Insurance Coordinator Manual
The Oklahoma Office of Management and Enterprise Services Employees Group Insurance Division was created and is governed by Oklahoma law. Its purpose is to provide health, dental, vision, life and disability benefits to state, local government and education employees and other entities designated by statute, as well as the retirees and dependents from these groups.
EGID would like to thank you in advance for taking the time to learn the rules, regulations, forms and electronic systems needed to be an effective insurance coordinator for your employer and employees. We understand your duties as an IC are just part of your responsibilities, and our goal is to make your continuing experience with us as easy as possible.
Member services is charged with assisting employees and ICs with the annual Option Period, answering benefit and eligibility questions, and providing general information regarding insurance coverage for the plans offered through EGID.
For general questions or non-urgent issues, call member services at 405-717-8780 or toll-free 800-752-9475, Monday through Friday from 8 a.m. to 4:30 p.m. Central time. TTY users call 711.
- Member services group management specialist – The specialist assigned to your account is your personal source for guidelines, eligibility, forms, meetings and all other group insurance related information. Keep your specialist’s contact information handy for when you need assistance. The easiest way to contact your specialist is by email. If your assigned specialist is unavailable, contact the Group Management team at 405-717-8780 or 800-752-9475; choose Option 2 and then Option 4.
- EGID website – To access the EGID website, go to Oklahoma.gov/omes, hover over Services on the top navigation bar and select Employees Group Insurance Division from the menu. You can find current EGID news and materials, the EGID calendar, the IC webpage, Administrative Rules, legal notices and more.
- IC webpage – On the EGID webpage, select the Insurance Coordinator box. You can access forms, retirement information, meeting registrations and COBRA materials, as well as other materials. After you complete Employer Self-Service Training, you will be able to log in to the IC Secure application from this page.
- Insurance Coordinator Manual – This convenient, online manual is maintained on the IC webpage.
- IC Option Period meetings – Held throughout the state in September, these meetings provide information about insurance options for the upcoming plan year.
- New IC Training – Available as an online webinar, you can register through the EGID website calendar. You can also request that your group management specialist come to your site for a one-on-one session. Training includes information from this manual and provides the basic information you need to successfully perform your duties as an IC.
- Employer Self-Service Training – You are strongly encouraged to take this training so you can process enrollments and eligibility changes using EGID’s Employer Self-Service application instead of mailing or faxing forms to EGID for processing. Upon completion of training, web support sends you a link to register for access to the Employer Self-Service application.
- Spring Training – Offered by group management as an annual refresher course, training sessions are available by webinar. Spring Training provides opportunities to voice comments or suggestions you have about EGID plans or materials.
- Option Period Training – Offered by group management to provide training to coordinators and members in reference to Option Period plan changes. Training sessions are available by webinar and at various locations across the state, or upon special request.
To be eligible to participate in the plans offered through EGID:
- An education employee must be eligible to participate in the Oklahoma Teachers’ Retirement System and work a minimum of four hours per day or 20 hours per week. Part-time education employees are those who meet the requirements of a half-time employee as defined by the Oklahoma Teachers’ Retirement System.
- A local government employee must be in a position requiring a minimum of 1,000 hours or more per year and not listed as a seasonal or temporary employee.
- Other persons must be elected by popular vote or on approved leave without pay status (not to exceed 24 months).
Coverage for a new employee is effective the first day of the month following their employment date or employer eligibility date. For additional details, refer to EGID administrative rule 260:50-3-15, Effective dates of coverage for current employees.
An employee may choose not to enroll in an EGID health or dental plan or may disenroll from these plans because of other health or group dental coverage or due to eligibility for military or Indian Health Service benefits within 30 days from the date they become eligible for the other health or group dental coverage. Subsequently, an employee who loses other health or group dental coverage (including military or IHS) may enroll in coverage through EGID within 30 days from the date of loss of the other coverage.
If you have an employee who chooses not to enroll in an EGID health or dental plan, proof of other health coverage is required. Proof of other health coverage includes:
- Certificate of health plan coverage.
- ID card for military health or Indian Health Service benefits.
- Letter from previous employer that lists dates of coverage and all covered dependents.
Other health coverage cannot be an excepted benefit. Refer to Excepted Benefits in the Glossary section. Vision coverage is the only benefit that is available without proof of other health coverage.
A new employee is eligible for Guaranteed Issue life coverage at the time of their initial enrollment. Guaranteed Issue refers to the set amount of Supplement Life coverage available to them during initial enrollment without providing a life insurance application. This amount is available to your employee during the first 30 days they are eligible to enroll. This is their only opportunity to have a guaranteed issue amount of life insurance. Guaranteed Issue is equal to two times their current annual salary, with the total rounded up to the next $20,000 unit. An employee who returns to work within two years is not eligible for Guaranteed Issue.
A new employee has 30 days from their eligibility date to make changes to their initial coverage by completing a new Insurance Enrollment Form. These changes are effective the first day of the month following the date of the change. Changes outside this 30-day window can be made only if a midyear qualifying event occurs or during the annual Option Period.
A new employee can enroll their eligible dependents within their 30-day initial enrollment period. Dependent coverage not elected at this time is not available until the next Option Period or within 30 days of a qualifying event. Refer to Midyear Enrollment Changes in the Enrollment section.
Dependents are eligible only for coverage in which the employee is enrolled.
For all elected coverage, if one eligible dependent is covered, all eligible dependents must be covered. An employee can exclude eligible dependents with proof of health, group dental or vision coverage. Also, the employee can elect not to cover dependents who do not reside with them, are married, are not financially dependent on them for support, have other coverage or are eligible for military health or IHS benefits. Refer to Excepted Benefits in the Glossary section.
When an employee’s spouse also works for an EGID-recognized employer and is covered under or eligible for benefits under EGID, the spouse and dependent children cannot have duplicate coverage, except for Dependent Life. This means dependents cannot be covered under two plans with EGID, even if they are with different companies. Dependent benefits can only be covered under one primary insured except in the case of Dependent Life.
Dependents are not required to have health coverage to be eligible for dental or life coverage. Only the primary member must have health coverage.
Effective dates of coverage for dependents
Coverage is effective the first day of the month following enrollment. Coverage for enrollment during Option Period is effective Jan. 1. Exceptions include:
- Newborn – The effective date of coverage is the first day of the month of birth. Refer to Policies for newborn coverage.
- Adoption or legal guardianship – At the employee’s option, the effective date of coverage is either the first day of the month in which the employee gains physical custody or the first day of the following month.
- Court order – The court dictates the effective date of coverage.
A spouse can be enrolled in coverage as long as a divorce or legal separation has not been filed. Likewise, a spouse cannot be dropped from coverage while in the process of divorce or legal separation. Refer to Divorce. Please note the following:
Common-law spouse – Common-law marriage is recognized by EGID. A new employee can add a common-law spouse at the time of enrollment. A current employee can request coverage on a common-law spouse during the annual Option Period or in the event the common-law spouse loses other coverage. To enroll a common-law spouse, the employee and spouse must sign the Common-Law Spouse Certification on the appropriate form. Once a common-law marriage is publicly declared, it can be dissolved only through a legal divorce.
Excluding a spouse
An employee can exclude their spouse from health, dental and/or vision coverage without proof of other coverage, even if they cover dependent children. To exclude their spouse while covering dependent children, the spouse must sign the Spouse Exclusion Certification on the appropriate form.
Eligible dependent children include:
- Daughter, son, stepdaughter, stepson, eligible foster child, adopted child, child for whom the employee has been granted legal guardianship or child legally placed with the employee for adoption, up to age 26, whether married or unmarried.
- A dependent, regardless of age, who is incapable of self-support due to a disability diagnosed prior to age 26. For additional information, refer to Special rules for a disabled dependent below.
- Other unmarried children up to age 26 who live with you and for whom you are primarily responsible. This requires completion and approval of an Application for Coverage for Other Dependent Children. A tax return showing dependency can be provided in lieu of the application.
If both parents are primary members under EGID, dependent children can be covered under either parent’s health, dental and vision plan (but not both) even if covered under different companies. However, both parents can cover dependents under Dependent Life.
Special rules for a disabled dependent
A disabled dependent child must be incapable of self-support because of mental or physical incapacity that existed prior to age 26. The dependent is eligible to continue coverage as long as they meet all eligibility rules. To apply to continue coverage for a disabled dependent beyond age 25, the primary member must:
- Submit a copy of their most recent federal or state tax returns to provide proof of dependent status.
- Complete a Disabled Dependent Assessment form and return it to EGID according to the time frames below:
- New employees must submit the form within 30 days of enrollment.
- Current employees must submit the form at least 30 days prior to the dependent’s 26th birthday.
- Former employees who added or continued coverage on a disabled dependent at retirement must submit the form at least 30 days prior to the dependent’s 26th birthday.
NOTE: The Disabled Dependent Assessment form must be approved by EGID before coverage begins or is continued. If the form is not received within the designated time frame, coverage or continuation of coverage is denied.
Policies for newborn coverage
For all health plans, employees have 30 days from the date of birth to enroll a newborn for coverage. The newborn must be enrolled effective the first of the month of the child’s birth.
Adding a newborn to coverage:
- A newborn must be added the first of the month of the child’s birth. The employee has 30 days from the date of birth to enroll a newborn. An Insurance Change Form must be completed and submitted to you or EGID.
- Premiums for the full month of the child’s birth must be paid.
- Unless there is proof of other coverage, when one or more eligible dependents are currently covered, a newborn must be enrolled in the same coverage, such as dental. Current employees must provide you with proof of the other coverage.
- When enrolling a newborn in coverage, all other eligible dependents must be enrolled (if they are not already enrolled). A member can exclude a spouse from health and/or dental coverage.
- A member can request coverage for a newborn grandchild by completing an Application for Coverage for Other Dependent Children. Coverage for a grandchild is effective the first of the month following the receipt and approval of the application and payment of premiums. Coverage is not retroactive to the month of birth except in the case of a newborn, which shall be added the first of the month of birth.
- A newborn’s Social Security number is not required at the time of initial enrollment but must be provided when received from the Social Security Administration.
Accepting the Newborn Limited Benefit when not enrolling the newborn:
- There is no additional premium for the Newborn Limited Benefit.
- The Newborn Limited Benefit is subject to applicable plan annual deductible, copayments, coinsurance and plan limitations. Employees are responsible for any charges over and above the Newborn Limited Benefit regardless of the facility’s network or non-network status. Refer to each plan for specific plan details.
- Enrollment of other eligible dependents is not required.
- The Newborn Limited Benefit applies only if the mother or father of the newborn is covered under an EGID health plan.
BlueLincs HMO, CommunityCare HMO and GlobalHealth HMO – A newborn is covered for 31 days without an additional premium.
A newborn has limited coverage for a routine birth for the first 48 hours following a vaginal delivery or for the first 96 hours following a C-section delivery without an additional premium.
- There are no benefits for services in addition to a routine hospital stay if the newborn is not enrolled and premiums are not paid for the month of birth.
- The member is responsible for any charges over and above the Newborn Limited Benefit regardless of the facility’s network or non-network status. A separate calendar year deductible and coinsurance apply.
NOTE: If the employee’s spouse also works for an EGID-recognized employer with health coverage provided by EGID, they should consult both plan carriers before opting for the Newborn Limited Benefit. Some providers may not be in network for all plans. It is important to confirm network coverage is available.
Declining the HealthChoice Newborn Limited Benefit
To decline the Newborn Limited Benefit, a Newborn Limited Benefit Waiver must be completed. This action is not recommended.
Oklahoma law prohibits dropping a spouse or dependent from coverage while in the process of a divorce or legal separation at any time. It is important employees contact their legal counsel for advice before making any changes to their coverage. Refer to Oklahoma statute 43 O.S. § 110.
If an employee is court-ordered to provide (pay for) insurance for a former spouse, the former spouse is not an eligible dependent and cannot enroll in or keep coverage under the employee through EGID.
A former spouse covered by the employee as a dependent at the time of the final divorce decree is eligible for coverage under COBRA. A former spouse is not eligible for COBRA coverage through EGID if they were not covered at the time of the final divorce decree.
DHS-directed dependent additions (National Medical Support Notice)
You may receive a document for an employee called a National Medical Support Notice. This is a court order requiring an employee to insure one or more of their children. This notice includes the following parts:
- Part A – Notice to Withhold for Health Care Coverage (your part).
- Part B – Medical Support Notice to Plan Administrator (EGID’s part).
You are required to complete the employer response in Part A and return it to the issuing agency. If you have any questions regarding Part A, please contact the Department of Human Service office listed on the front of the NMSO and provide them with the order number. If the employee is NOT obligated per Part A, you are only required to send Part A back to the DHS office listed. If the employee is obligated, you are required to forward Part B to EGID confirming the calculations on Part A, showing that the member is obligated. Depending on how the notice is worded, the employee may be required to add additional benefits or change carriers upon receipt of the National Medical Support Notice. If your employee is not yet enrolled in the system, EGID will need all enrollment information including Spousal Exclusion, if applicable. We request that you do not make any changes to your employee’s coverage through the web application in response to this notice. Once EGID receives Part B, our Web Support unit will make the appropriate changes to the employee’s coverage and will contact you to review them. All changes to the coverage will be effective the first of the month following receipt of the National Medical Support Notice.
If your employee would like to dispute this order, please provide them with the DHS contact information (do NOT include the custodial parent information). The National Medical Support Notice will remain active unless a termination form from DHS is received.
Please forward Part B to:
Attn: Web Support
P.O. Box 11137
Oklahoma City, OK 73136-9998
In the event of an employee’s death, please complete and return an Insurance Termination Form to EGID, and we will mail a survivor packet to all eligible dependents. To continue coverage, a surviving spouse and dependents have 60 days following the employee’s death to complete and return the Surviving Spouse and Dependent Election Form. Coverage is effective the first day of the month following the employee’s death.
- A surviving spouse is eligible to continue coverage as long as premiums are paid.
- Surviving dependent children are eligible to continue coverage until age 26.
- Disabled dependent children are eligible to continue coverage as long as they meet the EGID definition of a disabled dependent.
- If a survivor is age 65 or older, they must enroll in either a Medicare supplement plan or Medicare Advantage Prescription Drug plan.
- Premium Notices are sent to the survivors’ addresses, and premiums must be paid through the last day of active coverage.
NOTE: A surviving spouse is billed the primary member rate and dependent children are billed the appropriate dependent rate. When an adult is not listed as the primary member, each surviving dependent child is enrolled under a separate account and billed the child premium.
A transfer employee is someone who moves from one EGID participating employer to another. The break in coverage cannot be more than 30 days. A transfer employee is treated as a new employee with the following options:
- Enroll with coverage effective the first month of employment if the previous coverage ended the month prior. The employee is responsible for paying plan premiums for this first month of coverage.
- Continue coverage through their previous employer for one month until they are eligible to enroll through the new employer.
- Enroll in COBRA coverage for the gap in coverage.
- Enroll in the Guaranteed Issue amount of life insurance.
- Continue any amount of life insurance they had through their previous employer without a life insurance application.
If your employee transfers to another employer, you must terminate their current coverage immediately. Failure to terminate their account in a timely manner can result in a gap in coverage and possible payroll deduction errors with the new employer.
Returning to work after leaving employment
- If an employee elects the employer group health coverage, they must contact Medicare before the new coverage begins. They also need to contact Medicare when they terminate employment.
- If an employee chooses to keep coverage as a former employee, Medicare continues to be the primary payer.
EGID’s web-based enrollment application, Employer Self-Service, enables real-time changes to employee coverage. You can also print confirmation statements and print or view both monthly premium bills and estimated future bills.
You must attend a training session and register with EGID to use this valuable tool. If you are interested in attending one of our web enrollment training sessions, please register for the meeting of your choice on the Insurance Coordinator webpage or contact EGID Web Support at 405-717-8707 or toll-free 800-543-6044, ext. 8707 to enroll.
An employee must still complete the appropriate form even if you use web enrollment. If a review is not required by EGID, keep the form and any midyear change documentation in the employee’s file.
The Insurance Enrollment Form is used at initial enrollment for new hires or when a current employee has a midyear qualifying event that allows them to enroll. The employee must list all eligible dependents that are being covered in the Dependent Information section of the form. They must also provide their dependents’ Social Security numbers, with an exception for newborns per the Policies for Newborn Coverage in the Eligibility section. It is important to review the form with new employees and inform them of any benefit allowance provided by your employer. Refer to the Eligibility section for guidelines on coverage elections and effective dates.
Midyear enrollment changes
If an employee is enrolled in coverage through EGID but declined enrollment in certain coverage for themselves and/or their dependents because of other health or group dental, vision or life coverage, they and their dependents can enroll within 30 days of the loss of the other coverage. They must provide proof of the loss and complete an Insurance Change Form within 30 days of the event. Otherwise, they must wait until the next annual Option Period to enroll.
If an employee gains a new dependent, this is also a qualifying event to enroll a dependent midyear. The employee must complete an Insurance Change Form and provide the appropriate documentation, such as:
- A birth, marriage or death certificate, or divorce decree.
- A portion of the employee’s latest tax return listing dependents for income tax deduction purposes.
- Adoption or legal guardianship papers or other court records.
- A Disabled Dependent Assessment form.
- An Application for Coverage for Other Dependent Children.
NOTE: The Disabled Dependent Assessment form and Application for Coverage for Other Dependent Children must be approved by EGID.
Initial enrollment checklist
Enrolling an employee as a new hire
☐ Confirm the employee is eligible for insurance.
☐ From the IC webpage, print a current Insurance Enrollment Form and the General Notice of COBRA Continuation Coverage Rights.
☐ Complete the Employer Information section of the form and indicate this is a new hire enrollment.
☐ The effective date of coverage is normally the first day of the month following the entry-on-duty date or the end of a mandated employer probationary period.
☐ Inform the employee of the insurance options offered through your employer.
☐ Give the Insurance Enrollment Form and General Notice of COBRA Continuation Coverage Rights to the employee and inform them of your deadline to complete and return the form.
☐ Verify the employee has completed and signed the form and confirm elections with the employee.
☐ If the employee elects dental or life insurance without enrolling in health insurance, you must obtain proof of other health coverage, that is not an excepted benefit. Refer to Excepted Benefits in the Glossary section.
☐ Review the back of the form to make sure the employee has completed all required signatures and dates.
☐ If the employee elects Supplemental Life in excess of Guaranteed Issue, a life insurance application is required.
☐ Sign and date the form in the Insurance Coordinator signature section.
☐ If you use web enrollment, enter the information online.
☐ If you do not use web enrollment, make a copy of the front and back of the form and mail the original to EGID, Attn: Member Accounts, P.O. Box 11137, Oklahoma City, OK 73136-9998; email to EGIDMail@omes.ok.gov or fax to 405-717-8939 or 405-717-8942.
☐ Keep a copy of the form in the employee’s file.
The Employee Benefit Options Presentation for new employees is available on the IC webpage.
Certain life changes, known as qualifying events or midyear changes, allow employees to add or drop benefits as well as dependents. These events can happen any time during the year and more than one event can happen at a time. To make a change, an Insurance Enrollment Form or Insurance Change Form must be completed within 30 days of the qualifying event. Requests for changes received after the deadline are denied.
Qualifying events include:
- A change in marital status, such as marriage, divorce or the death of a spouse.
- A change in the number of dependents, such as the birth of a child.
- A change in employment status that affects an employee’s eligibility.
- A change in the coverage of a spouse or dependent under another employer’s plan.
- A change in a dependent’s status that causes them to gain or lose eligibility.
- The gain or loss of other coverage that is not an excepted benefit or is other group health, dental, vision or life coverage. Refer to Excepted Benefits in the Glossary section.
- The commencement or termination of adoption procedures.
- Court judgments, decrees or orders.
- Medicare or Medicaid (SoonerCare) eligibility for an employee or dependent.
- An employee’s eligibility for leave under the Family and Medical Leave Act.
- When an employee no longer lives or works within their HMO ZIP code service area (only a change of health plans is allowed).
NOTE: Changes in coverage due to Medicaid (SoonerCare) eligibility are limited to two changes per plan year; once out and once back in or vice versa.
When an employee becomes Medicare eligible, they have two options:
- Continue coverage through the employer group health plan and defer Part B enrollment through Social Security. The employer’s plan will remain the primary payer. This option allows the employee to avoid a Medicare late enrollment penalty.
- Discontinue coverage through the employer group health plan. Medicare becomes the primary payer for Medicare-covered services. An employer cannot provide a Medicare supplement or MAPD plan or pay a subsidy for such coverage.
Midyear elections are allowed under the circumstances outlined in Title 26, Section 125 of the Internal Revenue Code. An employee must notify and provide documentation to you within 30 days of a qualifying event. You are required to keep documentation to support a qualifying event and provide that documentation to EGID upon request.
Employees who do not elect to have their benefit costs withheld through a pre-tax payroll deduction and/or employers who do not administer their employees’ benefits under a Section 125 plan must still follow the rules for midyear changes under Section 125 guidelines.
Employee coverage can be added or dropped only within 30 days of an employee’s eligibility date, during the annual Option Period or with a Section 125 qualifying event. These same rules apply to dependent coverage. Most changes are effective the first day of the month following notification. Financial hardship is not a valid qualifying event that allows an employee to drop coverage.
If an employee did not elect coverage at initial enrollment, coverage can be added only during the annual Option Period or with a qualifying event. If coverage is declined due to enrollment in another group plan, the member and dependents may enroll in coverage through EGID within 30 days of losing other coverage.
If an employee’s provider leaves their plan, it is not a qualifying event that allows the employee to change plans midyear. The employee must choose another provider within their plan’s network or pay non-network charges.
Oklahoma law prohibits dropping a spouse or dependent child from coverage while in the process of a divorce or legal separation. It is important the employee contact their legal counsel for advice before making any changes to their coverage.
Leave without pay
If an employee is on leave without pay, their insurance coverage can continue for up to 24 months. The employee is responsible for payment of all premiums to the employer during this time. At the end of the 24-month period, you can terminate all coverage; however, if workers’ compensation or disability insurance is involved, contact your legal counsel.
Going on and returning from leave without pay are both qualifying events that allow an employee to make certain changes to coverage.
Under the Uniformed Services Employment and Reemployment Rights Act of 1994, coverage can be continued for up to 24 months. USERRA provides certain rights and protections for all employees called to serve our nation. All branches of the military, including the Army, Navy, Marines, Air Force, Coast Guard and all military reserve and National Guard units, come under USERRA.
In addition to health coverage provided by the military, employees can:
- Retain all coverage. You are responsible for collecting and forwarding all premiums to EGID.
- Discontinue member coverage but retain dependent coverage. This is the COBRA option and dependents are billed directly at 102% of premiums, the COBRA rate, for health, dental and/or vision coverage. Under COBRA rules, life insurance cannot be retained.
- Discontinue all coverage except life insurance. The member is billed directly. Have member complete the USERRA Life Insurance Form. You must sign and return the completed form to EGID.
- Discontinue all member and dependent coverage. There is no penalty when an employee renews coverage upon discharge from active duty if coverage is elected within 30 days of their return to the same employment.
NOTE: The HealthChoice Disability Plan is not available to state and participating county employees called to active military service. However, upon return to regular employment for five consecutive days, they become eligible for disability coverage.
Midyear change checklist
☐ Make sure the employee has a recognized qualifying event and request documentation, e.g., proof of the event.
☐ Obtain either an Insurance Enrollment Form or Insurance Change Form as appropriate and complete the Employer Information section.
☐ Give the form to the employee to complete and provide the date the form must be returned to you.
☐ Check that the employee has completed the form legibly and confirm elections with the employee.
☐ Review the back of the form to make sure the employee has all required signatures and dates completed.
☐ Prepare a COBRA packet for dropped dependents, if applicable.
☐ Sign and date the form in the Insurance Coordinator signature section. Your signature verifies that you know the form is correct and that you have the documentation to support it.
☐ If you use Employer Self-Service, make the change to the employee’s information.
☐ If you do not use Employer Self-Service, make a copy of the front and back of the form and mail the original to EGID, Attn: Member Accounts, P.O. Box 11137, Oklahoma City, OK 73136-9998; email to EGIDMail@omes.ok.gov; or fax to 405-717-8939 or 405-717-8942.
☐ Keep a copy of the form and all documentation in the employee’s file.
Common Qualifying Events
|LIFE EVENT||ADD||DROP||CHANGE PLAN||COBRA||NOTES|
|New hire, new eligibility, or rehired after 30 days||Yes||No||No||No||Employer probationary period may affect eligibility date|
|Acquire a dependent||Yes||No||No||No|
|Loss of eligibility for a covered dependent||No||Yes||No||May apply to dependent||Employee and spouse divorce; a child turns 26|
|Loss of other group coverage (member or dependent)||Yes||No||No||No||Affects only the type of coverage lost|
|Gain other group coverage (member or dependent)||No||Yes||No||No||Affects only the type of coverage gained|
|Move out of HMO service area||No||No||Yes||No||If employee works in HMO service area, then no QE|
|Commence LWOP or active military duty||No||Yes||No||Yes|
|Return from LWOP or active military duty (< 2 years)||Yes||No||No||No||Renew within 30 days of return|
|Loss of employment and eligibility||No||Yes||No||Yes||If termination is due to gross misconduct, employer may determine eligibility for COBRA|
|Rehire < 30 days with the same employer||No||No||No||No||Enrollment limited to previous coverage|
|Death of member||No||Yes||No||Yes||Refer to Surviving Dependents|
|Court-ordered coverage||Yes||Yes||No||May apply to dependent||Must follow instructions from the court|
|Enrollment in coverage through Marketplace||No||Yes||No||No||Marketplace plan must be effective immediately following drop of coverage|
What is Option Period?
Option Period is the annual enrollment period when employees can make the following benefit plan elections for the upcoming plan year without a qualifying event:
- Add coverage.
- Discontinue coverage.
- Change plans.
- Apply to add or increase life insurance.
When is Option Period?
Option Period begins in October for most current employees. For ICs who have completed ESS training, web enrollment for Option Period changes is available late September through mid-November. The deadlines for Option Period vary each year.
As the IC, you can enforce your own deadline for Option Period forms to be returned to you. Even after the deadline, you must correct employee or administrative errors within 60 days of notification of the error.
Effective date of Option Period changes
Option Period changes are effective Jan. 1 of each new plan year. One exception is when a member’s Life Insurance Application is delayed for additional information. If this occurs, the effective date of the life insurance is the first day of the month following approval of the application.
Resources for Option Period
- IC webpage.
- IC Option Period meetings.
- Employee Benefit Options Guide.
- ESS User Option Period Newsletter.
- Employee Benefit Options Presentation.
- EGID Member Services.
EGID Member Services is available to help during Option Period
Prior to Option Period, member services group management offers training seminars for ICs. You are strongly encouraged to attend training to get the most current information.
If you have questions during Option Period, call EGID Member Services at 405-717-8780 or toll-free 800-752-9475. TTY users call 711.
Important notice about Option Period
Terminating employee coverage
When an employee leaves active employment, you must complete an Insurance Termination Form and terminate the current employee account upon notice. This prevents delays and coverage errors if the employee transfers to another entity that participates with EGID. Always keep a copy of the form on file.
- Web enrollment users should process the termination online as soon as possible.
- If you do not use web enrollment, fax or mail the form to EGID.
The insurance termination date is the last month of coverage for which premiums are paid for the employee. This may or may not be the date the employee leaves employment.
- For state and local government employees, coverage terminates the end of the month the employee last worked.
- For education employees, the length of the employee’s contract determines the last day of insurance coverage. For example, an employee leaves employment in May, but their contract continues through July. In this instance, the employee’s insurance coverage must continue through the end of July.
NOTE: It is important employees understand that failure to continue insurance when leaving employment results in the loss of eligibility (i.e., vest/non-vest, retirement or COBRA). Late enrollment is not available.
Coverage termination checklist
Verify the reason for insurance termination is valid.
☐ Print the Insurance Termination Form from the IC webpage.
☐ Complete, sign and date the form.
☐ Terminate the employee’s coverage online or send the form to EGID.
☐ Send the employee a COBRA packet and retirement/vesting information, if applicable.
☐ Keep a copy of the form and log the mail date of the COBRA packet in the employee’s file.
Mail, email or fax the termination form to EGID.
P.O. Box 11137
Oklahoma City, OK 73136-9998
Attention: Member Accounts
- Eligibility to continue coverage.
- Retirement terms.
- Premium payment options.
- Continuing insurance when leaving active employment.
- Dependent coverage.
- Working past 65.
- Deferring coverage.
- Medicare eligibility.
- Decreasing/dropping coverage.
- Pre-retirement insurance seminars
- Additional information.
- Retiree checklist.
Eligibility to continue coverage
Eligibility to continue coverage through EGID as a former employee is defined by Oklahoma statutes, and certain requirements must be met, including:
- The employer must continue to participate in the plans offered through EGID.
- The employee must have the required years of creditable service to continue coverage.
The minimum years of creditable service required to continue coverage as a former employee:
- Teachers’ Retirement System – Education employees need 10 years of service.
- Oklahoma Public Employees Retirement System – State and local government employees need eight years of service.
- Oklahoma Law Enforcement Retirement System – Law enforcement employees need eight years of service.
- Other or no retirement system – Employment years may qualify as creditable service to continue coverage.
Employees can continue coverage under one of the following former employee status categories:
- Retiree – An employee who has worked long enough to retire, draw a retirement check and keep insurance benefits.
- Vested – An employee who has worked long enough to keep benefits and has contributed to a retirement system but is not ready to draw a retirement check.
- Non-vested – An employee who has worked long enough to keep benefits but did not contribute to a retirement system that participates with EGID or has withdrawn all retirement contributions and no longer qualifies for retiree or vested status.
- Defer – A retiree or vested employee who chooses to transfer health, dental and/or vision coverage to their spouse’s account through EGID. Life insurance must be kept in the member’s account; it cannot be deferred to a spouse’s account.
Discourage employees who qualify for any of the above status categories from electing COBRA, which is temporary coverage. If the employee elects COBRA, coverage through EGID ends at the same time their COBRA continuation period ends.
NOTE: There is no individual conversion COBRA option through EGID.
Premium payment options
- Retirement check deduction – Monthly premiums are automatically deducted from the member’s retirement check. Premiums are paid at the end of the month of coverage.
- Direct bill – Monthly premiums are billed directly to the member. Premiums are due on the 20th of the month of coverage.
- Automatic draft – Monthly premiums are automatically drafted from the member’s checking account. Premiums will be drafted on the 20th of the month of coverage.
To elect either the retirement check deduction or direct bill option, the employee must check the appropriate box in the Certification Signatures section of the retirement application.
If the employee prefers to use automatic draft, they must select the direct bill option on the retirement application and complete an Electronic Fund Transfer Authorization form.
Regardless of the payment option selected, any retirement system contribution toward health insurance premiums applies.
Continuing insurance when leaving active employment
An employee with the required years of creditable service can add, keep, drop or defer the health, dental and vision coverage offered by their employer within 30 days of active coverage ending. Life insurance must be in effect 30 days before the employee leaves active employment. Life insurance cannot be added or increased at retirement; however, it can be reduced or dropped during the annual Option Period. Retirement is not a qualifying event that allows an individual to make health plan changes unless the member or covered dependent is Medicare eligible. All covered dependents must enroll with the same health plan carrier. If the member moves out of the health plan’s service area, they are allowed to change health plans within 30 days of their move.
An employee can elect to add, keep or drop coverage for their spouse and other eligible dependents within 30 days of termination of employment.
If an employee elects to continue coverage for their eligible dependent children, all eligible dependents up to age 26 must be covered. The employee can exclude dependents from the relative coverage if the dependents have other health coverage or other group dental, vision or life coverage or are eligible for Indian or military benefits. An employee can also exclude dependents who do not reside with them, are married or are not financially dependent on them for support.
An employee can exclude a spouse while covering other dependents. The spouse must sign the Spouse Exclusion Certification on the Application for Retiree/Vested/Non-Vested/Defer Insurance Coverage.
A new spouse or dependent child can only be added within 30 days of one of the following qualifying events:
- Birth of a child.
- The member’s spouse or dependents under age 26 lose other health or group dental or vision coverage.
- The member marries.
- The member adopts or gains legal guardianship of a child under age 26.
Working past 65
If an employee works past age 65, they may contact Social Security to delay enrollment in Medicare Part B. Their employer insurance will be primary payer while working. Since all insurance offered through EGID is creditable coverage, they will not be assessed a penalty once employer insurance ends.
- If an employee’s spouse works for an EGID participating employer and carries coverage through EGID, the employee can defer (transfer) their health, dental and/or vision coverage to the spouse’s account as a dependent. The spouse must complete an Insurance Change Form through their employer to add the employee to their account. Deferring coverage does not mean an employee can drop coverage and pick it up later when they require insurance.
- An employee cannot defer life insurance; it must be carried in their own member account.
- The former employee can transfer to retiree/vested/non vested status, in their own account, when their spouse retires, with another qualifying event, during the annual Option Period, or when they become eligible for Medicare. Coverage through EGID must be continuous. The former employee must complete another Application for Retiree/Vested/Non-Vested/Defer Insurance Coverage. If they are eligible for Medicare, they must also complete either the Application for Medicare Supplement With Prescription Drug Plan or Application for Medicare Advantage Prescription Drug (MAPD) Plan.
If an employee or their covered dependents are Medicare eligible, an additional form is required based on the plan chosen.
- Application for Medicare Supplement With Prescription Drug Plan.
- Application for Medicare Advantage Prescription Drug (MAPD) Plan.
NOTE: Health plan changes can be made at retirement if the employee or the covered dependent is Medicare eligible or when a member/dependent becomes Medicare eligible.
If the application is not received prior to the effective date, the former employee or covered dependent will be enrolled in a Medicare supplement plan without Part D. To prevent late enrollment, EGID requests the application be submitted at least 30 days before active insurance coverage ends.
Former employees who are already drawing Social Security when they become Medicare eligible are automatically enrolled in Part A and Part B. Otherwise, they must contact Social Security before turning 65 to enroll in Part A and Part B.
EGID recommends Medicare-eligible former employees enroll in Medicare Part B. The benefits of all Medicare plans offered through EGID are based on enrollment in Part A and Part B.
About two months before they turn 65, EGID notifies each former employee of their options, including how to enroll in a Medicare supplement or MAPD plan.
If a former employee is under age 65 and becomes Medicare eligible, they must immediately notify EGID. At that time, EGID provides information about how to enroll in a Medicare supplement or MAPD plan.
If an employee chooses to decrease or drop coverage, inform them they cannot regain that coverage in the future. If they drop health coverage, any retirement system contribution paid toward their health insurance premium will be lost.
Pre-retirement insurance seminars
ICs and members are strongly encouraged to attend one of the EGID pre-retirement insurance seminars. Designed to provide important information about insurance in retirement, these seminars are available online monthly. You are encouraged to attend for useful information to assist your employees going through the retirement process. You can access the meeting schedule on the EGID Insurance Coordinator webpage.
Retirement is not a qualifying event that allows the member to make health plan changes unless they or the covered dependent is Medicare eligible. All covered dependents must enroll with the same carrier. If the member moves out of their health plan’s service area, they are allowed to change health plans within 30 days of their move.
In the event your employer terminates coverage through EGID, Oklahoma statutes dictate whether a retiree can continue coverage through EGID or must follow your employer to its new insurance carrier.
- Common school or career tech employees who retired before May 1, 1993, can continue coverage with EGID if their former employer elects another insurance carrier. If the retirement date was on or after May 1, 1993, all eligible former employees must follow their former employer to its new insurance carrier. TRS considers the last place of a teacher's employment as their former employer, even if their employment was brief.
- County and local government employees who retired before Jan. 1, 2002, can continue coverage with EGID if their former employer elects another insurance carrier. If the retirement date was on or after Jan. 1, 2002, all eligible former employees must follow their former employer to its new insurance carrier.
- Higher education and charter school employees must follow their most recent former employer to its new insurance carrier regardless of the retirement date.
- Groups that joined EGID after the dates listed above must take all retirees with them if they terminate coverage through EGID in the future.
A retiring employee is only eligible to add or continue the benefits their former employer offered through EGID.
☐ Have the employee review the Planning for Insurance Needs at Retirement guide on the EGID webpage and encourage them to attend an insurance seminar.
☐ Confirm the employee has the required number of years of creditable service to continue insurance.
☐ Give the employee an Application for Retiree/Vested/Non-Vested/Defer Insurance Coverage.
☐ Inform the employee they can add, keep, drop or defer health, dental and/or vision coverage at retirement (based on benefits available through their employer). Employees cannot change health plans until the next annual Option Period unless they move out of their HMO ZIP code service area or the employee or covered dependent is Medicare eligible.
☐ Inform the employee of the option to continue life insurance.
- Life insurance cannot be added or increased at retirement.
- Premiums are different for former employees.
- Remind the employee to review their beneficiary information and that a new Beneficiary Designation Form can be completed at any time.
☐ If the employee is enrolled in HealthChoice, remind them that they must continue to complete the tobacco-free attestation each Option Period until they and their covered dependents are on Medicare.
☐ If the employee or covered dependents are Medicare eligible and elect to continue health coverage, give each eligible individual an Application for Medicare Supplement with Prescription Drug Plan or Application for Medicare Advantage Prescription Drug (MAPD) Plan as appropriate.
☐ If the employee or covered dependents have delayed enrollment in Part B, they must call Social Security toll-free at 800-772-1213 to begin Part B coverage.
☐ Instruct the employee to complete and return all necessary forms to EGID at least 30 days before their active insurance coverage ends. To expedite, fax all forms to Attn: Member Accounts Retirement at 405-717-8939 or 405-717-8942 or email to EGIDMail@omes.ok.gov. Confirmation statements are mailed to new retirees electing coverage within seven to 10 days of receipt of completed retirement application. Former employees should contact EGID Member Services immediately if a confirmation statement is not received within this time period.
☐ Inform the employee that you are required by law to send a COBRA packet and to disregard it if they elect to continue coverage as a former employee.
- What is COBRA?
- Qualified beneficiary.
- Importance of documenting the COBRA process.
- COBRA packet.
- Coverage options for COBRA participants.
- Effective dates of COBRA coverage.
- Length of COBRA continuation of coverage periods.
- COBRA premiums.
- New employers
- Terminating employers
- Timeline for COBRA enrollment.
- COBRA checklist.
What is COBRA?
COBRA is the acronym for the Consolidated Omnibus Budget Reconciliation Act of 1985. In response to concerns regarding the loss of employer-sponsored group health, dental or vision insurance, Congress set rules that allow qualified employees and dependents to continue group insurance under certain conditions and for limited periods of time. Life insurance cannot be continued under COBRA.
The term COBRA is used to refer to a type of member eligibility status and not a particular plan. When an employee and/or eligible dependents qualify to continue coverage under COBRA, they can continue health, dental and/or vision coverage for a limited time period.
A qualified beneficiary is defined as a covered employee, their spouse (or former spouse) and dependent children who are covered under the group plan the day before the qualifying event. Federal COBRA rules state that the option to continue coverage under COBRA must be offered to all QBs enrolled in health, dental and/or vision insurance coverage when employment is terminated, or a dependent loses eligibility due to a qualifying event. COBRA must always be offered regardless of other options to continue coverage.
QBs can continue coverage under COBRA until they:
- Obtain other group insurance coverage that has no preexisting conditions, limitations or exclusions.
- Cancel the COBRA coverage.
- Exhaust the coverage continuation period.
- Fail to pay premiums.
An employee is eligible to continue coverage under COBRA if they have insurance coverage at least one day before a qualifying event occurs. Employees and dependents are not required to enroll under COBRA. It is up to each QB to decide if continuing coverage under COBRA is the right option for them.
Importance of documenting the COBRA process
You are responsible for notifying new employees and spouses of their rights under COBRA. The General Notice of COBRA Continuation Coverage Rights must be given to a new employee and also their spouse within 90 days of the coverage effective date. If you must mail the notice, send it first class. It can be included with the Summary of Benefits and Coverage.
You are required to complete various forms, meet numerous notification guidelines, and keep copies of signed forms in employees’ files, as well as a log of all COBRA mailings and hand deliveries.
You are responsible for sending a COBRA packet to an employee or dependent who becomes ineligible for coverage. A COBRA packet must include the following:
- A COBRA Continuation Coverage Election Form.
- An Eligibility for Continuation of Coverage form.
- A copy of Important Information about COBRA Continuation Coverage and Other Health Coverage Alternatives.
- A copy of the COBRA premium rates.
All COBRA materials, along with a complete packet, are available on the IC webpage.
You must complete the COBRA Qualifying Event Notice and put it in the employee’s file. If the QB returns a completed COBRA Continuation Coverage Election Form to you, forward both the COBRA Qualifying Event Notice and the COBRA Continuation Coverage Election Form to EGID. Keep a copy of both forms in the employee’s file.
If a dependent who loses eligibility does not reside with the employee, a packet must be sent to the dependent’s last known address. Be aware that failure to notify an employee’s qualified dependents of their COBRA rights is a common and potentially costly mistake.
Even if an employee is eligible to retire or vest, you must always mail a COBRA packet to all qualified beneficiaries; however, an employee who chooses to retire or vest should be instructed to disregard the COBRA packet and instead complete an Application for Retiree/Vested/Non-Vested/Defer Insurance Coverage. A retired/vested member can continue health, dental, vision and/or life insurance coverage indefinitely as long as premiums are paid.
If a COBRA packet is returned for an incorrect address and you can locate the QB’s new address, mail a copy of the original packet (do not redate it) within the 60-day COBRA election period and document the date it is remailed. If no other address is available or the packet is again returned, attach the returned mail forms to the COBRA Qualifying Event Notice. Keep the returned COBRA packet on file.
Coverage options for COBRA participants
Electing COBRA does not allow a change in plans, except when a QB moves outside, or worked but never lived in, their health plan’s service area. Plan changes can also be made during the annual Option Period.
A QB can continue health, dental and/or vision coverage in effect at the time of the qualifying event.
If a QB was not enrolled in health, dental and/or vision coverage, it can be added during the next annual Option Period.
Effective dates of COBRA coverage
COBRA coverage begins the first day after active coverage ends (no lapse in coverage is allowed). Enrollment is processed after EGID receives at least 90% of the first month’s premium, COBRA Qualifying Event Notice and COBRA Election Form.
Length of COBRA continuation of coverage periods
A COBRA continuation period of up to 18 months is available to employees and dependents who lose coverage due to one of the following qualifying events:
- Termination of employment, whether voluntary or involuntary (except for termination due to gross misconduct).
- Reduction in hours resulting in the loss of eligibility for coverage.
- Leave of absence.
- Reduction in force/strike/layoff.
A COBRA continuation period of up to 36 months is available to dependents who lose coverage due to one of the following qualifying events:
- Divorce or legal separation from the employee.
- Dependent child turns 26.
- Employee becomes Medicare eligible during an 18-month COBRA continuation period.
- Employee’s death.
NOTE: After an employee’s death, the covered spouse and dependents are also eligible to continue coverage as surviving dependents as long as premiums are paid.
A COBRA continuation period of up to 36 months is available to other dependent children who have coverage through an approved Application for Coverage for Other Dependent Children, or a tax return showing dependency. In addition to the qualifying events above, a qualifying event may also occur when one of these dependents:
- No longer resides with the member.
- Is no longer financially dependent on the member.
- Is no longer in the member’s care.
If a QB marries while on COBRA, they can add their new spouse and dependents to COBRA coverage within 30 days of their marriage, but only for the remainder of their established continuation period. Voluntarily dropping a dependent during Option Period is not a COBRA qualifying event.
If a 36-month event occurs during an 18-month COBRA continuation period, a dependent QB can extend eligibility for a maximum of 36 months from the date of the original qualifying event. For example, if an employee and spouse divorce during their 17th month of COBRA coverage, the former spouse and covered dependents are eligible to continue coverage for an additional 19 months. The COBRA continuation period cannot exceed 36 months.
A QB who qualifies for Social Security disability benefits can extend coverage for up to 29 months. They must be disabled at the time of the qualifying event or become disabled within 60 days of the start of their COBRA continuation period. All covered QBs can continue coverage for up to 29 months or until their Medicare coverage becomes effective, whichever is earlier.
The QB must notify EGID within 30 days of a Social Security disability determination, or if it is determined they are no longer disabled. This determination reduces the COBRA continuation period.
Each QB has the right to continue coverage under COBRA and elect separate benefit options; e.g., an employee may elect to keep health and dental coverage under COBRA while their spouse may elect to keep only health coverage.
A QB is eligible to continue only the coverage they had in effect the day before the qualifying event. COBRA eligibility does not allow a QB to add benefits or change plans. Coverage or plan changes are allowed only during the annual Option Period.
When a QB gains other group health, dental or vision insurance during the COBRA continuation period, they must notify EGID, and COBRA coverage must be terminated for that benefit.
When a QB’s COBRA continuation period expires, they must seek other coverage unless they qualify for coverage as a dependent on a primary member’s plan through EGID.
Employees and dependents are not required to elect COBRA. It is up to each QB to decide if continuing coverage under COBRA is the right option.
NOTE: In the event a retiring or vesting employee elects COBRA, they forfeit their right to continue insurance coverage through EGID as a retired or vested member. When the COBRA continuation period ends, they are not eligible for further coverage through EGID.
COBRA premiums are categorized by member, spouse, child and children.
EGID policy states that for any benefit continued under COBRA, one person must always pay the primary member premium. In cases where a spouse, child or children are insured under a particular benefit and the member did not retain that coverage, one person is always billed the primary member rate, even child only coverage.
At least 90% of the first month’s premium are due within 45 days of the QB’s signature on the COBRA Election Form.
Premiums can be paid by check, bank draft, money order or online. Partial or cash payments are never accepted. Premiums for a COBRA dependent cannot be deducted from a current employee’s payroll check.
When an employer enrolls with EGID or merges with an EGID participating employer, they must use a Group COBRA to COBRA Continuation Form to enroll QBs who already participate in COBRA through their previous employer. Complete this form and include the QB’s name and Social Security number, as well as the effective date and end date of the original COBRA continuation period. COBRA-to-COBRA QBs can continue coverage only for the remainder of their original continuation period; e.g., a QB exhausted 12 months of COBRA coverage before enrollment through EGID; since their continuation period was 18 months, there are still six months of continuation coverage remaining.
If the employer terminates its group coverage through EGID, QBs must be offered COBRA continuation coverage through the new carrier. All coverage through EGID, including coverage for COBRA members, ends on the employer’s last day of coverage through EGID.
Timeline for COBRA enrollment
- Employee and/or dependent COBRA qualifying event
- QB has 30 days to notify their employer.
- IC has 14 days to send a COBRA packet to QB.
- QB has 60 days from the date of notice or the date of loss of coverage, whichever is later, to elect COBRA.
- QB has 45 days from the election date to pay full premiums directly to EGID. Premiums are billed retroactively to the last day of active coverage.
- Once EGID has all forms and premiums, insurance benefits activate.
When you receive notice of an employee’s or dependent’s COBRA qualifying event:
☐ Complete either the Insurance Change Form or Insurance Termination Form, whichever is appropriate.
☐ Enter the change in Employer Self-Service or send the form to EGID.
☐ Complete the COBRA Qualifying Event Notice and put it in the employee’s file.
☐ Mail a COBRA packet within 14 days by first class mail to the last known mailing address on file. Address the packet to all covered individuals; e.g., John and Mary Smith and Children. If the covered dependents do not live with the employee, mail a separate COBRA packet to each dependent.
☐ Keep a mailing and hand delivery log of all COBRA materials.
☐ If the COBRA packet is returned as non-deliverable, check your records for an updated address and mail the packet again. If no updated address is available, keep proof of the returned packet in the employee’s file. If a new mailing address becomes available, resend the original packet and log the information.
☐ When a QB returns the COBRA Election Form, verify it is still within the 60-day election period. Attach the COBRA Qualifying Event Notice to the COBRA Election Form and fax or mail them to EGID. Keep a copy of both forms in the employee’s file.
☐ If the QB sends the premium payment with the COBRA Election Form, make a photocopy of the payment for the employee’s file. Mail the payment with the COBRA forms to EGID.
NOTE: COBRA payments must be sent in full to EGID separately from the employer’s regular monthly premium payment to ensure proper credit to the QB’s account. Per EGID policy, cash payments are never accepted.
COBRA forms can be mailed, emailed or faxed to EGID.
P.O. Box 11137
Oklahoma City, OK 73136-9998
Attention: Member Accounts
Definition of HIPAA
HIPAA is the acronym for the Health Insurance Portability and Accountability Act of 1996. It provides employees and dependents certain rights and protections related to their ability to transfer group health insurance from one employer to another. HIPAA includes protections against limitations or exclusions for preexisting conditions and prohibits discrimination against employees and dependents based on their health status. As amended in 2013, HIPAA also includes provisions related to the security and privacy of protected health information and the way it is used, shared and stored by medical providers and insurance plans. The Health Information Technology for Economic and Clinical Health Act imposes additional administrative, physical and technical safeguards for protected health information under HIPAA. For more information, visit hhs.gov/ocr/hipaa/.
Disclosure of health information
All the health plans available through EGID, as well as the HealthChoice Dental, Life and Disability plans, have processes in place that allow employees and adult dependents to authorize the release of their personal health information, also known as protected health information. For specific information, the employee should contact their plan directly.
For all HealthChoice plans, a HIPAA Authorization to Disclose HealthChoice Information form must be on file for each person authorized to access the member’s or dependent’s information. An authorization remains in effect for one year unless an expiration date is indicated. To revoke their authorization, the member or adult dependent must complete and submit a HIPAA Revocation of Authorization to Disclose HealthChoice Information form. An authorization can be revoked at any time.
Members can authorize a family member, friend or provider to access their PHI. Members can also limit the information to a specific claim, medical condition or time frame. Limitations must be indicated on the appropriate line of the authorization form. Members should keep a copy of the original authorization.
Certificates of coverage
Upon request, EGID provides a Certificate of Group Health Plan Coverage, also referred to as a HIPAA Certificate, to employees and covered dependents when health coverage terminates.
If necessary, EGID Member Services can issue a certificate prior to the date coverage ends; however, the termination date must first be in our eligibility system.
Requests for certificates from anyone other than covered employees, covered dependents or ICs are not accepted. To request a HIPAA Certificate, call EGID Member Services at 405-717-8780 or toll-free 800-752-9475. TTY users call 711.
Privacy issues for ICs
As an IC, it is your responsibility to maintain the security and privacy of the health and personal information of employees and their dependents. Disclosure of this information to others, such as when completing insurance forms, granting medical leave, or discussing the Family and Medical Leave Act, must be limited to a need-to-know basis.
Correspondence with EGID must include the employee’s name and member ID number or Social Security number. Due to privacy issues, please include only the last four digits of an employee’s Social Security number in email correspondence.
If an employee asks for your help dealing with a specific claim, know that HIPAA regulations require EGID to protect the privacy of our member’s health information. EGID discloses a member’s health information according to the terms of the OMES Privacy Notice. You can assist an employee with eligibility or other enrollment issues; however, to discuss a specific claim issue with customer service, the employee must submit a completed HIPAA authorization granting you permission. Please instruct the employee to limit the scope of their authorization to the specific claim or issue. If the claim is with an HMO plan, the employee must contact the HMO for an authorization.
NOTE: In the event you receive information for employees of other entities, contact the OMES HIPAA Privacy Officer at firstname.lastname@example.org instructions on how to handle the data.
Billing and reconciliation processes
The following notices and forms are part of the monthly premium billing and reconciliation processes:
- Premium billing statement – monthly group premium bill.
- Payment voucher – last page of the monthly Premium Billing Statement.
- Group Audit Report – lists insurance premium discrepancies for each employee.
- Discrepancy Report – prepared by you to explain differences in the amounts billed to your employer and what is owed to EGID.
- Request for Insurance Premium Refund – used to request a refund of premium overpayment.
- Late notice – email or written notice that indicates a payment is past due.
Two types of billing statements are available:
- Online billing statement – If you use web enrollment, you can access your original bill or estimated bill online at any time. The manual received during web enrollment training has more information on the bill retrieval process. If you are not registered to use web enrollment, you can obtain limited access only to download the billing statements.
- Electronic billing statement – The electronic billing statement is available only through EGID’s secure portal, and an email is sent each month when your statement is ready to access. The bill shows each employee’s name, member ID, the premium for each benefit and the total amount billed. It does not include adjustments made to coverage for previous months.
The following steps can help ensure the payment process goes smoothly:
- Verify the insurance premiums deducted from your employees’ checks are correct.
- Audit your billing statement to make sure it is accurate.
- Collect premiums from any employees who are on leave.
- Send your monthly premium payment to EGID by the 10th of the month following the month of coverage.
- Maintain payroll records regarding premium deductions.
Payment and payment vouchers
Payments are due by the 10th of the month following the month of coverage. If payment is not received by the end of the month in which the payment is due, coverage shall be canceled effective the end of the month for which payment was last received. Prompt payment of group premiums ensures employees’ access to benefits.
Use the payment voucher included in your billing statement to list all checks and warrants you are sending to EGID. Warrants and checks listed on the voucher should equal the total amount due. If the totals do not match, please explain the differences and note changes or corrections as a Discrepancy Report on a copy of your billing statement.
Auditing the premium billing statement
Use the following steps to reconcile your group bill and payroll records:
- Compare the amounts on your billing statement with your employer’s payroll records and identify any discrepancies. You must research discrepancies to determine if adjustments are needed.
- Review premium adjustments to determine if they were calculated into the previous month’s payment. If not, premiums may be outstanding or a refund may be due.
- Correct discrepancies by changing your next payroll, correcting eligibility through web enrollment, or mailing or faxing the appropriate form to EGID.
- Prepare a Discrepancy Report. Copy your billing statement and indicate changes or corrections on the pages that list the employees with discrepancies.
- Prepare warrants and checks for premium payment.
- Submit a copy of your Discrepancy Report with your payment voucher.
Please return the payment voucher, Discrepancy Report and actual warrants and checks to:
ATTN: Member Accounts
P.O. Box 269022
Oklahoma City, OK 73157-8010
EGID Member Accounts researches all discrepancies listed on your Discrepancy Report. Discrepancies that cannot be resolved are listed on a Group Audit Report and returned to you. Review the Group Audit Report as soon as it is received.
When possible, a premium overpayment should be handled through your payroll department by adjusting the employee’s withholding for the next payroll period.
Refunds are issued only after EGID is notified in writing of a premium overpayment. Notification must be made within 60 days of the overpayment, unless the lack of notification is beyond your control as determined by EGID.
Complete a Request for Insurance Premium Refund form, which is available on the EGID website.
Refund requests are usually processed within 10 days. Any refund issued on behalf of an employee is paid directly to the employer.
NOTE: EGID cannot process a refund request if our records do not indicate an adequate group credit or the refund does not meet the criteria listed in the Administrative Rules. A denied refund request is returned to you along with a letter explaining the reasons for denial.
Mail or email your Request for Insurance Premium Refund form with supporting documentation, such as an Insurance Change Form or Insurance Termination Form.
ATTN: Member Accounts
P.O. Box 11137
Oklahoma City, OK 73136-9998
Common billing issues
If a terminated or ineligible employee appears on your billing statement, do not make payment for that employee. Strike through the employee’s information and subtract their premium amount from the total due.
To the right of the employee premium line, indicate the termination date or date the employee became ineligible. Complete an Insurance Termination Form and process the termination through web enrollment. If you do not use web enrollment, send the form to EGID. Keep a copy of the form in the employee’s file.
NOTE: Education employees who terminate employment at the end of the school year can continue coverage until their contract ends.
If an eligible employee is not listed on the billing statement, verify the employee’s enrollment and the effective date of coverage using web enrollment or call EGID Member Services. If information is incorrect or missing, correct the information in web enrollment or submit an Insurance Enrollment Form to EGID.
Enter the employee’s name, member ID and premium amount on the billing statement. Then add the premium to the total amount due.
If an employee’s premiums do not add up correctly, you can verify coverage and correct any errors within 30 days of the employee’s enrollment or change date through web enrollment or call EGID Member Services.
If a coverage change is not reflected in your billing statement, the change may have been made after the bill was generated. Verify the correct coverage and effective date using web enrollment or call EGID Member Services. Locate the employee’s name on the billing statement and change the amount billed to the correct amount. Always provide a brief explanation of the reason for the adjustment in the Explanation of Differences box; e.g., added a dependent child on 01/01/22.
NOTE: It is important that web enrollment is updated or all forms for terminations, changes and refunds are faxed or mailed immediately.
An employee is eligible to continue coverage while on leave without pay for up to 24 months. The employee will still be listed on your billing statement, but it is their responsibility to pay premiums to you to forward to EGID.
Age-rated Supplemental Life premiums increase Jan. 1 of the year following a birthday that advances a member into the next age bracket.
If a payment is returned for insufficient funds, EGID sends a letter to you requesting a replacement of funds by money order or cashier’s check.
An employee must have continuous coverage and premiums must be paid in full to continue coverage under retirement, vesting, disability or COBRA.
NOTE: You must send COBRA and retirement premiums separately. These payments are processed individually and should not be included with the group premium payment.
Billing and reconciliation assistance
If you need help with any billing or reconciliation issue, contact EGID Member Accounts for assistance. Refer to the Contact Information section.
HMO vs. PPO-type indemnity plan
An HMO is a type of managed care plan regulated by the Oklahoma State Insurance Department. To be eligible to enroll in an HMO, an employee must live or work within that HMO’s ZIP code service area. When an employee enrolls in an HMO, they must designate a primary care physician to coordinate all health care needs.
A PPO-type indemnity plan is a traditional fee-for-service plan that gives the member the freedom to visit any licensed health care professional without a referral. Members are responsible for deductibles, copays and coinsurance, and a calendar year out-of-pocket maximum typically applies. Once the out-of-pocket maximum is met, the plan typically pays 100% of allowable fees for covered services for the rest of that plan year.
All health plans offered through EGID provide medical and prescription drug benefits. Benefits are subject to each plan’s rules and certain cost-sharing features such as copays, deductibles and coinsurance.
HMO ZIP code service areas
Choosing a health care provider
If an HMO plan is selected, the employee must designate a PCP. If they do not designate a PCP, one is selected for them. The PCP is the first point of contact when seeking health care and is responsible for coordinating and authorizing all health care. Failure to obtain authorization from the PCP can result in the denial of claims. For information on an HMO’s benefits, providers or drug formulary, please contact the HMO directly.
If a PPO plan is selected, the employee should confirm their medical provider or facility participates in the PPO Provider Network. The most current list of network providers is available on the PPO plan’s website or by calling EGID Member Services. If the employee decides to use a non-network provider or facility, the employee’s out-of-pocket costs can be substantially higher.
Each plan issues ID cards to its members. Providers and facilities often require a copy of the employee’s plan ID card and driver’s license or photo ID when they receive services.
Case management provides personalized assistance and coordination of medical services to help maximize benefits and is available with all health plans offered through EGID. Case management is helpful in these situations:
- Terminal illness.
- Pregnancy and preterm infants.
- Mental health and substance use disorder.
- Non-network emergencies.
Medical and pharmacy claims
All PPO health plans use central claims offices that process claims and track annual deductibles, out-of-pocket maximums and services that have plan limitations.
The medical claims administrator processes an electronic explanation of benefits for each claim. An EOB describes how benefits were applied, such as the amount billed by the provider, write-off amount, member copay, deductible and coinsurance, and total payment to the provider. Members can check claim status and view EOBs via the PPO plan’s website.
In the event of an urgent eligibility issue, such as when a new employee needs a prescription and their pharmacy rejects the claim for no coverage, please contact EGID Member Services for assistance.
To safeguard your employees’ private health information, limit your exposure to their claims information. All the health plans available through EGID have processes in place that allow an employee or adult dependent to authorize the release of their protected health information to another person.
Coordination of benefits
If an employee or their dependents have medical or pharmacy costs that are also covered by another group health plan, the insurance plans coordinate their payments so that the total benefits are not greater than the billed charges, benefits allowed or amount of member responsibility. This is known as coordination of benefits.
When a health or dental plan needs information on a member’s or dependent’s other health coverage to process a claim, verification of other insurance coverage is needed. If the member fails to provide the requested information, the claim is delayed or denied for noncompliance.
An employee’s group insurance plan through their employer is always primary. If the employee is also covered as a dependent under a spouse’s plan, that plan is secondary to the employee’s plan.
Different guidelines apply to dependents covered under both parents. In the absence of a court order indicating the primary plan, the determination may be based on which parent’s birth month, or birthday, is earlier in the calendar year. For example, if one parent was born in February and the other in April, the plan of the parent born in February is primary. This guideline is commonly known in the insurance industry as the birthday rule.
In cases where the birthday rule cannot apply, the determination is based on a court order, custody or financial responsibility for the dependents.
When there are two group health plans:
- Medical claims must be filed with the primary plan first. Once that claim is processed, a claim can then be filed with the secondary plan. This secondary claim can be only for amounts not paid by the primary plan, such as deductibles, coinsurance or copays. An employee must follow the COB procedures of both plans to ensure claims are processed smoothly. Under no circumstances will both plans pay as primary.
- Most pharmacies can electronically file claims with both the primary and secondary insurance plans; however, some pharmacies cannot file a secondary claim electronically. In this case, a paper pharmacy claim must be filed with the secondary plan after the primary plan processes the claim.
If you have questions about coordination of benefits, contact the specific plan.
More information about the health plans
If your employer participates in the dental plans offered through EGID, employees are eligible to enroll if they have health coverage through EGID or provide you with proof of other health coverage that is not an excepted benefit. Refer to Excepted Benefits in the Glossary section.
The dental plans offered through EGID provide benefits for preventive, basic and major restorative and orthodontic services. Benefits are subject to each plan’s rules and cost-sharing features such as copays, deductibles and coinsurance.
All the dental plans have certain benefit limitations and plan year maximums. Charges that exceed the annual maximum are handled differently by each dental plan. Some plans also apply a waiting period for orthodontic benefits. Check with each plan for benefit details.
The dental plans do not include prescription drug benefits. Dental prescriptions, written by licensed dentists, may be covered under the prescription drug benefits of the employee’s health plan.
Each plan issues ID cards to its members. Providers often require a copy of the employee’s plan ID card and driver’s license or photo ID when they receive services.
Coordination of benefits
COB is discussed in the Health Insurance section. The same rules and processes apply when a member has other group dental coverage. All dental plans offered through EGID coordinate benefits with other group dental plans.
Choosing a dental provider
If a prepaid dental plan is selected, the employee must designate a primary care dentist. If they do not designate a PCD, one is selected for them. The PCD is the first point of contact when seeking dental care and is responsible for coordinating and authorizing all dental care. Failure to obtain authorization from the PCD can result in denial of the claim.
If a dental indemnity plan is selected, the employee should confirm their providers participate in that plan’s network. The most current list of network providers is available on each plan’s website, or employees can contact the plan directly. If an employee decides to use a non-network provider, their out-of-pocket costs can be substantially higher.
More information about the dental plans
All the dental plans offered through EGID are available statewide, although provider access may be limited in some areas. Encourage employees to check each plan’s list of network providers before selecting a dental plan.
A current list of the available dental plans and a comparison of benefits for each plan are in the Employee Benefit Options Guide on the Insurance Coordinators webpage. Contact each plan for more details. Refer to Vendor Contact Information.
HealthChoice Life Insurance Plan
The HealthChoice Life Insurance Plan is a group term life insurance plan available through employers who carry the EGID life insurance plan. What does this mean to your members?
- No individual policies are issued.
- Term life insurance pays benefits upon the death of the insured but has no cash surrender value. This means a member cannot borrow money against the life insurance or cash it out when coverage ends.
- If the life insurance coverage is termed due to cancellation or for nonpayment of premiums, the life insurance coverage ends.
- The insurance is through HealthChoice only and is not underwritten by another insurance company.
- Claims on life insurance are paid to the beneficiaries that the member has selected. Advise members to keep a copy of their confirmation statement showing life insurance amounts and a copy of their beneficiary form to ensure life claims are paid accurately.
Important life insurance reminder: In order to be eligible for life insurance, the employee must be covered under health insurance that is not an excepted benefit. Refer to Excepted Benefits in the Glossary section. If this health insurance is with a plan other than through EGID, you must get proof of the other health coverage. Keep a copy of this proof in the employee’s file. If the employee drops or loses this other health insurance, it is the employee’s responsibility to notify you of the loss. If the employee does not have continuous health insurance in effect, they are not eligible for HealthChoice life insurance.
Basic and Supplemental Life
Basic Life: This is the first $20,000 of life coverage. Because some employers pay this portion as a benefit to employees, it is listed separately.
Supplemental Life: Any life insurance that is above the Basic Life amount of $20,000. Supplemental Life is only available in $20,000 units.
For new hires only. When enrolling in Basic Life, a new hire can also elect Supplemental Life in the amount equal to two times their annual salary rounded up to the next $20,000 unit without completing a life insurance application. Guaranteed Issue is not for established employees who have never had life before and want to add life coverage at Option Period.
Example: A newly hired employee has a salary of $36,000 a year and wants to enroll in the Guaranteed Issue amount of life insurance. Multiply the $36,000 by two ($72,000), then round up to the next $20,000 ($80,000). The total amount of Guaranteed Issue is $80,000. With the Basic Life, the newly hired employee’s total life insurance coverage is $100,000. If the new hire requests additional amounts above this Guaranteed Issue amount, a completed life insurance application must be approved. The maximum amount of Supplemental Life available through HealthChoice is $500,000. With the $20,000 Basic Life, the employee’s maximum life insurance available is $520,000.
NOTE: Employees rehired by the same employer within 24 months are not considered new hires and cannot elect a greater amount of life insurance than they had at the time of termination unless they submit a life insurance application.
|HealthChoice Basic Life ($20,000) $4.20|
|First $20,000 of Supplemental Life $4.20|
|Age-Rated Supplemental Life – Cost per $20,000|
|<30 --------- $1.20||35-49 ------ $2.80||65-69 ------ $14.80|
|30-34 ------ $1.20||50-54 ------ $5.20||70-74 ------ $25.60|
|35-39 ------ $1.20||55-59 ------ $8.00||75+ --------- $39.20|
|40-44 ------ $1.60||60-64 ------ $9.20|
Accidental Death and Dismemberment benefits
Basic Life and the first $20,000 of Supplemental Life include Accidental Death and Dismemberment benefits. AD&D benefits are only available to current employees and apply when death, dismemberment or loss of sight occur as the result of an accident. Refer to the HealthChoice Life Insurance Handbook for more information. Former employee and Dependent Life coverage do not include AD&D benefits.
|AD&D BENEFIT (Member Only)|
|LOSS OF||WITH BASIC LIFE||WITH SUPPLEMENTAL LIFE|
|Both hands, both feet or sight of both eyes||$20,000||$20,000|
|One hand, one foot or sight of one eye||$10,000||$10,000|
Dependent Life is available to any employee with at least Basic Life. No life insurance application is required since that is the only criterion to cover eligible dependents. There are three levels of Dependent Life benefits and one set premium per level regardless of the number of dependents covered. If one dependent is covered under Dependent Life, all eligible dependents must be covered under Dependent Life.
|DEPENDENT LIFE||LOW OPTION
($2.60 per month)
($4.32 per month)
($9.42 per month)
|Child live birth to 26 years||$3,000||$5,000||$10,000|
Dependent Life is the only benefit that allows a dependent to be covered under more than one member’s account (i.e., a child covered under both parents’ accounts for Dependent Life). The employee is the only beneficiary of Dependent Life coverage. There are no Accidental Death and Dismemberment benefits attached to Dependent Life.
In the case of simultaneous death with the employee and a dependent covered under Dependent Life, if it cannot be determined who passed first, the claim will be paid as if the dependent passed first and the proceeds will go to the employee’s estate. If it is determined that the employee passed first, the Dependent Life ceases and nothing is paid out. This type of occurrence is rare.
Life insurance application
An application is required when:
- A new employee applies for Supplemental Life coverage in an amount greater than Guaranteed Issue (new hires only).
- A rehired employee (within 24 months) wants to increase the amount of insurance they previously carried.
- A current employee elects to enroll in or increase life insurance coverage at Option Period or during a midyear qualifying event.
An application is not required when an employee:
- Makes no changes to life insurance in effect.
- Decreases or drops their current amount of life insurance.
- Adds Dependent Life when at least Basic Life is in effect.
- Is a newly hired employee who transferred from another EGID employer and wishes to continue the amount of life insurance coverage already approved by EGID.
COORDINATOR RESPONSIBILITY FOR THE LIFE INSURANCE APPLICATIONS
- To ensure you are using the most current copy, print the appropriate life insurance application from the EGID website.
- Complete the coordinator section at the top of Page 1. Refer to the form later in this manual.
- If the employee requests assistance completing Section 2 of the life insurance application, you may do so without violating privacy guidelines.
- Make a copy of Page 1 before you give the application to the employee.
- The employee must complete Page 2 and sign and date Section 3.
- Do not add this additional life insurance to the employee’s coverage. If approved, the additional life insurance will be added by EGID Member Accounts. A letter of approval or denial will be sent to the insurance coordinator.
EMPLOYEE RESPONSIBILITY FOR THE LIFE INSURANCE APPLICATIONS
- Forms must be submitted within the set deadline.
- Height and weight fields are required.
- Requests of $300,000 or greater require the employee to submit a minimum of two years of medical records from a U.S.-licensed medical provider.
- Employee is responsible for any costs related to the copying of medical records.
- Approval or denial of application is sent to the employee’s address and a copy is sent to the coordinator.
It is the employee’s responsibility, not the coordinator’s, to ensure the life insurance application is accurate, complete, signed, dated and returned by the deadline to:
P.O. Box 11137
Oklahoma City, OK 73136-9998
An incomplete life insurance application will result in automatic denial.
To designate how life insurance benefits are to be paid out upon their death, the member completes the Beneficiary Designation Form. An employee electing life insurance should name a beneficiary at that time. Some things to remember or consider when assisting the member with the Beneficiary Designation Form:
- Primary beneficiaries are who the employee wants to have the life insurance proceeds. If more than one primary beneficiary is designated, life proceeds are shared equally unless the employee provided other instructions on the form.
- Contingent beneficiaries are alternate beneficiaries who will receive the benefits only if all primary beneficiaries die prior to or simultaneously with the employee.
- The Beneficiary Designation Form can be updated at any time. The last one dated in the EGID system will supersede all previous Beneficiary Designation Forms.
- A beneficiary can be one person, several people, an estate, trust, charitable organization, foundation or anyone who can provide EGID a legal receipt for life insurance benefits.
- When a minor is named as a beneficiary and the life proceeds are $10,000 or less, a claim can be made by the adult responsible for the minor. If the life proceeds are over $10,000, a court must appoint a guardian for the minor before proceeds can be paid.
- If there is no beneficiary designated or the member neglected to sign the Beneficiary Designation Form, life proceeds are paid to the employee’s estate.
Special Instructions due to legal separation and divorce
If an employee is legally separated or has filed for divorce that is not finalized, remind the employee that state statute prohibits changes to any insurance coverage that directly affects the spouse unless specifically stated in the legal separation or divorce filing. This includes updating the Beneficiary Designation Form if the spouse is listed as a beneficiary.
If an employee gets divorced, remind the employee to update their Beneficiary Designation Form even if the employee wants the now former spouse to remain a beneficiary. State law says that any beneficiary designation signed before a divorce listing the former spouse as a beneficiary shall be considered void. If the employee wants the former spouse to be the beneficiary, a new Beneficiary Designation Form must be completed and signed after the divorce date to make the former spouse a valid beneficiary.
Retirement life insurance
Leaving employment is a major event in an employee’s life. Planning for life insurance needs is a vital decision to be considered carefully. Here are some valuable reminders for retiring employees:
- An employee can keep any life insurance they currently have with HealthChoice in a vested, non-vested or retirement account.
- An employee cannot add or increase life insurance at or after retirement.
- An employee going on COBRA cannot take life insurance.
- An employee who elects to defer their insurance coverage to a spouse also covered under EGID insurance must take their life insurance out in their own vested, non-vested or retirement account or lose it. Life insurance cannot be deferred.
- The employee can keep member life insurance in $5,000 units up to the amount they currently have in effect.
- The employee can keep Dependent Life insurance currently in place in $500 units.
- If the employee is receiving a pension from an Oklahoman retirement system, have the employee check with their retirement system about any death benefits for which they may be eligible.
Life insurance premiums increase at retirement for the first $40,000 of member coverage. The premium for $5,000 to $40,000 is rated at $2.56/$1,000 of coverage. Any amount above $40,000 is age-rated. Dependent Life increases to $1.28 per $500 unit per dependent.
There is no Accidental Death and Dismemberment benefit for former employee life insurance. Since retirement is a life-changing decision, EGID recommends a new Beneficiary Designation Form be completed and sent to EGID at retirement. The Beneficiary Designation Form can be updated at any time, and the most updated form received by EGID supersedes all previous Beneficiary Designation Forms.
Filing a life claim
A completed Life Insurance Claim Form Packet and an original or certified copy of the death certificate are required to file a life insurance claim. Only one death certificate is required, even with multiple claims on the life insurance. Additional documentation may be required.
For additional information, the Filing for Life Benefits brochure is available on the IC webpage, where you can also download the claim form packet for a beneficiary.
In the event of an employee’s death, life proceeds are paid to the beneficiary listed on the most recent signed beneficiary designation provided to EGID. If no beneficiary is designated prior to the employee’s death or there is no signed beneficiary designation, proceeds are paid to the employee’s estate.
In the event of a covered dependent’s death, Dependent Life proceeds are always paid to the employee. If an employee or dependent dies at the first of the month before premiums are paid, any insurance premiums due at the time of the insured’s death are withheld from the life insurance proceeds.
A beneficiary can assign all or a portion of the life insurance proceeds to a funeral home to help pay for burial costs.
Because life insurance premiums are paid post tax, benefits are not taxed when paid out. For former employees drawing a pension from a state retirement system, the $5,000 death benefit offered through a retirement system such as OPERS and TRS is a taxable benefit. Assignment to a funeral home for the death benefit will assist in lowering the tax burden of the benefit.
The vision plans offered through EGID provide routine benefits such as eye exams, frames, lenses and/or contact lenses. Some of the plans also provide discounts for laser vision correction surgery when approved facilities are used.
The vision plans do not cover cataract surgery, glaucoma or injuries to the eye. Eye injuries and diseases, including cataracts and glaucoma, are covered under the employee’s health plan.
An employee will always receive the greatest benefit when using a network provider. All vision plans have limited coverage for services provided by out-of-network providers. Each plan determines its own premiums and copays.
Members should verify their vision provider participates in a vision plan’s network by contacting the plan, visiting the plan’s website or calling their provider. An employee who fails to enroll in vision coverage, or one who elected a plan in error, must wait until the next annual Option Period to make a change.
Most vision plans do not provide an ID card. In general, most plans use the employee’s Social Security number to verify coverage.
A current list of the available vision plans and a comparison of benefits for each plan are in the Employee Benefit Options Guide on the Insurance Coordinators webpage. Contact each plan for more details. Refer to Vendor Contact Information.
To access vision plan benefits:
- The employee must contact their vision care provider and identify themselves as a vision plan member.
- The employee must provide their Social Security number or vision plan ID card.
- The vision care provider will then contact the employee’s plan to confirm eligibility and benefits.
Disability plan benefits
Oklahoma statutes limit participation in the HealthChoice Disability Plan to state employees and participating county employees. (Education employers usually have disability plans through a third party. Consult administration for more information.)
The HealthChoice Disability Plan is designed to provide employees with partial replacement of income lost as a result of a disabling illness or injury. The plan is not unemployment insurance, workers’ compensation, Social Security disability or disability retirement.
An employee is considered disabled if, as a result of injury or illness, they are unable to perform the material duties of their occupation and the condition is expected to last 31 consecutive days or longer. A disability may or may not be related to employment. After 24 months, a disability is defined as the employee’s inability to perform the material duties of any gainful occupation they are or may become reasonably qualified for by training, education or experience.
Disability benefits are limited to a maximum benefit period based on the employee’s disability, years of service and age at the time of disability. Refer to Maximum Benefit Period later in this section.
Before the plan pays any benefits, the employee must complete a 30-day elimination period. Benefits are calculated using the employee’s base salary at the time the disability began. Benefits are subject to state and federal taxes.
Plan benefits are offset, or reduced, by other income the employee receives that is related to their disability. Refer to Offsets/Reductions in Benefits later in this section.
To remain eligible for disability benefits, the employee must provide proof of continuing disability as required, as well as participate in a rehabilitation program as appropriate.
Disability benefits are divided into two types:
- Short-term disability benefits are paid for a maximum of 150 days (after the 30-day elimination period). The plan pays a monthly benefit equal to 60% of the employee’s base salary less any offsets. The maximum monthly benefit is $2,500. There is no minimum monthly benefit.
- Long-term disability benefits begin after the 180 days of short-term disability ends. The plan pays a monthly benefit equal to 60% of the employee’s base salary less any offsets. The maximum monthly benefit is $3,000, and the minimum monthly benefit is $50.
Any disability payments made for a partial month are prorated.
Maximum benefit period
The maximum benefit period is based on the employee’s disability, years of service and age at the time the disability occurred. Benefits end when the disability ends, when the employee reaches the end of the maximum benefit period or when the employee dies.
|AGE AT DISABILITY||MAXIMUM BENEFIT PERIOD|
|EMPLOYEES WITH LESS THAN ONE YEAR OF SERVICE|
|ANY AGE||6 months|
|EMPLOYEES WITH LESS THAN FIVE YEARS OF SERVICE|
|65 AND YOUNGER||24 months|
|69 AND OLDER||12 months|
|EMPLOYEES WITH FIVE OR MORE YEARS OF SERVICE|
|59 AND YOUNGER||Up to age 65|
|69 AND OLDER||12 months|
If an employee who is receiving disability benefits leaves employment and continues to meet disability eligibility requirements, they can continue to receive disability benefits until their maximum benefit period is reached.
Mental health and substance abuse disability benefits have a maximum benefit period of 24 months from the date the employee becomes disabled. There is a lifetime benefit period of 60 months for mental health and substance abuse benefits.
Offsets/reductions in benefits
Short-term and long-term disability benefits are offset, or reduced, by other benefits or payments the employee receives, or is eligible to receive, for any period of disability.
Offsets may include but are not limited to:
- Available sick, annual or shared leave.
- Earnings the employee receives from any other employment, excluding longevity pay and one-time bonuses.
- Unemployment compensation benefits.
- Social Security benefits related to the disability, excluding:
- Social Security widow’s/widower’s benefits unrelated to the current disability.
- Supplemental Security Income Program awards.
- Benefits paid to the employee by State of Oklahoma or county retirement systems, except those benefits that began prior to the disability.
- Disability related benefits paid under workers’ or workman’s compensation law, occupational disease law or other similar act or law.
- Fifty percent of any wages earned while partially disabled or during limited return to work (rehabilitative employment).
- Overpayment of previous disability payments, including retroactive Social Security disability awards.
- Veterans Affairs benefits.
- Disability benefits paid by another group plan, except for:
- Plans funded entirely by the employee’s contributions.
- Plans where payment of benefits reduces benefits at retirement.
- Benefits paid for conditions documented one year or more before the date of the current disability claim.
- Profit-sharing plans, 401K plans, thrift plans, individual retirement accounts, stock ownership plans, tax-sheltered annuities, or benefits from non-qualified deferred compensation plans.
Statutory or cost of living increases from pension or pension disability programs, Social Security or workers’ compensation do not reduce monthly disability benefits.
If lump sum benefits are received, offsets are prorated over the benefit period or the employee’s expected lifetime.
Benefit offsets can be estimated if they have not yet been awarded or denied, or if a denial is being appealed. The responsible party must repay any overpayment or underpayment once actual benefits are determined.
Returning to work/partial disability
A time of partial disability may follow a period of total disability. An employee is considered partially disabled if they can perform at least one of the duties of any occupation but earn less than 80% of their pre-disability gross base salary. If an employee is able to return to work, their disability benefits are reduced by 50% of any income earned from any other employment.
Partial disability must result from the same condition as the total disability. Proof of partial disability must be submitted within 31 days of the date the employee’s total disability period ends.
Partial disability benefits may be available for up to 24 months, or until the employee:
- Reaches the maximum benefit period.
- Earns gross wages from any employment equal to 80% or more of their pre-disability gross base salary.
A recurrent disability is related to or caused by a prior disability for which the employee received benefits under the plan. A recurrent disability is considered a continuation of the prior disability if the employee has been back to their regular full-time job for less than six months and performed all the assigned duties of that job. A recurrent disability does not alter the beginning date of a benefit period and does not require another 30-day elimination period.
If an employee has been back to their regular full-time job for more than six months, the recurrent disability is treated as a new disability. In this case, a new 30-day elimination period applies.
Multiple disabilities occur when an employee experiences a second, unrelated disability while already receiving disability benefits. If the second disability claim is eligible for benefits, the two claims are combined into one continuous disability period.
More information about the disability plan
To participate in the plan, employees must be actively at work and regularly scheduled to work at least 1,000 hours per year. Former employees are not eligible.
Enrollment in the plan begins the first day of the month following the employment date or the date the employee becomes eligible based on the employer’s rules.
To be eligible for disability plan benefits, an employee must:
- Be a covered employee of a participating employer.
- Be on duty at least 31 consecutive days.
- File their claim within one year of the date the disability began.
An employee who is confined in a correctional institution for conviction of an offense is not eligible for disability plan benefits.
The disability must be documented and certified by a qualified physician and cannot be related to a preexisting condition.
The elimination period is the first 30 days following the onset of an illness or an injury when no benefits are paid. An employee is eligible for benefits on the 31st day of their disability.
Written notice of a claim for disability benefits must be provided to the HealthChoice disability claims administrator within 60 days following the beginning of the disability. The claims administrator has the right to waive the 60-day notice requirement for good cause.
Filing for Social Security disability
To remain eligible for long-term disability benefits, an employee must apply for Social Security disability benefits by the seventh month of their disability. If Social Security denies the employee’s application and the employee does not appeal the denial, plan benefits are terminated. If after 24 months of disability, Social Security has still not found the employee eligible for disability benefits, the employee’s benefits under the plan will be terminated. Exceptions to this rule may be granted by EGID on a case-by-case basis.
The HealthChoice Disability Plan provides assistance to employees through a company called Sedgwick Claims Management Services, Inc. This service is provided at no cost to the employee; however, the employee is under no obligation to use Sedgwick’s services.
When appropriate, an employee is referred to Sedgwick by the HealthChoice disability claims administrator. Have your employee contact the disability claims administrator for more details.
If an employee is receiving HealthChoice Disability Plan benefits, the claims administrator sends you a monthly Employer Report Form. To avoid delays or problems with your employees’ disability benefits, this form must be completed and returned as quickly as possible.
The form requests the following employee information:
- Salary at onset of disability.
- Present salary.
- Employment status.
- Insurance premiums deducted, if any.
- Leave time used.
- Any other financial compensation.
The Employer Report Form cannot be used to make eligibility changes. Coverage changes must go through normal procedures.
If you feel you need additional training, the HealthChoice disability claims administrator is available to assist you with completing forms and answering questions about how the use of leave affects disability benefits and how premium deductions are handled. Representatives can also conduct training onsite or in their offices, whichever you prefer. To request training, please contact the HealthChoice disability claims administrator, Sedgwick, at 855-262-0613.
Member Accounts Billing and Reconciliation
Pharmacy Claims, Formulary and ID Cards
American Fidelity Health Services Administration
Cigna Prepaid Dental
HealthChoice (limited city and county participation)
Sedgwick Claims Management Services, Inc.
Primary Vision Care Services
Vision Care Direct
|OTHER HELPFUL CONTACT INFORMATION|
Social Security Administration
Oklahoma Public Employees Retirement System
Teachers’ Retirement System
Oklahoma Law Enforcement Retirement
TRICARE Defense Enrollment Eligibility Reporting System Selman & Company
Accidental Death and Dismemberment (AD&D): AD&D benefits are available only to current employees and apply when death, dismemberment or loss of sight occurs as the result of an accident.
Accidental Injury: Bodily injury sustained as the direct result of an accident, independent of any other cause, which occurs while insurance coverage is in force.
Allowable Fee: The set dollar amount allowed under an insurance plan for a covered service or supply.
Base Salary: The rate of earnings in effect on the date disability begins. Base salary does not include overtime, commissions, bonuses, longevity pay, productivity enhancement program payments, or any other compensation.
Basic Life: The first $20,000 of term life insurance coverage available to an eligible employee under the HealthChoice Life Insurance Plan.
Benefit Period: The period during which benefits are paid. The first day of the benefit period is the day the member becomes eligible for benefits. The end of the benefit period is the last day of eligibility as determined by the maximum benefit period and/or eligibility limits.
Case Management: The function of coordinating a patient’s medical care. The care usually involves multiple services from multiple providers.
Centers for Medicare & Medicaid Services (CMS): The federal agency that manages the Medicare and Medicaid programs.
COBRA: The acronym for the Consolidated Omnibus Budget Reconciliation Act of 1985 which gives workers and their families who lose their health, dental and/or vision benefits the right to continue group coverage provided by their group insurance plan. COBRA is available for limited periods of time and under certain circumstances, such as voluntary or involuntary job loss, reduction in hours worked, transition between jobs, death, divorce, and other life events.
COBRA Qualifying Event: Certain events resulting in a loss of health, dental and/or vision coverage for an employee and/or covered dependent that allow them to continue coverage under COBRA.
Coinsurance: The percentage of allowable fees paid by the member once the deductible is satisfied.
Copay: A set amount the member pays for certain services as a cost-sharing agreement.
Current Annual Salary: An individual’s annual gross pay. Current annual salary does not include overtime, longevity pay, benefit allowance or retirement contribution.
Deductible: The out-of-pocket amount that typically must be paid before the insurance pays benefits.
Disability: The inability to perform each of the material duties of any gainful occupation an employee is or may become reasonably qualified for by training, education or experience.
EGID: The Office of Management and Enterprise Services Employees Group Insurance Division.
- An employee’s legal spouse (including common-law).
- An employee’s daughter, son, stepdaughter, stepson, eligible foster child, child for whom the employee has been granted legal guardianship, or child legally placed with the employee for adoption, up to age 26, whether married or unmarried.
- An employee’s dependent, regardless of age, who is incapable of self-support due to a disability that was diagnosed prior to age 26. Refer to Special rules for a disabled dependent in the Eligibility section.
- Other unmarried dependent children up to age 26, upon approval of an Application for Coverage for Other Dependent Children. A tax return showing dependency may be provided in lieu of the application.
Eligible Employee: An employee of a participating employer who receives compensation for services rendered and is listed on that employer’s payroll.
Eligible Participating Former Employee: An employee who participates in any of the plans authorized by or through the Oklahoma Employees Insurance and Benefits Act who retired or vested their rights with a state funded retirement plan, or has the required years of service with a participating employer.
Elimination Period: The first 30 consecutive calendar days of disability when no benefits are paid.
Excepted Benefits: The four categories of benefits as established in section 2791 of the PHS Act, section 733 of ERISA and section 9832 of the Internal Revenue Code, as summarized in IRS Bulletin 2015-14 and subsequent regulatory guidance. These excepted benefits include but are not limited to vision coverage, dental coverage, long-term care insurance, Medicare supplement coverage, automobile liability insurance, workers compensation, accidental death and dismemberment insurance and specific disease coverage (such as cancer).
Guaranteed Issue: Two times an employee’s current annual salary rounded up to the next $20,000. This is available only during the employee’s initial enrollment. A Life Insurance Application is not required.
HealthChoice: The name for the insurance plans administered by EGID.
Health Maintenance Organization (HMO): A type of managed care plan that contracts with doctors, hospitals, clinics, and other health care providers such as pharmacies, labs, X-ray centers and medical equipment vendors. An HMO typically requires the use of a primary care physician to manage and coordinate all care.
Indemnity Plan: A traditional fee-for-service insurance plan that gives the employee the freedom to visit any licensed health care professional without a referral. The member is responsible for deductibles and coinsurance, and a calendar year out-of-pocket maximum typically applies. Once the out-of-pocket maximum is reached, the plan typically pays 100 percent of allowable fees for covered services for the rest of the year.
Initial Enrollment: The 30 days following an employee’s date of employment or date they become eligible with a participating employer. An initial enrollment is not created when an employee transfers employment between participating employers sharing the same Section 125 Plan, e.g., state agency to state agency or school to school within the same district.
Life Insurance Application: Documentation of an employee’s medical fitness for review of insurability.
Medically Necessary: Health care services or supplies within the standards of good medical practice that are necessary to prevent, diagnose or treat an illness, injury, condition, disease or its symptoms.
Network Provider: A provider who has entered into a contract with an insurance plan to accept the plan’s allowable fees for services and/or supplies provided to plan participants.
Non-Covered Service: Any service, procedure or supply excluded from coverage and not paid for by a plan.
Non-Vested: An employee who has worked long enough to keep benefits but did not contribute to a retirement system, or who has withdrawn all contributions and no longer qualifies for retirement or vested status.
Option Period: The annual time period established by EGID when changes can be made to coverage.
Orthodontic Limitation: A waiting period for orthodontic benefits.
Out-of-Pocket Maximum: The amount for which a member is responsible based on the use of network or non-network providers, including deductible and coinsurance, before eligible charges are paid at 100 percent of allowable fees. The out-of-pocket maximum does not include charges for non-covered services or balance billing charges from non-network providers.
Participant: An employee or former employee of a participating employer who is eligible and is participating in coverage through EGID.
Participating Employer: Any municipality, county, education employer, or state agency whose employees or members are eligible to participate in any plan authorized by or through the Oklahoma Employees Insurance and Benefits Act.
Plan: The insurance product for a specific benefit, such as health or dental.
Preexisting Condition: A preexisting condition refers to an illness or injury for which the employee received medical care, diagnosis, consultation or treatment, or took prescribed drugs or medicines, during the 90-day period immediately preceding the employee’s employment date. The term preexisting condition also includes any condition which is related to such injury or illness.
Proof of Claim: Written documentation submitted to EGID and/or the disability claims administrator confirming a claim for benefits.
Qualified Beneficiary (QB): An employee, their spouse and/or dependent children who were covered under the employee’s group health, dental and/or vision plan on the day before a COBRA qualifying event. This includes any child who is born to, or placed for adoption with, the employee during COBRA coverage.
Qualifying Event: A life status change that allows an individual to make midyear changes to insurance benefits.
Reconciliation: The process of making the net difference in credits and debits of a premium bill agree with the balance.
Retiree: An employee who has worked long enough to retire and draw a retirement check.
Section 125 Plan: A type of employee benefit plan offered pursuant to Section 125 of the Internal Revenue Code that allows employees to participate pre-tax in different types of benefits.
Social Security Disability: An insurance program offered by the federal government that pays benefits to those who are determined to be unable to work.
Term Life: A policy that furnishes life insurance for a limited period of time. If death occurs during this period of time, insurance benefits are paid. If death occurs after the policy has expired, no insurance benefits are paid. A term policy has no cash surrender value.
Third-Party Administrator (TPA): An entity or company that an insurance company contracts with to process claims and administer certain business functions; also called claims administrator.
Vested: An employee who has worked long enough to keep benefits and contributed to a retirement system, but is not ready to retire or draw retirement benefits.
Years of Service: Time spent as an active employee performing full-time duties with an employer that participates in one of the State of Oklahoma retirement systems.