OAR 101-020-0066: Public Employees' Benefit Board Appeal Procedure

(1) Eligible employees may submit appeal requests to PEBB concerning PEBB policy, eligibility, or plan enrollments. PEBB staff and the Board Appeals Subcommittee use relevant state and federal regulations, policy, PEBB’s documented Internal Revenue Code (IRC) 125 Cafeteria plan, and Oregon Administrative Rules to provide appeal decisions. (2) PEBB does not accept appeals related to contracted plans or plan administrators, such as but not limited to medical, dental, life, disability, COBRA, and long term care, services, decisions, or claims. The Board’s Appeal Committee may hear appeals concerning benefit design. (3) If PEBB rescinds plan coverage due to an individual’s ineligibility for coverage, the ineligible individual may appeal the rescission decision to PEBB using this rule. Until the appeal process for the rescission is exhausted the individual’s premium and claim payments will continue as if the rescission had not occurred. Upon final appeal determination and the rescission is upheld the employee will be responsible to pay all claims and premium payments paid by the Plan or PEBB during the period of ineligibility. (4) Eligible Employees, or individuals who believe they received an incorrect or unfair decision from PEBB staff, an employing agency, retiree plan administrator, or an individual notified of a rescission have three levels of PEBB appeal. (a) Level One: An eligible employee who believes he or she received an incorrect or unfair decision from PEBB, an employing agency, or retiree plan administrator, or an individual notified of a rescission may appeal the decision to PEBB. The appeal must be within 30 days the decision or action considered by the employee or individual as unfair or incorrect. (A) The employee or individual must submit the appeal to PEBB using the correct forms and provide any supporting documentation for the appeal. (B) A PEBB Benefit Analyst will review the appeal documents and may request additional information from the employee, individual, employer, or plan. Information requested from the employee must be received within 10 business days or PEBB will close the appeal. (C) The analyst will complete the review of the appeal within 30 days from the date PEBB receives all necessary appeal documentation. PEBB will notify the employee or individual of any delay. (D) When the review is complete, the analyst will provide a written explanation and determination to the employee or individual. If the appeal is denied, continued appeal steps will be included in the document. (b) Level Two: An eligible employee or an individual who is dissatisfied with a Level One appeal determination may within 30 days of the level one determination request a Level Two review from the PEBB Plan Design Manager. (A) The employee or individual must submit the request to the Plan Design Manager in writing and provide new supporting documentation. The manager may request additional information from the employee, the employer, or plan. Information requested from the employee must be received within 10 business days or PEBB will close the appeal. (B) The Plan Design Manager will review the request and determine whether to provide a determination to the employee or individual, or to move the request directly to the third level of appeals. (C) If the Plan Design Manager completes a review, the employee or individual will receive a written letter of explanation and determination. If the appeal is denied, continued appeal steps will be included in the document. (D) If the Plan Design Manager sends the appeal directly to Level Three without providing a determination, the employee will receive written notice. (c) Level Three: An eligible employee or individual receiving both a first and second level appeal denial can request that the Board Appeals Subcommittee review the appeal. The Subcommittee can also review appeals submitted directly to them by the Plan Design Manager. The Board Appeals Subcommittee will provide a final decision to the employee or the individual. (A) An employee or individual requesting a Level Three review must submit the request in writing to the Plan Design Manager within 30 days of the Level Two determination date. (B) The Subcommittee appeal determination requires a majority vote of the members. If an agreement cannot be reached, the appeal may be referred to the full Board. Decisions by the full Board require a majority vote. The Appeals Subcommittee may render a decision to the employee or individual and also refer the issue to the full Board for a benefit policy review. (C) When the Subcommittee completes a review, or in the case of a full Board review, the employee or individual will receive a written explanation and determination within 30 days after the meeting. (5) An individual may appeal the Subcommittee or Board’s decision as provided under the Oregon Administrative Procedures Act, ORS Chapter 183