OAR 111-080-0055: Eligibility Verifications and Reviews

(1) OEBB shall plan and conduct eligibility verifications and reviews to monitor compliance with OEBB administrative rules. Reviews shall include, but are not be limited to the following: (a) Dependent eligibility; (b) Employee eligibility; (c) Election change limitations; and (c) Plan enrollment limitations. (2)(a) Employee eligibility, election change and plan enrollment reviews may occur on a random basis throughout the year, or if anomalies in data warrant a formal review. (b) The Eligible Employee and Entity are responsible to submit documentation upon request. (3) Dependent eligibility verifications shall be completed at least once every five years per Entity. (a) Entities may have a formal dependent eligibility verification and review completed by a third party vendor on or after October 1, 2013. The use of a third party vendor for a dependent eligibility verification and review may meet the once every five years requirement provided the vendor meets the standards and criteria set in the OEBB verification and review plan and agrees to report all findings via a secure electronic file. All requests to substitute a third party vendor for this purpose must be pre-approved by OEBB. (b) The Eligible Employee, Eligible Early Retiree or COBRA participant is responsible to submit documentation upon request. In the event the required documentation is not provided to sufficiently prove the dependent meets eligibility requirements, or the documentation provided is insufficient, the dependent’s coverage will be terminated. Retroactive terminations may occur if the documentation provided shows the dependent was not eligible for coverage and the member misrepresented the dependent as being an eligible dependent as defined by OAR 111-080-0045. (4) If an Eligible Employee does not complete the dependent eligibility review and moves to a different Entity under OEBB, their terminated dependent records will be locked in the MyOEBB benefit management system. The Eligible Employee must submit documentation to OEBB to be verified before the dependent records are unlocked.