OAR 101-070-0005: Participation Requirements

(1) Notice of Interest: (a) Local Governments choosing voluntarily to participate in PEBB must complete and submit to PEBB a written Notice of Interest to Participate. The following notification timeline applies if the Local Government employs: (A) 50 or fewer participating, eligible employees - 90 days prior to the Local Government's coverage effective start date with PEBB, or; (B) 51 participating, eligible employees but fewer than 500 participating, eligible employees — 120 days prior to the Local Government's coverage effective start date with PEBB, or; (C) More than 501 participating, eligible employees — 180 days prior to the Local Government's coverage effective start date with PEBB. (b) Local Governments employing more than 501 participating, eligible employees that submit a Notice of Interest may allow individual employee groups entry into the PEBB program upon expiration of collective bargaining agreements that govern employee health and welfare benefits for the individual employee groups. (c) PEBB reserves the right to extend any deadline or time within which a Local Government must take any action under these rules if the Local Government applies in writing for relief to PEBB and demonstrates in writing that special circumstances warrant the grant of such relief. For the purpose of this subsection, special circumstances that warrant the grant of relief include emergencies that reasonably can be regarded as imposing an obstacle to the Local Government. Special circumstances are circumstances beyond the reasonable control of the individual or organization including, but not limited to, Local Government employee groups facing above average increases in health benefit plan rates that prevent renewal, emergency reorganizations or replacements of the current benefit plans, board of directors or executive officers of the organization, acts of God and comparable practical impediments to an individual's or organization's ability to meet a deadline or achieve the correction of a violation of rules. The grant or denial of relief under this subsection must be determined by the PEBB official specifically delegated that task. PEBB also reserves the right to waive or to permit the correction of minor or technical violations of OAR 101-070-0005. (2)(a) Financial Participation: (b) Local Governments must provide PEBB with the most recent two years of medical premium-equivalent rates for self-insured groups and the most recent two years of medical premium rates for fully insured groups before submitting a Notice of Interest. Demographic data and logistical data may be requested as well. This information is used by PEBB's Consultant to perform an actuarial plan comparison. (A) If an actuarial plan comparison completed by PEBB’s Consultant demonstrates these premium rates are less than 10 percent over PEBB’s costs during the same two-year period, the Local Government may participate at current PEBB premium rates. (B) If an actuarial plan comparison demonstrates these premium rates are equal to or greater than 10 percent of PEBB’s costs during the same two-year period, PEBB may add a rate surcharge for up to three years, as determined by PEBB's Consultant. (i) Upon entry into PEBB, Local Governments with 501 or more self-insured employees must either: (I) Deposit a sufficient monetary reserve by January 1 of the first plan year to finance the stabilization account of the PEBB revolving fund to the PEBB risk-adjusted level as determined by PEBB's Consultant; or (II) Agree to pay an additional surcharge to premiums to establish a reserve fund for the Local Government over a period of time as determined by PEBB’s Consultant. (ii) When a Local Government with 501 or more self-insured employees terminates participation in PEBB, the initial contribution paid into the stabilization account of the PEBB revolving fund may be refunded as determined by PEBB’s Consultant. (iii) When a Local Government provides a cash incentive to a member for opting-out of health coverage and the value of the incentive is 50% or more than the PEBB premium rate for an employee-only tier, PEBB may assess a surcharge to the Local Government. (iv) Monthly Remittance. For subsections (6) through (11), the terms below have been identified: (I) "ACH credit" means a payment initiated by a participating Local Government that is cleared through the Automated Clearing House (ACH) network for deposit to the PEBB treasury account; (II) "ACH debit" means a payment initiated by PEBB and cleared through the ACH network to debit a participating Local Government’s financial account and credit the PEBB treasury account; (III) “Local Government Payment” means the monthly Local Government Payment to PEBB that includes the contributions of both Local Government as the employer, and its employees as required to pay the monthly premiums in full for selected PEBB benefit plans; (IV) “Local Government Payment Invoice" means a monthly itemized statement provided by PEBB that includes the enrollment elections of the employees and dependents of a Local Government and the PEBB premium rate associated with the benefit coverage enrollment month. (V) “Pay-As-Billed” means billing a Local Government based upon its monthly enrollment file in the PEBB benefit management system. (VI) “Overpayment” means the amount of a Local Government’s monthly payment to PEBB that exceeds the amount due. (VII) “Underpayment” means a payment submitted by a Local Government that is less than the invoiced amount. (VIII) “Electronic Funds Transfer” refers to a payment through ACH credit or ACH debit. (IX) “Due date” means the seventh business day of the current month of coverage. (v) Local Governments will receive a monthly invoice from PEBB by the first business day of the month of coverage that details the payments due for that month of coverage. (vi) Local Governments are required to submit payment to PEBB through Electronic Funds Transfer no later than the due date. (vii) PEBB reserves the right to issue surcharges or take other appropriate measures to Local Governments that submit monthly payments after the due date. (viii) Local Governments must select an electronic funds transfer method by submitting an Electronic Funds Transfer authorization form to PEBB 45 days prior to participation in a PEBB plan year. (ix) Local Governments seeking a refund of an overpayment must notify PEBB within 45 calendar days from the date the overpayment occurred. (x) The Local Government shall submit any underpayment to PEBB as soon as it is discovered. (I) PEBB will request a refund from a carrier in accordance with the law. The carrier will refund the premium to PEBB back to the date of the termination or the date allowed by law for recoupment. (II) PEBB will generally reimburse a Local Government overpayment by making an adjustment to the next monthly invoice. (III) The Local Government must reconcile their monthly invoice and process appropriate termination or Qualified Status Changes. Failure to do this timely will result in the Local Government being responsible for premium costs. (3) General Participation Requirements (a) Local Governments who choose to participate in PEBB must comply with PEBB eligibility, enrollment, and continuation of insurance rules as defined in OAR Division 101-10, 101-015 and 101-030, regardless of whether the Local Government is administering a Section 125 Cafeteria Plan. (b) Local Governments must agree to and sign an inter-governmental agreement (IGA) with PEBB that includes provisions of their participation in the PEBB program, including, but not limited to, the following participation requirements. Local Governments must: (A) Retain full authority to define employee-employer premium cost share arrangements compliant with Affordable Care Act (ACA) regulations. (B) Use the PEBB tiered-rate structure for all benefit coverage types. (C) Participate in all PEBB health and wellness and programs offered by PEBB. (D) Comply with the PEBB benefit plan-year cycle, Open Enrollment period, and plan renewal timeline. (E) Submit all monthly premium payments to PEBB. Premium submission to PEBB is completed through Electronic Funds Transfer, no later than the due date as indicated by PEBB. (F) Not transfer to any PEBB plan any deductibles or annual out-of-pocket maximums met with a prior carrier. (G) Agree that the PEBB benefit management system is the authority for managing and reporting all billing, eligibility and enrollment information communicated to the insurance plan carriers by PEBB. Local Governments will update employment changes timely in the PEBB benefit management system as they occur. (c) Local Governments may allow currently enrolled Early Retirees to participate in PEBB retiree plans only if the retirees participated in the Local Government’s retiree medical plan for at least two years prior to January 1, 2014. The PEBB Retiree Rules as defined in OAR Division 101-50-0005 et. seq. apply to all Early Retirees. (d) Local Governments may request transfer of term life insurance coverage through the Local Government group life policy to the PEBB term life insurance policy. PEBB will transfer the life insurance amount in force on the last day the prior group coverage was in effect if requested and documented by the Local Government rounded to the nearest multiple of $10,000. Premium rates for the coverage will be at the current PEBB life insurance rate tier structure. (e) Local Governments that elect to participate in benefit plans provided by PEBB may elect to terminate participation in PEBB, subject to the following rules: (A) Termination of participation in PEBB will be allowed on a one-time basis only. The Local Government may elect to return to participate in plans provided by PEBB once. Upon returning to PEBB, a Local Government must again satisfy all Notice of Interest and other participation requirements. PEBB's Consultant will perform an actuarial analysis to determine if a surcharge should be applied, as outlined above in (2)(b). (B) PEBB may terminate participation of a Local Government within three months of entering PEBB if the Local Government fails to perform any action required by Oregon Revised Statutes (ORS) 243.105 to 243.285 and 292.051 or by PEBB rule. (f) Local Governments may purchase employee benefits not offered by PEBB.