OAR 111-040-0040: Qualified Status Changes (QSCs)

(1) An eligible employee experiencing a change in family or work status as noted below after an annual open enrollment, or anytime during the plan year, has 31 calendar days beginning on the date of the event to make allowable changes. If the event is gaining a child, as defined by 111-040-0040(4)(c), or results in a loss of eligibility, the eligible employee has 60 calendar days after the event to make allowable changes. (2) An eligible employee may only make changes that are consistent with the event for themselves and/or dependents. (3) An eligible employee must report the Qualified Status Change (QSC) to their entity within the specified timeframe. Failure to report a QSC that results in removal of a spouse, domestic partner, or child within the timeframe stated in 111-040-0040(1) may be considered intentional misrepresentation, and OEBB may rescind the individual’s coverage back to the last day of the month in which the individual lost eligibility. Please refer to the Qualified Status Change (QSC) matrix below for details on what changes may occur with each event. (4) Qualified Status Changes which allow an employee to make changes to his or her coverage are: (a) Gaining a spouse by marriage or domestic partner by meeting domestic partner eligibility; (b) Loss of spouse or domestic partner by divorce, annulment, death or termination of domestic partnership, (c) Gaining a child by birth, placement for/or adoption, or Domestic Partner’s children (by affidavit of domestic partnership), (d) Change in employee group which affects plan option availability; (e) Spouse, domestic partner or child starts new employment or other change in employment status which affects eligibility for benefits; (f) Spouse, domestic partner’s or child’s employment ends or other change in employment status resulting in a loss of eligibility for benefits under their employer’s plan; (g) Event by which a child satisfies eligibility requirements under OEBB plans; (h) Event by which a child ceases to satisfy eligibility requirements under OEBB plans; (i) Changes in the residence of the active eligible employee, spouse, domestic partner, or child (i.e., moving out of the service area of an HMO or limited network service area plan); (j) Significant changes in cost of the eligible employee’s or early retiree’s current plan and tier level that result in a negative or positive impact of 10 percent or more to: (A) The amount an eligible employee or early retiree must contribute toward benefits. (B) The amount a spouse or domestic partner must contribute toward his or her group health insurance plan cost. (k) Different Open Enrollment/Plan Year under a spouse/domestic partner’s employer plan. (l) Related laws or court orders. For example: Qualified Medical Child Support Order (QMSCO), Entitlement to Medicare or Medicaid, HIPAA, or Children’s Health Insurance Program (CHIP) Changes are determined by the applicable law or court order. (5) Changes in coverage do not constitute a Qualified Status Change. (6) The following applies to the Long Term Care benefit plans only: (a) Cancel the plan at any time without a QSC event. (b) Plan additions or changes require a QSC event as defined 111-040-0040(2). The addition of a plan or change in plans with a QSC is subject to a medical evidence review by the LTC carrier. (7) If optional life insurance is requested beyond the guarantee issued amount, Evidence of Insurability must be submitted to the OEBB life insurance carrier(s) within 90 calendar days of the QSC event. [ED. NOTE: To view attachments referenced in rule text, click here to view rule.]