Except as otherwise provided under federal law or
regulation, specified employees, annuitants and their family members who become
Medicare-eligible, as defined below, may not be enrolled in a basic health
benefits plan. Failure of a Medicare-eligible basic plan member to enroll in
Part B of Medicare and in a Medicare Plan will result in termination of basic
plan coverage.
(a) As used in this
section and in Government Code section
22844:
(1) "Post-1997 Basic Health Plan Enrollees"
means those annuitants and their family members who (a) have been continuously
enrolled in a basic health benefits plan on or after January 1, 1998, and (b)
turned 65 on or after January 1, 1998 and before January 1, 2005.
(2) "Post-2000 CSU Basic Health Plan
Enrollees" means those annuitants of the California State University and their
family members who (a) have been continuously enrolled in a basic health
benefits plan on or after January 1, 2001, and (b) turned 65 on or after
January 1, 2001 and before January 1, 2005.
(3) "Prospective Medicare Beneficiary" means
an annuitant, employee or family member who is enrolled in a basic health
benefits plan and, at the time of notification hereunder, is within the
Medicare Initial Enrollment Period.
(4) "Medicare-Eligible" means eligible for
Medicare Part A without cost and Part B.
(5) "Medicare Plan" means a Medicare
supplement or Medicare-risk health benefits plan approved or contracted for by
the board.
(6) "Deferral of Part B
Enrollment" means deferral of Part B enrollment by a Medicare-eligible state or
a contracting agency employee who, pursuant to federal law and regulations, has
deferred enrollment in Part B of Medicare because he or she is actively
employed and covered by a basic health benefits plan by virtue of that
employment.
(b)
Enrollment and continuation in a basic health benefits plan.
(1) Except as set forth below, Post-1997
Basic Health Plan Enrollees, Post-2000 CSU Basic Health Plan Enrollees, and
Prospective Medicare Beneficiaries who are Medicare-eligible may not continue
to be enrolled in a basic health benefits plan.
(2) A Medicare-eligible individual who
applies for initial enrollment in a basic health benefits plan, or
re-enrollment after a break in coverage, shall not be permitted to enroll in a
basic plan notwithstanding the fact that he or she was enrolled in an
employer-sponsored basic health plan prior to, or on the date of, the
application for enrollment.
(3) A
Medicare-eligible state or contracting agency employee who has deferred his or
her enrollment in Part B, may continue to be enrolled in a basic health
benefits plan until the earlier of retirement or termination of employment.
Such employee must notify the Board immediately upon termination of his or her
deferred status and must enroll in Part B of Medicare during his or her special
enrollment period.
(c)
Notice of Requirement to Enroll in Medicare.
(1) Post-1997 Basic Health Plan Enrollees and
Post-2000 CSU Basic Health Plan Enrollees. No later than December 1, 2004, the
Board shall provide notice to Post-1997 Basic Health Plan Enrollees and
Post-2000 CSU Basic Health Plan Enrollees of their requirement to enroll in
Part B of Medicare. This notice shall provide that (a) if they are
Medicare-eligible they may not remain in a basic plan, (b) if they are eligible
for Part A of Medicare without cost, they must enroll in Part B of Medicare and
in a Medicare Plan in order to retain health plan coverage; and (c) the failure
to provide the board with satisfactory evidence of enrollment in Part B,
ineligibility for Part A without cost, or deferral of Part B enrollment will
result in the termination of their basic plan enrollment.
(2) Prospective Medicare Beneficiaries.
Commencing four (4) months prior to a Prospective Medicare Beneficiary's 65th
birth month, the Board shall provide notice of the requirement to enroll in
Medicare. This notice shall inform the Prospective Medicare Beneficiary that if
he or she is Medicare-eligible, he or she may not remain in a basic health
benefits plan and must timely enroll in Part B of Medicare and a Medicare Plan
in order to retain health plan coverage. The notice shall also inform the
Prospective Medicare Beneficiary that failure to provide the board with
satisfactory evidence of enrollment in Part B, ineligibility for Part A of
Medicare without cost, or deferral of Part B enrollment will result in the
termination of his or her basic plan enrollment.
(d) Termination of enrollment in a basic
health benefits plan.
(1) On or before March
31, 2005, Post-1997 Basic Health Plan Enrollees and Post-2000 CSU Basic Health
Plan Enrollees shall provide the Board with satisfactory evidence of
application for enrollment in Part B of Medicare during the 2005 Medicare open
enrollment period, ineligibility for enrollment in Part A of Medicare without
cost, or deferral of Part B enrollment. Failure to do so will result in
termination of basic plan enrollment effective April 1, 2005.
(2) On or before June 1, 2005, a Post-1997
Basic Health Plan Enrollee or a Post-2000 CSU Basic Health Plan Enrollee who
applied to enroll in Part B of Medicare during the 2005 open enrollment period
shall provide the Board with satisfactory evidence of enrollment in Part B of
Medicare and an application for enrollment in a Medicare plan. Failure to do so
will result in termination of basic plan enrollment effective July 1,
2005.
(3) The basic plan enrollment
of a Prospective Medicare Beneficiary who fails to provide to the Board
satisfactory evidence of enrollment in Part B of Medicare, ineligibility for
Part A of Medicare without cost, or deferral of Part B enrollment by the last
day of his or her birth month, will be terminated effective the first of the
subsequent month.
(4) To the full
extent permitted by law, the Board shall have no liability for any costs,
losses or damages incurred by any person as a result of, or arising from or
related to, the termination of basic health benefits plan coverage in
accordance with this section.
(e) Enrollment in a Supplemental Plan.
(1) Post-1997 Basic Health Plan Enrollees,
Post-2000 CSU Basic Health Plan Enrollees, and Prospective Medicare
Beneficiaries who are Medicare-eligible may enroll in a Medicare Plan by
submitting an application to the Board and proof of enrollment in Parts A and B
of Medicare. Enrollment in the Medicare Plan shall be effective on the date
Medicare coverage became effective or the first of the month following receipt
of the application, whichever is later.
(2) Notwithstanding (1) above, a person whose
coverage has been terminated pursuant to subsection (d) and who subsequently
submits evidence of enrollment in Parts A and B of Medicare may only enroll in
a Medicare Plan under the following conditions:
(A) If the application and proof of
enrollment in Parts A and B of Medicare are submitted within 90 days of the
date that basic plan coverage terminated, enrollment in the Medicare Plan shall
be retroactive to the effective date of Medicare coverage or a date 90 days
prior to the submission of evidence of Medicare enrollment, whichever is
later.
(B) If the application and
proof of enrollment in Parts A and B of Medicare are submitted more than 90
days after the date that basic plan coverage terminated, the effective date of
enrollment shall be the first of the month following receipt of the application
or, if applicable, the effective date of coverage under open
enrollment.
(f)
Enrollment in a basic health benefits plan after termination.
If a person whose basic plan coverage has been terminated
pursuant to subsection (d) subsequently submits satisfactory written
confirmation that he or she is either not eligible for Part A of Medicare
without cost or has deferred enrollment in Part B of Medicare, he or she may
enroll in a basic health benefits plan under the following conditions:
(1) If the documentation is received by the
Board within 90 days of the date that coverage terminated, re-enrollment in a
basic plan shall be retroactive to the date coverage terminated.
(2) An application for enrollment received
more than 90 days after basic plan coverage has terminated may be submitted
only during a CalPERS Health Benefits Open Enrollment
period.
(g) Request for
administrative review--termination of enrollment in basic health benefits plan.
(1) A person who has been notified that his
or her enrollment in a basic plan has, or will be, terminated pursuant to
subsection (d), may request an administrative review of the termination. The
filing of a request for administrative review shall not delay the termination
of basic plan enrollment.
(2) A
request for administrative review must be filed with the Health Branch
Assistant Executive Officer within 90 days of the termination date or the date
of the notice of termination, whichever is later. The request for
administrative review shall be in writing, state the grounds on which it is
requested, the relief that is sought, and include all supporting
evidence.
(3) The Health Branch
Assistant Executive Officer or his or her designee shall acknowledge the
request within 15 days of receipt. The Health Branch Assistant Executive
Officer or his or her designee shall review the request and may request
additional documentation. Written notification of the decision shall be mailed
within 60 days of receipt of all pertinent information.
(h) Request for administrative
review--effective date of Medicare Plan enrollment.
(1) A person whose enrollment in a Medicare
Plan is delayed pursuant to subsection (e)(2)(B) due to failure to timely
submit evidence of enrollment in Part B of Medicare, may seek administrative
review of the basis for the delayed effective date. The filing of a request for
administrative review shall not delay the termination of basic plan
enrollment.
(2) A request for
administrative review must be filed with the Health Branch Assistant Executive
Officer within 90 days of the notice of the effective date of enrollment in the
Medicare Plan. The request for administrative review shall be in writing, state
the grounds on which it is requested, the relief that is sought, and include
all supporting evidence.
(3) The
Health Branch Assistant Executive Officer or his or her designee shall
acknowledge the request within 15 days of receipt. The Health Branch Assistant
Executive Officer or his or her designee shall review the request and may
request additional information. Written notification of the decision shall be
mailed within 60 days of receipt of all pertinent
information.