Authority for rules promulgated in this chapter is found
in:
State of Colorado Constitution Article XII, Section 13; The
Patient Protection and Affordable Care Act (PPACA), commonly called the
Affordable Care Act (ACA), and 26 United States Code (U.S.C.) 63; The Family
Medical Leave Act (FMLA); Americans with Disabilities Act (ADA); Family Care
Act (FCA); Uniformed Services Employment and Reemployment Rights Act
(USERRA).
State of Colorado Revised Statutes (C.R.S.) §
24-50-104,
24-50-109.5, and Part 6, 1-6-115,
1-6-122, 1-7-102, 8-40-101, 14-2-101, 14-15-103, 24-11-101, 24-11-112,
24-18-102, 24-33.5-825, 24-50-401, 28-1-104, 28-3-601, 28-6-602, 28-3-607,
28-3-609, and 28-3-610.
General Principles
11-1. The state reserves the sole right to
add, modify, or discontinue any State of Colorado Employees Group Benefits Plan
(the "state benefits") as deemed necessary.
11-2. The Director complies with applicable
federal and state law and regulations that govern state benefits plans, as well
as the terms and conditions of the state benefits plans contracts and plan
documents. Governing laws and regulations, and these rules shall prevail in the
event of a conflict with contracts or plan documents. (7/1/10)
11-3. Chapter 11, State Benefits Plans rules
apply to all departments administering and all employees eligible for state
benefits plans. (02/2017)
Director Responsibilities
11-4. The Director will provide all benefits
information, written directives and training to departments necessary for
department benefits administrators to fulfill their responsibilities as
delegated agents to the plans. (7/1/10)
11-5. The Director has sole authority to
determine eligibility, negotiate contracts, determine plan designs, set rates
and coverage tiers, define the plan year, and establish open enrollment
periods, in accordance with law, regulations, and approved funding.
(7/1/10)
11-6. The Director's
online benefits administration system is the official system of record for all
eligibility and enrollment transactions. (7/1/10)
Department Responsibilities
11-7. All departments shall exercise due
diligence when administering benefits in the best interests of the plans and
all members. Benefits administrators are delegated agents of the Director in
their respective departments. As a delegated agent of the Director, the
responsibilities of the department benefits administrator(s) include, but are
not limited to, the following:
A. Know and
comply with plan documents and basic plan features, law and regulations, rules,
benefits administration system, deadlines, the Director's website, and written
directives;
B. Communicate,
disseminate, explain, and answer questions on all benefits-related information
including, but not limited to, options and changes, process, requirements and
eligibility;
C. Provide prompt
notice of enrollment opportunities and information so employees can elect
benefits during open enrollment or enroll within thirty-one (31) days of hire
or an employee's notice of a qualified event. The first day (day 1 of the 31
days) is the day after hire or a qualified event;
1. Qualifying Life Events due to Medicare or
Medicaid, allow for sixty (60) day notification period.
2. Effective dates for all Qualifying Life
Events, except for births and adoptions, are the first of the month following
the date the event is entered into the benefits administration system.
Effective dates for births and adoptions are the date of the event.
D. Monitor deadlines and assist
employees with meeting those deadlines;
E. Provide employees with access to and
training in the use of the benefits administration system, and assist employees
with transactions;
F. Refrain from
advising an employee of which individual elections to make and assisting an
employee in the commission of fraud or attempted fraud of a state benefits
plan; and
G. Process timely and
accurate transactions and payments. This includes regular review of pending
actions, supporting documentation, and system reports in order to promptly
approve elections, terminate coverage, investigate suspicious or questionable
actions or data, correct errors, and verify continuing dependent
eligibility.
11-8. These
responsibilities apply to all departments, including those that offer their own
separate group benefits plans to other employees not covered by the
24-50-Section 6 "State Employees Group Benefits Act". (7/1/10)
Employee Responsibilities
11-9. Employees are responsible for knowing,
understanding, and adhering to these rules, plan documents for the terms and
conditions of coverage, and eligibility and enrollment requirements in order to
make timely and informed choices, including, but not limited to, the following:
A. Employees shall enter all required
information in the benefits administration system in a timely and accurate
manner in order to comply with eligibility and enrollment requirements for
themselves and eligible dependents;
B. Enrollment of employees and eligible
dependents is restricted to initial hire, annual open enrollment, and
Qualifying Life Events defined by law and plan documents. Elections are
irrevocable for the plan year, except in limited circumstances specified by law
or regulations.
1. Any permitted enrollment,
modification, or termination of enrollment shall be entered into the official
benefits administration system within thirty-one (31) days before or after a
Qualifying Life Event (sixty (60) days for Medicare and Medicaid Qualifying
Life Events).
a. Coverage changes are
effective the first of the month following the date the Qualifying Life Event
is entered into the benefits administration system except for births/adoptions
where coverage is retroactive to the date of birth/adoption.
b. Any supporting documentation required for
the enrollment, modification, or termination of enrollment shall be submitted
within forty-five () days of the qualifying event.
c. For open enrollment only, the transactions
shall be entered into the official benefits administration system with
accompanying documentation within the allotted time established.
(07/01/2022)
2. Due
dates are strictly enforced. Employees shall proactively communicate with their
department benefits administrator before missing a deadline to determine if an
extension can be provided due to unforeseen circumstances.
3. Employees are responsible for verifying
their benefit elections annually during open enrollment; and
4. Employees who transfer from one (1)
department to another shall notify both department benefits administrators to
avoid a potential lapse in coverage.
C. Employees shall remove any dependent by
the end of the month in which the dependent ceases to meet eligibility
requirements.
1. Failure to do so may result
in the employee's continuing financial liability for total premium (employee
and employer contributions) and/or cost of paid claims for the ineligible
dependent, as specified in law and regulations, plan documents, and these
rules.
D. Any enrollment
or qualified change to enrollment constitutes authorization to begin or end
payroll deductions.
1. Employees shall verify
the accuracy of their payroll deductions and notify their department benefits
administrator of any error. The notice shall be in writing and within fifteen
(15) days from the pay date in which the first payroll deduction
occurred.
2. If an employee fails
to notify the department of the payroll error within the fifteen (15) day
period, the employee may continue to be liable for the election for the
remainder of the plan year unless the election is not consistent with plan
documents, rules, laws, regulations, and written directives.
11-10. It is unlawful
for any employee or dependent to intentionally provide false, incomplete, or
misleading facts, information, or documents in written or electronic form,
including within the benefits administration system for the purpose of
defrauding or attempting to defraud the State of Colorado. The Director shall
investigate when there is reason to believe an employee or dependent is
committing or attempting to commit fraud against any state benefits plan. If
the Director finds evidence of fraud or attempted fraud, the employee,
dependent, or both may be subject to any or all of the following sanctions:
(7/1/10)
A. Immediate termination of
coverage;
B. Denial of future
enrollment;
C. Requirement to
reimburse the state contributions and claims costs during the time of
ineligible coverage;
D. Filing of
criminal charges; and/or
E. Notice
to the employee's department, which may take employment action, such as
corrective or disciplinary action.
Eligibility
11-11. Employees and their dependents shall
meet the eligibility requirements as defined in state law, plan documents, and
rules to qualify for enrollment in the state benefits plans. (7/1/10)
A. Dependents may not enroll in the state
benefits plans unless the employee is enrolled.
B. If the employee and spouse/partner are
both employees of the state;
1. Each employee
may be enrolled separately, or may be covered as a dependent of one of the
spouse/partners, but not both.
2.
If both the employee and spouse/partner make a separate election under the
state benefits plans, only one (1) parent may enroll children as
dependents.
11-12. Additional criteria and documentation
requirements are contained in the State of Colorado Employees Group Benefits
Plan, law and regulations, rule, and other written directives, which are
available in the Division of Human Resources (DHR) Employee Benefits Unit.
Dependents may be federal tax dependents (qualified) or non-tax dependents
(non-qualified). Coverage for non- qualified dependents is subject to taxable
income regulations. Eligible dependents are specified in statutes, primarily
§
24-50-603(5),
C.R.S., as modified or further defined by other state statutes.
11-13. Legal documentation is required to add
any dependent to a state benefits plans. (1/1/14)
Coverage of Benefits
11-14. Initial coverage in state benefits
plans is effective on the first (1st) day of the month following the date of
hire or initial eligibility unless otherwise specified by the contracts, law,
or regulations. (1/1/14)
11-15. All
coverage for a qualifying event is prospective from the beginning of the next
month or the date of entry into the official benefits administration system,
whichever is later, except for initial coverage for new employees and newborn
children. (1/1/14)
11-16. Elections
made during open enrollment are effective the first (1st) day of the new plan
year.
11-17. Termination of
coverage is subject to law and regulation, plan documents, and contracts, as
well as the following rules. (7/1/10)
A. If at
any time during the plan year any dependent ceases to meet the eligibility
criteria, coverage ends on the last day of the month in which that dependent
becomes ineligible.
B. Coverage in
state benefits plans is terminated on the last day of the month that employment
ends.
Payment of Contributions
11-18. Departments shall make
prompt monthly payments based on enrollment in the official benefits
administration system. (7/1/10)
A. The
employee's current department as of the last day of the month is responsible
for payment.
B. A department is
liable for both state and employee contributions when failing to promptly enter
an employee termination.
11-19. Employees shall make an irrevocable
election for the plan year to have contributions deducted on a pre-tax or
after-tax basis as defined by the State of Colorado Salary Reduction Plan, law
and regulations, rule, and written directives. The employee's contribution is
deducted from the employee's pay or, under certain circumstances, paid by
personal payment for the selected state benefits plans, in arrears by the end
of the month in which an employee is covered. (02/2017)
11-20. An enrolled employee who works or is
on paid leave one (1) or more regularly scheduled, full workdays in a month, is
eligible for the full state benefits contribution. (7/1/10)
11-21. When an employee is on leave,
departments shall continue to pay the state contribution for noncontributory,
fully paid benefits (e.g., basic life and short-term disability) as long as the
employee remains on the payroll, regardless of status. The department shall
contact the employee to arrange a payment plan for benefit contributions that
will be owed for the duration of the employee's leave.
A. During paid leave or mandatory furlough,
the employee contribution continues to be paid through payroll deduction and
the department continues to pay the state contribution.
B. During unpaid leave, the employee shall
pay the total premium (employee and employer contributions) to the department
within the month of coverage, except as follows.
1. During unpaid leave pursuant to the Family
Medical Leave Act of 1993, the department shall continue to pay the state
contribution as long as the employee continues to pay the employee contribution
by the due date specified in the family/medical leave notice. If the employee
fails to pay the employee contribution when due, coverage will be terminated
but shall be reinstated upon return to work with the exception of any benefit
that will require late entrant underwriting for reinstatement. In the event any
contributions are owed upon the employee's return to work, such contributions
shall be collected from the employee. If the employee fails to return after the
leave, any contributions due will be recovered as specified by federal
regulations. (02/2017)
2. While an
employee is on voluntary furlough or short-term disability leave, the
department shall continue to pay the state contribution as long as the employee
continues to pay the employee contribution in a timely manner. If the employee
fails to pay the employee contribution by the due date, coverage shall be
terminated and the employee may reapply subject to late entrant underwriting.
3. While an employee is on FAMLI
leave, the state continues to pay its portion of insurance premiums. The
employee shall continue to pay their share of the cost of benefits as required
prior to the commencement of leave. (12/1/2023)
11-22. Refunds for employee and state
contributions are subject to plan limitations and as defined in law and
regulations, rule, and written directives. (7/1/10)
11-23. When there is a difference between the
contribution paid by the employee and the actual contribution due, the
difference is paid by the employee. (e.g., change in coverage tier). (7/1/10)
Director's Review of Benefits Appeals
11-24. The Director's Benefits
Appeal Filing. All Director's Benefits Appeals are administratively processed
through the Division of Human Resources (DHR) Employee Benefits Unit using the
Colorado State Employees Group Benefits Eligibility Determination Appeal Form.
A.
The Director's Benefits
Appeal. The Director's Benefits Appeal shall use the Colorado
State Employees Group Benefits Eligibility Determination Appeal Form found on
the DHR website.
B.
Contents of the Director's Benefits Appeal. The
Director's Benefits Appeal contains the information for denial of eligibility
for the state benefits plan.
C. The
filing of a timely Director's Benefits Appeal must meet the following criteria:
1. The Director's Benefits Appeal shall be
filed with the DHR Employee Benefits Unit within thirty-one (31) days of the
denial of eligibility for state benefits plans. The first day of the count is
the day after the date on the notification and each calendar day
thereafter.
2. If a deadline falls
on a weekend, official state holiday, or by governor order the deadline is
extended to the next regular business day.
3. Any filing via facsimile or email that is
received by the DHR Employee Benefits Unit by 5:00 p.m. Colorado time shall be
deemed to have been filed on that date.
4. If the filing is through mail by the
United States Postal Services, the date of filing is the postmark.
5. Failure to timely file an appeal may
result in the Director's Benefits Appeal being dismissed without a
review.
D.
Where to File. Appeals and other documents may be
filed by United States Postal Service, facsimile, or via email.
1. The mailing address for filing is
Department of Personnel and Administration, Division of Human Resources
Employee Benefits Unit, 1525 Sherman Street, Denver, Colorado 80203.
a. Normal business hours for the DHR Employee
Benefits Unit are from 8:00 a.m. to 5:00 p.m., Monday through Friday, except
for official state holidays or days that state offices in Denver are closed due
to weather or safety by governor order.
2. The facsimile number is 303-866-3879.
Facsimile filings may not exceed ten (10) pages.
3. The DHR Employee Benefits Unit's email
address is state_benefits@state.co.us.
E. The Director will issue a final written
decision within forty-five (45) days of receipt of the benefits appeal.
1. The ineligibility decision may be
overturned only if found to be arbitrary, capricious or contrary to rule or
law.
Denial of Claims Appeals
11-25. Provider Denied
Claim: Appeals of denied claims under any of the state benefits plans shall
follow the specific appeal process defined in the specific contract, plan
document, summary plan description, or regulated entity. The provider will
issue a final written decision in accordance with its process. (7/1/10)
A. Appeals of denied claims under fully
insured plans are regulated by the State of Colorado Division of Insurance, and
follow the plan's appeal process as defined in the contract and plan
document.
B. Appeals of denied
claims under self-funded plans are not regulated by the State of Colorado
Division of Insurance, and follow the third-party administrator's appeal
process as defined in the contract and plan document.
Colorado State Employee Assistance Program
(CSEAP)
11-26. Services provided include but are not
limited to counseling services, crisis intervention, consultations with
supervisors and managers, facilitated groups, trainings, and workshops.
(7/1/10)
11-27. Any state employee
and any participating departments or entities may use CSEAP services. State
employees from non-participating departments or entities may have limited
access to CSEAP services.
A. Participating
departments and entities and individual state employees from participating
departments and entities may access or participate in all CSEAP services. Some
services provided by CSEAP may include cost(s) incurred by the participating
department or employees.
B. Any
individual state employee from a non-participating department or entity may
access counseling and available open-access webinar services from
CSEAP.
C. Non-participating
departments or entities may access limited CSEAP crisis counseling or critical
incident response services regardless of whether the department or entity
financially contributes to CSEAP. Availability of these services to
non-participating departments is based upon available CSEAP
resources.
D. The program may
include other persons if necessary to provide effective assistance to the
employee.
E. The Director will
determine the number of sessions available to employees within a twelve (12)
month period. Additional sessions may be authorized at the discretion of the
counselor.
11-28.
Participating departments or entities are defined as those that make payments
to any state fund or account that funds CSEAP. In the event that departments or
entities do not contribute to the state risk management fund and/or other
funding source for CSEAP, departments or entities may arrange payment (when a
structure for payment exists) to the Department of Personnel and Administration
for CSEAP services.
Supplement State Contribution Program
11-29. State employees who are
eligible to enroll in medical and dental benefits and have at least one (1)
dependent child who will be or could be covered under state benefits may apply
to the Supplement State Contribution Program. A child cannot be covered under
Child Health Plan Plus (CHP+).
11-30. Approval of application is subject to
the established Supplement State Contribution Program's policy.
11-31. Determination of the Supplement State
Contribution Program is final and cannot be appealed, as it does not relate to
eligibility.
Notes
37
CR 22, November 25, 2014, effective 1/1/2015
37
CR 24, December 25, 2014, effective
1/14/2015
40
CR 02, January 25, 2017, effective
2/14/2017
40
CR 23, December 10, 2017, effective
1/1/2018
40
CR 24, December 25, 2017, effective
1/14/2018
42
CR 19, October 10, 2019, effective
11/1/2019
43
CR 05, March 10, 2020, effective
4/1/2020
43
CR 13, July 10, 2020, effective
8/1/2020
43
CR 24, December 25, 2020, effective
2/1/2021
44
CR 05, March 10, 2021, effective
4/1/2021
44
CR 07, April 10, 2021, effective
5/1/2021
44
CR 10, May 25, 2021, effective
7/1/2021
44
CR 12, June 25, 2021, effective
9/1/2021
45
CR 11, June 10, 2022, effective
7/1/2022
45
CR 14, July 25, 2022, effective
9/1/2022
46
CR 08, April 25, 2023, effective
7/1/2023
46
CR 21, November 10, 2023, effective
12/1/2023