) calendar days of the return to work.
(6) Qualifying Event Coverage Changes.
(a) A Member shall be eligible to make a change in coverage or tier on account of the qualifying events set forth, and in the manner described, in Internal Revenue Service Regulation 1.125-4, so long as the Member and the Employing Entity (if applicable) satisfy requirements established by the Administrator. This subsection does not apply to a Retired Employee who has discontinued SHBP coverage for him or herself. In general, requests to enroll, change, or discontinue coverage must be received by the Administrator no later than thirty-one (31) calendar days following the qualifying event. Requests to enroll newly eligible Dependent children must be received by the Administrator no later than ninety (90) calendar days following the qualifying event. Requests to make election changes as a result of death must be received by the Administrator no later than ninety (90) calendar days following the qualifying event. Where necessary to comply with federal law, election changes may be accepted within the deadline established by the law. The effective date of the Coverage election shall be the first of the month following receipt of the request, unless otherwise noted in Internal Revenue Service Regulation 1.125-4. The Administrator shall request supporting documentation to demonstrate the Qualifying Event has occurred. Failure to fully document the occurrence of the Qualifying Event within the allotted time shall result in reversal of the Coverage election and restoration of the Member's prior Coverage election.
(b) Additional Changes Permitted for Retirees. An enrolled Retiree may change to any Option to which the Retiree is eligible upon occurrence of one or more of the following events, provided the request is received by the Administrator within thirty-one (31) calendar days following the Qualifying Event: at the time of retirement; at the time that the annuity amount to be received from a state supported participating retirement system becomes insufficient to satisfy the Option premium; at the time that the Retired Member becomes eligible for Medicare coverage; or, subject to approval by the Centers for Medicare and Medicaid Services, at the time the enrolled Retiree requests in writing to move from his or her current Option to a Medicare Advantage plan offered by the same Third Party Administrator.
(c) Married enrolled Retirees may change Tier in order to become individual Enrolled Members at any time when no individuals other than the Spouse are enrolled in the Coverage. The change in Coverage will be effective within two (2) calendar months following the requested change.
(7) Documentation. The Administrator may require documentation that a Qualifying Event permitting enrollment, change or discontinuation of Coverage has in fact occurred outside the annual enrollment period. When required, documentation appropriate to the event will be specifically described and must be received by the Administrator within the allotted time. Failure to document appropriately or within the allotted time shall result in the reversal of the requested Coverage action and restoration of the Member's prior Coverage.

Rule 111-4-1-.07 Extended Coverage Under State Law

(1) Employee. Employees are permitted to continue the current Coverage under conditions outlined by State law. Application for Extended Coverage must be made to the Administrator within thirty-one (31) calendar days following Coverage termination as an Active Employee or Extended Beneficiary. Coverage election under Section 111-4-1-.08, Extended Coverage Under Federal law, delays eligibility to enroll under State law provisions until the expiration of the Extended Beneficiary Coverage privileges, except as specifically stated in these provisions.
(a) State Employee.
1. Any State Employee who resigns from employment or who is not re-elected on and after July 1, 1978 and who has completed eight (8) or more years of service as an Employee, exclusive of Approved Leaves of Absence Without Pay for which health benefit Coverage may have been continued, under Section 111-4-1-.04(1)(a) shall have the privilege of continuing Coverage.
2. Any State Employee who has been eligible for Coverage under this Plan for a period of ten (10) years, is discharged and is appealing the discharge to the State Personnel Board shall be entitled to continue Coverage for a period required for the State Personnel Board to render a decision but no longer than six (6) calendar months. The Premium for such Coverage will be the same amount as paid by the Active Employee through payroll Deduction/Reduction. The Employing Entity must notify the Member and the Administrator of the Member's eligibility to continue Coverage. Failure to pay the full Premium within the allotted time shall result in suspension of benefit payments and/or termination of Coverage and forfeit all eligibility for continued Coverage.
(b) General Assembly Member. Any member of the General Assembly who ceases to hold office after July 1, 1981, and who was eligible to retire at the time of leaving office, except for the attainment of retirement age, pursuant to a public retirement system to which the General Assembly appropriates Funds, and who does not withdraw Employee contributions from public retirement systems shall be eligible to continue Coverage for the Enrolled Member and eligible Dependents, subject to the conditions of these regulations. The Premium shall be the same amount as an Active Employee. Coverage shall cease if the Member fails to pay the required Premium billed by the Administrator within thirty (30) calendar days following receipt of a Premium notice or the Member withdraws Employee contributions from the respective retirement system. Failure to pay the full Premium within the allotted time shall result in suspension of benefit payments and/or termination of coverage and forfeit all eligibility for continued Coverage.
(c) Teacher. Any Teacher as defined in Section 111-4-1-.04(1)(b) and any Surviving Spouse of a Teacher who died prior to January 1, 1979 who has eight (8) or more years of creditable service in a teachers retirement system in Georgia and who is not presently eligible to receive retirement benefits shall have the privilege of continuing Coverage.
(d) Public School Employee. Any Public School Employee as defined in Section 111-4-1-.04(1)(c) and who has eight (8) or more years of creditable service in a retirement system in Georgia and who is not eligible to receive retirement benefits because of age shall have the privilege of continuing Coverage. Prior to December 1, 1986, a Public School Employee whose employment terminated after January 1, 1985, and prior to July 1, 1986, under these conditions shall have the privilege of re-enrolling for Coverage by making application to the Administrator; provided that Coverage shall not become effective earlier than the first of the month in which the application for Coverage was received by the Administrator.
1. Correctional Officers Injured in Service. The SHBP shall provide a Coverage exception from the eight-year or more employment requirement for continued Coverage under the SHBP for a correctional officer injured by inmate violence while on duty if the correctional officer demonstrates that he or she was injured within a time period of five (5) years or less from becoming eligible for Medicare. The correctional officer must remit the Premium amount established for Active Employees. Eligibility for Coverage shall extend to an eligible correctional officer's Spouse or Dependents.
(e) Required Premiums. Except as noted in subparagraphs (a)(2) and (b), premiums for continuing Coverage under this provision shall be billed to the Enrolled Member monthly in an amount equal to the total cost for Coverage, which is the Employee's share and the Employer's cost for benefits and administration, plus processing and administrative fees where applicable. Failure to pay the full Premium within the allotted time shall result in suspension of benefit payments and/or termination of Coverage and forfeit all eligibility for continued c overage.
(f) Notice. The Administrator shall include a notice of payment requirements and penalties on application forms for continued Coverages.
(2) Pending Retiree. An Enrolled Member who has made application for disability or service retirement and who may be eligible for retirement shall have the privilege of continuing any health benefit Coverage during the period between termination of Coverage as an Active Employee and the effective date of Coverage as a Retiree, subject to conditions as outlined in these regulations. The Member may request Coverage as a Pending Retiree within thirty-one (31) calendar days following Coverage termination as an Active Employee. The Administrator shall have the option to enroll and bill the Member directly for Pending Retiree Coverage should a break in Coverage occur.
(a) Coverage as a pending Retiree must be based on a reasonable expectation that the Enrolled Member is eligible for retirement except for completion of the administrative processing to begin the annuity payments. The Administrator may define reasonable expectation; however, continuation of coverage under this provision shall not exceed six (6) calendar months, unless a decision on the retirement application has not been rendered by the respective retirement system's administrative processes. Any months of coverage as a Pending Retiree shall be inclusive of Extended Coverage provisions under Federal law.
(b) Denial of Annuity Payments. At the point that a Board of trustees or retirement Administrator denies the immediate onset of annuity payments, the separated Employee shall no longer be eligible to continue Coverage under this provision. Any Coverage under this provision is inclusive of the maximum length of time allowed under the Extended Coverage provisions that are allowed under Federal law.
(c) Reinstatement of Retiree Coverage. Upon receipt of information that the respective retirement system has reversed an earlier denial to award retirement benefits to an Employee, Coverage may be reinstated as a Retiree. Coverage reinstatement is allowed if the Retiree requests reinstatement within thirty-one (31) calendar days following the reversal of the retirement system's decision. Reinstatement shall be effective as soon as administrative processes for Deduction are completed, but no later than sixty (60) calendar days following notification to the Administrator. The Retiree and Dependents who were enrolled in the Plan will be reinstated without regard to the Pre-existing Condition limitations. The Administrator may review the circumstances and, if undue hardship will be imposed upon the Retiree, may allow retroactive coverage for up to six (6) calendar months from the date of notification that the Retiree is eligible for reinstatement.
(d) Required Premiums. Premiums for continuing coverage under this provision shall be the same as the Employee Deduction Rate plus a processing fee and shall be paid monthly. Failure to pay the full Premium within the allotted time shall result in suspension of benefit payments and/or termination of Coverage and forfeit all eligibility for continued Coverage.
(3) Retiree Retirement Benefit. If the retirement benefit to be received by a Retiree of any one of the respective retirement systems is not sufficient to pay the Premium amount by annuity Deduction, the Retiree shall be permitted to continue Coverage by paying a monthly Premium as set by the Board directly to the Plan. The Premium Rate shall be the same as the Retiree Deduction Rate plus a processing fee. Failure to pay the full Premium within the allotted time shall result in suspension of benefit payments and/or termination of Coverage and forfeit all eligibility for continued Coverage.

Rule 111-4-1-.08 Extended Coverage Under Federal Law (COBRA)

(1) Extended Beneficiary. Persons who lose coverage under the Plan and who meet requirements as specified in these regulations or as specified by federal law are eligible to continue Coverage in the enrolled Option, without evidence of insurability. An Extended Beneficiary shall have the same opportunities for enrolling eligible Dependents and changing Coverage election as Active Employees. The SHBP will be administered in compliance with federal law or regulation under the Consolidated Omnibus Budget Reconciliation Act (COBRA).
(a) Terminated Employee. An enrolled Employee who terminates employment or is separated from his employment for any reason other than for gross misconduct, or whose Approved Leave Without Pay Coverage period expires shall be eligible to continue Coverage under the Plan for a period not longer than eighteen (18) calendar months following the termination of Coverage as an Employee.
(b) Reduction of Required Hours. An enrolled Employee who continues SHBP eligibility under the definition of Employee, except for working the required number of hours, shall be eligible to continue Coverage under the Plan for a period not longer than eighteen (18) calendar months following the end of the month in which the reduction of hours occurred. If the reduced hours take effect on a day other than the first work day of the month, the eighteen (18) calendar month period would begin on the first of the month following termination of Coverage through payroll Deductions.
(c) Laid-off Employee. An Enrolled Employee who is determined to be a laid-off Employee shall be eligible to continue Coverage under the Plan for a period not longer than eighteen (18) months. The extended period begins on the first of the month following termination of Coverage through payroll Deductions.
(d) Spouse of Deceased Employee. The spouse of a deceased enrolled Employee who is not eligible as a Surviving Spouse, an Employee, or an Annuitant shall be eligible to continue Coverage for the Spouse and any Covered, eligible dependents under the Plan for a period not longer than thirty-six (36) calendar months. The extended period of Coverage begins on the first of the month following termination of Coverage through the deceased Employee's payroll Deductions, or if the Employee is on an Approved Leave Without Pay, the later of the end of the month or the end of one month following the month in which the Employee died when Premium was paid in advance.
(e) Surviving Dependent Child. An eligible Dependent child of a deceased enrolled Employee who is not eligible as a Dependent of another Employee, a Surviving Beneficiary under Section 111-4-1-.04(10), and Employee, or an Annuitant shall be eligible to continue individual Coverage under the Plan for a period not longer than thirty-six (36) calendar months following the end of the month in which death occurred. Any months for which Coverage was granted under Section 111-4-1-.04 will be included in the maximum allowance under this provision. The Extended Coverage period begins on the first of the month following termination of the deceased Employee's Coverage through payroll Deductions.
(f) Dependent Child. An eligible Dependent child of an enrolled Employee who is not eligible as an Employee or an Annuitant shall be eligible to continue Coverage under the Plan for a period not longer than thirty-six (36) calendar months following the end of the month in which the child is no longer an eligible Dependent under the Plan.
(g) Legally Separated or Divorced Spouse. A legally separated or divorced Spouse of an enrolled Employee who is not eligible as a Surviving Spouse, an Employee, or an Annuitant shall be eligible to continue Coverage for a period not longer than thirty-six (36) calendar months for the Spouse and any Covered dependents, who are no longer Covered Dependents of the Employee, under the SHBP. The Extended Coverage period begins on the first of the month following the month in which the legal separation documents were approved by a court of competent jurisdiction or the divorce was final.
(h) Disability under Social Security. An additional eleven (11) calendar months of Coverage may be provided to an Extended Beneficiary who meets the definition of disability under Title II or XVI of the Social Security Act prior to or within sixty (60) calendar days of the Qualifying Event. The eleven (11) additional months of Coverage applies to all Beneficiaries eligible under the contract. Eligibility for the additional eleven (11) months is based on the Beneficiary notifying the Administrator of the determination of disability no later than sixty (60) calendar days following the date of the determination. Such notices must be given within the initial eighteen (18) month continuation period. Additionally, the Extended Beneficiary must notify the Administrator within thirty (30) calendar days of the date of any final determination that the Beneficiary is no longer disabled. The Administrator is authorized to charge one hundred fifty percent (150%) of the applicable Premium as outlined in this section.
(i) Multiple qualifying events. If additional Qualifying Events occur which provide for a thirty-six (36) calendar month maximum period during the period when an Extended Beneficiary is covered, the maximum period of Coverage may be extended to a maximum of thirty-six (36) calendar months for Spouse or Dependent Child.
(j) Beginning of the maximum period. The maximum period of Extended Coverage as a result of one or more Qualifying Events shall begin on the day following termination of Coverage as a result of the first Qualifying Event.
(k) Limitation for Individuals Added to Coverage of ExtendedBeneficiary. Individuals enrolled under an Extended Beneficiary's Coverage shall not be eligible to become an Extended Beneficiary as a result of the enrollment.
(l) Payment for Extended Beneficiary Coverages. The applicable Premium for any Coverage election shall include the total Employer and Employee cost plus two percent (2%) of the total Premium cost as established by the Board for Active Employees with eligibility under this section, except that the Extended Beneficiary shall pay this Premium on a monthly basis. An additional forty eight percent (48%) of the total Premium for the Coverage election under the Plan shall be required for the eleven (11) months extension as a result of disability under the Social Security Act. One (1) advance monthly premium plus any retroactive premiums for unpaid periods of Coverage will, however, be requested as a part of the application. Failure to pay the full Premium within the allotted time shall result in suspension of benefit payments and/or termination of Coverage and forfeit all eligibility for continued Coverage.
(m) Notice Requirements. At the time of implementation of the Extended Beneficiary provisions, the Administrator shall distribute to the Employing Entities, having Active Employees, a notice of reasons for the extended eligibility. The Employing Entities shall distribute this notice to each eligible Employee. The Administrator shall incorporate the Extended Beneficiary eligibility provisions in the Employee Summary Plan Description.
1. The Employing Entity must notify the Administrator of the Employee's termination, death, layoff, or reduce hours within thirty (30) calendar days following the event.
2. The enrolled Employee or eligible Beneficiary must notify the Administrator of a Qualifying Event in case of divorce, legal separation, or the Dependent child's loss of eligibility within sixty (60) calendar days of the later of the Qualifying Event or termination of Coverage as a result of the Qualifying Event. Failure to notify the Administrator within the sixty (60) calendar days will forfeit eligibility to enroll as an Extended Beneficiary.
3. The Administrator shall notify the Extended Beneficiary at the known address. The Administrator shall provide notice of the continuation rights within fourteen (14) calendar days following notification from the Employing Entity of the enrolled Employee's death, termination of employment, or reduction of hours. Notice to the Employee's Spouse other than upon the Employee's termination or reduction of hours shall be deemed to be notification to all other Beneficiaries under the contract.
4. The Administrator shall notify the Extended Beneficiary of the continuation rights at the address specified by the Employee or Extended Beneficiary within fourteen (14) calendar days following notification from the Employee of a divorce, legal separation, or the Dependent child's Coverage ineligibility as a Dependent.
5. The Administrator shall notify each newly covered Spouse of the Plans Extended Beneficiary continuation rights within fourteen (14) calendar days of the Spouse's effective date.
6. If the Administrator fails to notify the Extended Beneficiary of the continuation rights within the required time limits as a result of failure of the Employing Entity to notify the Administrator, any penalty required of the Administrator shall be billed to the Employing Entity who failed to notify the Administrator.
(n) Extended Beneficiary's Election Period. The Extended Beneficiary may elect to continue Coverage during the later of sixty (60) calendar days following the Administrator's notification to the Extended Beneficiary or the sixty (60) calendar days following Coverage termination. Coverage will be continued from the Coverage termination date through the months for which payment is received, provided payment is received no later than forty-five (45) calendar days following the Beneficiary's election to continue Coverage.
(o) Extended Beneficiary's Independent Election. Each Beneficiary eligible for Extended Coverage shall be afforded the opportunity to make an independent election to continue Coverage in the enrolled Option, provided the Beneficiary is not enrolled under the SHBP as an Employee, Spouse, Dependent, or Annuitant. If a Beneficiary, either the Employee or Spouse of a enrolled Employee makes an election to provide Coverage for the other Extended Beneficiary, the election shall be binding on that other Beneficiary. An election on behalf of a minor child can be made by the child's parent or legal guardian. An election on behalf of an eligible Beneficiary who is incapacitated can be made by the legal representative of the Beneficiary. Except for any child who is born to or placed with an Extended Beneficiary, Dependents enrolled in the Plan during a period of Extended Coverage under federal law do not themselves become Extended Beneficiaries and may not make separate Coverage elections or participate in Open Enrollment.
(p) Required Documentation. The Administrator may require a monthly certification on the Premium billing by the Extended Beneficiary that the conditions as outlined in Section 111-4-1-.09(11) have not occurred.
(q) Recovery of Paid Benefits. The Administrator shall have the right to recover all benefit payments made on behalf of any Extended Beneficiary as a result of and after the occurrence of any of the conditions outlined in Section 111-4-1-.09(11).

Rule 111-4-1-.09 Termination of Coverage

(1) Termination from Employment. Termination from employment includes resignation, abandonment of job, release from job, forfeiture of job, and all other types of termination. Health benefit Coverage shall terminate at the end of the month following the month of the last date of employment that was transmitted to the Administrator unless continued under the provision of Extended Coverage. This date will normally be the end of the month following the month in which separation or termination of employment occurred.
(2) Employment Layoff. Employment layoff means that the Employer has formalized a reduction in staff plan and the Employee will no longer be employed by one of the Employing Entities. Health Benefit Coverage shall terminate at the end of the month following the month of the last date of employment that was transmitted to the Administrator, unless continued under the provisions of Extended Coverage. The Coverage termination date will normally be the end of the month following the month in which the layoff occurred.
(3) Reduction of Hours. A reduction in hours worked may result in loss of eligibility to continue health benefit Coverage.
(a) If for any reason the number of worked hours is reduced for a covered State Employee to less than thirty (30) hours per week, Coverage shall terminate at the end of the month following the month in which the reduced hours took effect; unless continued under the provisions of Extended Coverage.
(b) If for any reason the number of worked hours is reduced for a covered Teacher to less than half-time or a minimum of seventeen and one-half (17 ½) hours per week, Coverage shall terminate at the end of the month following the month in which the reduced hours took effect; unless continued under the provisions of Extended Coverage.
(c) If for any reason the number of worked hours is reduced for a covered Public School Employee to less than sixty (60) percent of that required to perform the position duties, Coverage shall terminate at the end of the month following the month in which the reduced hours took effect; unless continued under the provisions of Extended Coverage. However, the sixty (60) percent cannot be less than twenty (20) hours if the Member is a participant in the Teachers Retirement System and less than fifteen (15) hours if the member is a participant in the Public School Employees Retirement System.
(4) Failure to Return from an Approved Leave of Absence Without Pay. If an Employee on an Approved Leave of Absence Without Pay fails to return to Active employment, Coverage will terminate at the earlier of the end of the month for which the Leave Without Pay was approved or the end of the month for which a valid Premium payment has been received. Failure to return to Active employment from an Approved Leave of Absence Without Pay will be considered termination of employment for the purposes of Extended Coverage eligibility.
(5) Legal Separation or Divorce. Coverage for a legally separated or divorced Spouse will terminate at the end of the month in which the separation papers were approved by a court of competent jurisdiction or in which the divorce decree is approved by the court of competent jurisdiction unless continued as an Extended Beneficiary.
(6) Dependent Child. Coverage for an eligible Dependent child shall terminate at the end of the month in which the child reaches age twenty-six (26) unless a Qualified Medical Child Support Order (QMCSO) or other court order bears an earlier expiration date or Coverage is continued under the provisions for a Totally Disabled Child or an Extended Beneficiary.
(7) Failure to Remit Premium. Failure to remit the billed Premium amount in full within thirty (30) calendar days following the end of the month for which Coverage has been paid will result in suspension of benefit payments and will constitute forfeiture of eligibility to continue Coverage while on Approved Leave of Absence Without Pay or Extended Coverages of any kind. Coverage will not be reinstated for payments received thirty (30) calendar days following termination of Coverage for insufficient payment, unless an administrative error has been made. Failure to remit Premium will constitute a declination of eligibility to continue coverage as an Extended Beneficiary without further notice by the Administrator.
(8) Expiration of Approval Leave of Absence Without Pay. Coverage will terminate at the end of the month following expiration of the Approved Leave of Absence Without Pay period unless the leave is extended by the appropriate organizational official and such extension is approved by the Administrator or the Employee returns to work, or the Employee extends coverage under the provisions of Extended Coverage. Coverage may be terminated earlier than the expiration of such leave when the Failure to Remit Premium provisions of these regulations apply.
(9) Expiration of Coverage as a Pending Retiree. Health benefit Coverage will terminate at the end of the month following determination that the Retiree is not immediately eligible to receive an annuity under a state supported participating retirement system operated for Employees, unless the Retiree is eligible to continue Coverage under the Extended Coverage provisions of these regulations. Pending Retirees appealing a denial of retirement benefits may continue up to the maximum period outlined in Section 111-4-1-.07.
(10) Expiration of Extended Beneficiary Coverage Privileges. Health benefit Coverage for Extended Beneficiaries will terminate at the end of the month in which the earliest of the following conditions occur:
(a) The full Premium amount is not paid within the time allowed under these regulations;
(b) The maximum Coverage period permitted under these regulations is exhausted;
(c) The Extended Beneficiary becomes enrolled in Medicare benefits;
(d) The Extended Beneficiary becomes covered under another group health care plan by reason of employment or marriage, and pre-existing condition exclusions are not applied under the new coverage;
(e) Cancellation of contract with an organization with whom the Board of Community Health is authorized to contract;
(f) The State Health Benefit Plan is terminated.
(11) Deceased Enrolled Member. Coverage shall terminate no later than the end of the month of death of a Member enrolled in employee only Coverage. Coverage shall terminate no later than the end of the month following the month of death of a Member when the Coverage includes Dependents. The Employing Entity, retirement system or deceased's estate shall remit the appropriate Premium. A surviving Beneficiary may continue coverage as outlined in 111-4-1-.04, the Extended Coverage provisions of these regulations.
(12) Discontinuation of Coverage Outside Open Enrollment. Coverage shall terminate no earlier than the end of the month following receipt of the request to discontinue Coverage outside the annual Open Enrollment period. Requests to discontinue Coverage must be approved by the Administrator. The Administrator may require documentation of other Coverage.
(13) Suspension of Benefits Due to Nonpayment. If an Employing Entity fails to remit Premiums or documentation or fails to reconcile bills in the manner required by the Plan, the Plan may suspend benefit payments for Enrolled Members of the Employing Entity.

Rule 111-4-1-.10 Plan Benefits

(1) Creation of Benefit Schedule. The Board is authorized to establish benefit schedules for Options to be included in a health benefit plan for eligible persons as defined in Georgia law. Benefit schedules shall comply with applicable state and federal law. Benefit schedules shall further the plan design goals set forth by O.C.G.A. Sections 45-18-3; 20-2-883; 20-2-913: "to (1) Provide a reasonable relationship between the hospital, surgical and medical benefits to be included and the expected distribution of expenses of each such type to be incurred by the covered employees and dependents; and (2) Include reasonable controls, which may include deductible and reinsurance provisions applicable to some or all of the benefits, to reduce unnecessary utilization of the various hospital, surgical, and medical services to be provided and to provide reasonable assurance of stability in the future years of the plan." Benefit schedules for Options may include a different schedule for Medicare enrolled Retirees and non-Medicare enrolled Retirees. Benefit schedules of Options shall be considered in the calculation of Employer and Employee Contribution Rates. The Regular Insurance Option benefit schedules shall be established upon approval of the Employer and Employee Contribution Rates for such Options. The Medicare Advantage Option benefit schedules shall be established upon approval of the Employer and Employee Contribution Rates for such Options. The dates of approval of Employer and Employee Contribution Rates shall be recorded in official minutes of Board meetings. Medicare Advantage Options must be developed and administered in the manner approved by the Centers for Medicare and Medicaid Services. Accordingly, the following subsections apply only to Regular Insurance Options.
(a) The Administrator shall authorize the use of established procedures by the TPA to terminate benefit payments if continuation of treatment in the mode being billed is not medically necessary. The TPA's procedures must ensure that the Member shall have the right to ask for a record review by medical consultants.
(b) The Administrator shall interpret the general schedules into specific benefit language for inclusion in the Summary Plan Description and for use by the TPA in adjudicating claim payments.
(c) The Administrator shall incorporate specific benefit language to be used by the TPA for review of utilization patterns and to implement claim cost containment features, including but not limited to, medical review of excessive utilization and audits of hospital or other claims.
(d) The Administrator shall be authorized to require pre-authorization by the TPA of any new medical service before approval for benefit payment. Generally, the service will not be considered for coverage unless medical consultants/advisors substantiate through literature research that clinical trials demonstrate the medical effectiveness of the service. Other guidelines, such as those of the Federal Drug Administration of the Centers for Medicare & Medicaid Services may also be used, at the discretion of the Administrator, in the determination of coverage.
(e) The Administrator shall authorize the use of established procedures by the TPA for obtaining additional medical information from members and from providers of medical services and supplies, in order to determine the amount and appropriateness of benefit payments.
(f) The Administrator shall establish procedures for permitting the Member to appeal an adverse determination of eligibility for Coverage or of a benefit, service, or Claim. These procedures shall be outlined in the Summary Plan Description to advise the Member of the process to initiate an appeal. However, the Administrator has delegated the final authority to the TPA for approval in accordance with the schedule of Benefits and the interpretation thereof. The Administrator shall have final authority for approval of al eligibility appeals.
(g) The Administrator may contract for or employ professionals from any medical discipline to advise the Administrator on continuing medical necessity, quality of medical care, or the level of fees charged by the providers of medical care.
(h) The Administrator is authorized to develop appropriate medical policy in conformity with the schedule of benefits and these regulations so that new procedures will be included for coverage when the new procedures are adopted as accepted medical practice and that medical procedures which are excessively used without significantly improving the treatment of an illness or injury are reviewed.
(2) Exclusions. Plan benefits shall exclude expenses incurred by or on account of an individual prior to the effective date of coverage; expenses for services received for injury or sickness due to war or any act of war, whether declared or undeclared, which war or act of war shall have occurred after the effective date of this plan; expenses for which the individual is not required to make payment; expenses to the extent of benefits provided under any employer group plan other than this plan of benefits in which the state participates in the cost thereof. In addition, for all Regular Insurance Options, the Administrator shall publish in the Summary Plan Description interpretative language showing the exclusions for the following types of charges:
(a) Charges for treatment for Pre-existing Conditions in excess of one thousand dollars ($1,000), to the extent this exclusion is permitted by federal law;
(b) Charges for treatment or supplies which are determined to be not medically necessary;
(c) Charges for treatment before the effective date of coverage or after coverage termination, except for Extended Coverage benefits;
(d) Charges other than Wellness/Preventive benefits, that are not specifically related to the care and treatment of a sickness or an injury;
(e) Charges for treatment specifically for dental or vision care;
(f) Charges for treatment for experimental or investigative services or supplies;
(g) Charges that are considered educational or treatment to restore learning capacity;
(h) Charges in connection with custodial care, extended care facilities or a nursing home;
(i) Charges in connection with rehabilitation, rehabilitation therapy, or restorative therapy when the condition is no longer expected to improve significantly in a reasonable and generally predictable period of time;
(j) Charges in connection with therapy for learning disabilities;
(k) Charges for prosthesis or equipment which are determined to be not medically necessary.
(3) Actions. In creating the SHBP, neither the Georgia General Assembly nor the Board of Community Health has waived its sovereign immunity. Thus no action either in law or in equity, can be brought or maintained against the State of Georgia, the Board of Community Health, or any other department or political subdivision of the State of Georgia to recover any money under this Plan. In like fashion, no suit may be maintained against any officials or Employees of these bodies if the ultimate financial responsibility would have to be borne by public Funds from the General Treasury, the health benefit Funds or elsewhere.
(a) The Board of Community Health, however, does reserve the right to maintain any suits, either in its own name, or through its officials, Employees, or agents, which it deems necessary to the administration of the SHBP, including actions to recover money from participants, beneficiaries, agents, Employees, officials, or any other person.
(b) The Board of Community Health reserves the right to modify its Benefits, Coverages, and eligibility requirements at any time, subject only to reasonable advance notice to its Members. When such a change is made, it will apply as of the effective date of the modification to any and all charges which are incurred by Members from that date forward, unless otherwise specified by the Board of Community Health.
(c) The Administrator is authorized to act as interpreter of the terms and conditions of the Plan.
(4) Non-duplication of Benefits and Subrogation. The Plan will not duplicate payments for medical expenses made under third-party personal-injury-protection contracts nor will it duplicate payments made as the result of any litigation. The Plan will be subrogated to any right of recovery that a Member has against a person or organization where medical expenses were incurred as a result of injuries suffered because of alleged negligence or misconduct. In any case where the primary plan provides for subrogation for third-party liability and this Plan would be determined to be secondary, benefits under this Plan shall be reduced to the amount that would have been paid under the secondary provisions of this Plan.
(5) Recovery of Benefit Overpayments. The Administrator shall seek repayment for any benefits paid to any individual, corporation, firm, or other entity who or which is not qualified, in the opinion of the Administrator, to receive benefits from the Plan. The Administrator shall establish procedures for collecting the overpayments, duplicate payments, or wrong payee payments. The procedures may include, but are not limited to, establishing installment payments, withholding future benefit payment, or filing suit or garnishment.

Rule 111-4-1-.11 Claims

(1) Filing Claims. The Administrator shall coordinate the procedures for filing claims with the TPA. Such procedures may not establish a liability period greater than the maximum liability period set forth below. Claim forms shall be designed and printed for the Member's and providers' use when appropriate.
(2) Maximum Liability Period. All Claims of Benefits must be presented in writing to the Administrator or TPA in accordance with the procedures established by the Administrator and the TPA, which procedures may not permit payment of claims submitted after twenty-four (24) calendar months following the month of service in which the service was rendered. If any Claim for Benefits is presented to the Administrator or TPA after two (2) years from the date the service was rendered, benefits will not be owed or paid.
(3) Unclaimed or Uncased Claim Checks. All drafts issued on behalf of the Plan shall be void if not presented and accepted by the drawer's bank within six (6) calendar months of the date the draft was drawn. If the payee or Subscriber does not present the draft or request a reissue of the draft for a period of seven (7) years from the date the draft was drawn, the draft will be void and funds retained in the appropriate trust Fund.

Rule 111-4-1-.12 Repealed

Rule 111-4-1-.13 Georgia Retiree Health Benefit Fund

(1) Functions, Duties and Responsibilities of the Board of Community Health. The Board shall establish the Georgia Retiree Health Benefit Fund (GRHBF). The Board in its official capacity shall be the GRHBF's trustee. The Board shall annually review Other Post Employment Benefits (OPEB) liability. The Board shall determine Annual Required Contributions (ARC), which may not be the same as employer and employee contribution rates. The Board shall also determine annual employer and employee contribution rates. The Board shall collect employee and employer contributions and deposit the contributions into the GRHBF. The Board may utilize the investment services of the Employee Retirement System, Division of Investment Services to invest a portion of the GRHBF for long-term investments. No member of the Board or employee of the Department shall have any personal interest in the gains or profits from any investment made by the Board or use the assets of the GRHBF in any manner, directly or indirectly, except to make such payments as may be authorized by the Board or by the Commissioner as the executive officer of the Board.
(a) Establish and Design Plan. The Board is authorized to establish the GRHBF to collect employee and employer contributions for OPEB. The Board shall account for employee and employer contributions by each pension plan, as delineated at 111-4-1-.01(50), separately.
(b) Promulgate Regulations. The Board is authorized to adopt and promulgate rules and regulations for the effective administration of the GRHBF.
(c) EstablishContributionsonBehalf of Retirees. The Board shall establish by Resolution, contributions by public school teacher retirees, retired public school employees, retired State employees, and any other Annuitant listed at 111-4-1-.01(50) and shall deposit those contributions into the GRHBF. The Board shall consider the actuarial estimates of OPEB in establishing the contributions.
(d) Establish Employer Rates. The Board shall establish by Resolution, OPEB employer contribution rates and shall deposit those contributions into the GRHBF.
(2) Functions, Duties and Responsibilities of the Commissioner. The Commissioner in his or her official capacity shall be the Administrator of the GRHBF and shall be the custodian of the GRHBF.
(a) Administer Regulations and Policies. The Commissioner shall administer the GRHBF consistent with Board regulation and policy. The Department shall contract with the Division of Investment Services of the Teachers Retirement System of Georgia and the Employees' Retirement System of Georgia with respect to GRHBF investments. The Department shall maintain all necessary records regarding the GRHBF in accordance with generally accepted accounting principles. The Department shall collect all moneys due to the GRHBF and shall pay any administrative expenses necessary and appropriate for the operation of the GRHBF from the GRHBF.
(b) Annual Report. The Department shall prepare an annual report of GRHBF activities for the Board, the House Appropriations Committee, and the Senate Appropriations Committee. Such reports shall include, but not be limited to, audited financial statements. The reports shall contain the most recent information reasonably available to the Department reflecting the obligations of the GRHBF, earnings on investments, revenue and expenses by pension plan, and such other information as the Board deems necessary and appropriate. This report shall reflect activity on a state fiscal year basis. The Department shall be entitled to any information that it deems necessary and appropriate from a retirement system, as delineated at 111-4-1-.01(50), so that the provisions of Code Section 45-18-103 may be fulfilled.
(c) Regulations. The Commissioner shall recommend to the Board amendments to the regulations, submit the approved regulations to appropriate filing entities, cause all regulations to be published, and provide a copy to the Employing Entities.
(d) Provide Notice of OPEB Employer Contribution. The Commissioner shall provide notice and certification of the required OPEB employer contribution rate to each of the Employing Entities and the Department of Education on or before June 1st of each year.
(3) Duties and Responsibilities of Employing Entity. Each Employing Entity is responsible for complying with these regulations. It shall be the responsibility of State agencies to make contributions to the GRHBF, subject to appropriations, in accordance with the OPEB employer contribution rate established by the Board. It shall be the responsibility of all other Employing Entities to make contributions to the GRHBF in accordance with the OPEB employer contribution rates established by the Board in addition to the employer contributions required to be made to the GRHBF for the health plan as determined from fiscal year to fiscal year.
(a) Deduct Enrolled Member Premium Amounts. The Employing Entity shall withhold the contribution rate as approved by the Board.
(b) Remit Employer Contributions. The Employing Entity shall calculate and remit the appropriate OPEB employer contribution.