Kan. Admin. Regs. § 108-1-3 - School district employee health care benefits plan
(a)
Definitions. Each of the following terms, as used in this regulation, shall
have the meaning specified in this subsection:
(1) "Active participant" means any person who
is enrolled in the school district plan.
(2) "Child" means any of the following:
(A) A natural son or daughter of a primary
participant;
(B) a lawfully adopted
son or daughter of a primary participant. The term "lawfully adopted" shall
include those instances in which a primary participant has filed the petition
for adoption with the court, has a placement agreement for adoption, or has
been granted legal custody;
(C) a
stepchild of a primary participant. However, if the natural or adoptive parent
of the stepchild is divorced from the primary participant, the stepchild shall
no longer qualify;
(D) a child of
whom the primary participant has legal custody; or
(E) a grandchild, if at least one of the
following conditions is met:
(i) The primary
participant has legal custody of the grandchild or has lawfully adopted the
grandchild;
(ii) the grandchild
lives in the home of the primary participant and is the child of a covered
eligible dependent child, and the primary participant provides more than 50
percent of the support for the grandchild; or
(iii) the grandchild is the child of a
covered eligible dependent child and is considered to reside with the primary
participant even when the grandchild or eligible dependent child is temporarily
absent due to special circumstances including education of the covered eligible
dependent child, and the primary participant provides more than 50 percent of
the support for the grandchild.
(3) "COBRA" means the consolidated omnibus
budget reconciliation act, public law 99-272, as amended.
(4) "Commission" means the Kansas state
employees health care commission.
(5) "Direct bill participant" means any
person enrolled in the school district plan pursuant to subsections (d), (e),
and (h).
(6) "Eligible dependent
child" means any dependent child who meets one of the following criteria:
(A) The child is under 26 years of
age.
(B) The child is aged 26 or
older, has a permanent and total disability, and has continuously maintained
group coverage as an eligible dependent child of the primary participant before
attaining the age of 26. The child shall be chiefly dependent on the primary
participant for support.
(7) "Health care benefits program" means the
state of Kansas health care benefits program established by the
commission.
(8) "Permanent and
total disability" means that an individual is unable to engage in any
substantial gainful activity by reason of any medically determinable physical
or mental impairment that can be expected to result in death or has lasted or
can be expected to last for a continuous period of at least 12 months. An
individual shall not be considered to have a permanent and total disability
unless that person furnishes proof of the permanent and total disability in the
form and manner, and at the times, that the health care benefits program may
require.
(9) "Primary participant"
means any person enrolled in the school district plan under subsection (b), a
direct bill participant under subsection (d), or a COBRA participant.
(10) "Qualified school district" means a
public school district, community college, area vocational technical school, or
technical college that meets the terms, conditions, limitations, exclusions,
and other provisions established by the commission for participation in the
school district employee health care benefits component of the health care
benefits program and has entered into a written agreement with the commission
to participate in the program.
(11)
"School district employee" means any individual who is employed by a qualified
school district and who meets the definition of employee under K.S.A.
74-4932(4), and amendments thereto, except that the following employees shall
be employed in a position that requires at least 1,000 hours of work per year:
(A) Employees of community colleges;
and
(B) employees of area
vocational technical schools and technical colleges that are not governed by a
unified school district.
For purposes of this definition, a technical college shall be a participating employer under K.S.A. 74-4931, and amendments thereto, in accordance with K.S.A. 7432,456, and amendments thereto.
(12) "School district plan" means
the school district employee health care benefits component of the health care
benefits program.
(13)
"Variable-hour employee" means any school district employee for whom, at the
date of hire, it cannot be determined that the employee is reasonably expected
to work at least 1,000 hours per year.
(b) Primary participants. Subject to the
provisions of subsection (c), each school district employee shall be eligible
to participate as a primary participant in the school district plan.
Eligibility and participation shall be subject to terms, conditions,
limitations, exclusions, and other provisions established by the commission,
including the amount and method of payment for employee and employer
contributions.
(c) Eligibility upon
beginning employment.
Each school district employee whose first day of work for a qualified school district is on or after the first day on which the employee's qualified school district participates in the school district plan shall become eligible for coverage on the first day of work for the qualified school district. Each school district employee shall have 31 days after becoming eligible to elect coverage.
(d) Classes of direct bill participants.
Subject to the provisions of subsection (e), the classes of persons eligible to
participate as members of the school district plan on a direct bill basis shall
be the following:
(1) Any retired school
district employee who is eligible to receive retirement benefits;
(2) any totally disabled former school
district employee who is receiving benefits under K.S.A. 74-4927, and
amendments thereto;
(3) any
surviving spouse or dependent of a primary participant in the school district
plan;
(4) any person who is a
school district employee and who is on approved leave without pay in accordance
with the practices of the qualified school district; and
(5) any individual who was covered by the
health care plan offered by the qualified school district on the day
immediately before the first day on which the qualified school district
participates in the school district plan, except that no individual who is an
employee of the qualified school district and who does not meet the definition
of school district employee in subsection (a) shall be qualified as a direct
bill participant under this paragraph.
(e) Conditions for direct bill participants.
Each person who is within a class listed in subsection (d) shall be eligible to
participate on a direct bill basis only if the person meets both of the
following conditions:
(1) The person was
covered by the school district plan or the health care insurance plan offered
by the qualified school district on one of the following bases:
(A) Immediately before the date the person
ceased to be eligible for coverage, or for any person identified in paragraph
(d)(5), immediately before the first day on which the qualified school district
participates in the school district plan, the person either was covered as a
primary participant under subsection (b) or was covered by the health care
insurance plan offered by the employee's qualified school district.
(B) The person is a surviving spouse or
dependent of a plan participant who was enrolled as a primary participant or a
direct bill participant when the primary participant died, and the surviving
spouse or eligible dependent child was covered by the health care benefits
program as a dependent under subsection (g) when the primary participant
died.
(C) The person is a surviving
spouse or dependent of a primary participant who was enrolled under the health
care insurance plan offered by the participant's qualified school district when
the primary participant died, and the person has maintained continuous coverage
under the qualified school district's health care insurance plan before joining
the health care benefits program.
(2) The person completes an enrollment form
requesting transfer to the direct bill program and submits the form to the
health care benefits program. The form shall be submitted no more than 30 days
after the person ceased to be eligible for coverage, or in the case of any
individual identified in paragraph (d)(5), no more than 30 days after the first
day on which the qualified school district participates in the school district
plan.
(f) COBRA
participants. Any individual with rights to extend coverage under COBRA may
participate in the school district plan, subject to the provisions of that
federal law.
(g) Eligible dependent
participants.
(1) Any person enrolled in the
school district plan as a primary participant may enroll the following
dependents, subject to the same conditions and limitations that apply to the
primary participant:
(A) The primary
participant's lawful wife or husband, as recognized by Kansas law and subject
to the documentation requirements of the commission or its designee;
and
(B) any of the primary
participant's eligible dependent children, subject to the documentation
requirements of the commission or its designee.
(2) An eligible dependent child who is
enrolled by one primary participant shall not be eligible to be enrolled by
another primary participant.
(3) An
individual who is eligible to enroll as a primary participant in the health
care benefits program shall be eligible to be enrolled under this subsection as
a dependent in the health care benefits program, subject to the following
requirements:
(A) The individual who enrolls
as a dependent of a primary participant shall be the lawful spouse, as defined
in paragraph (g)(1)(A).
(B) An
individual who enrolls as a dependent of a primary participant shall not be
eligible to be enrolled as a primary participant during that plan
year.
(C) Each individual who
enrolls as a dependent of a primary participant shall be subject to the copays,
deductibles, coinsurance, and employer contribution levels as a dependent and
not as a primary participant.
(4) The term "dependent" shall exclude any
individual who is not a citizen or national of the United States, unless the
individual is a resident of the United States or a country contiguous to the
United States, is a member of a primary participant's household, and resides
with the primary participant for more than six months of the calendar year. The
dependent shall be considered to reside with the primary participant even when
the dependent is temporarily absent due to special circumstances, including
illness, education, business, vacation, and military service.
(h) Direct bill participants;
continuous coverage provisions.
(1) Except as
otherwise provided in this subsection, each direct bill participant enrolled in
the health care benefits program on or after January 21, 2001 shall maintain
continuous coverage in the program or shall lose eligibility to be in the
health care benefits program as a direct bill participant.
(2) Any person who discontinued direct bill
coverage in the health care benefits program before January 21, 2001 and who
was not a direct bill participant on that date may return one time to the
health care benefits program if the person meets the criteria specified in
subsections (d) and (e) and if that person has not previously discontinued and
returned to direct bill coverage before January 21, 2001.
Notes
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No prior version found.