AUTHORITY: Implementing and authorized by Section 8(d-5) and (d-6) of the State Employees Group Insurance Act of 1971 [5 ILCS 375/8(d-5) and (d-6)].

SOURCE: Adopted by emergency rulemaking at 29 Ill. Reg. 15976, effective October 5, 2005, for a maximum of 150 days; modification of emergency rulemaking to meet the objection of the Joint Committee on Administrative Rules at 30 Ill. Reg. 138, effective December 22, 2005 and not to exceed the 150-day time limit of the original rulemaking; adopted at 30 Ill. Reg. 4597, effective March 1, 2006; emergency amendment at 37 Ill. Reg. 10715, effective June 28, 2013, for a maximum of 150 days; amended at 37 Ill. Reg. 17575, effective October 24, 2013.

SUBPART A: GENERAL

 

Section 2106.110  Governing Authority

 

The financial incentive for non-Medicare annuitants to opt out of the State Employees Group Insurance Health Plan will be governed by PA 94-0109, PA 98-0019, the State Employees Group Insurance Act of 1971 [5 ILCS 375] (see specifically Section 8(d-5) and (d-6)), and this Part.

 

(Source:  Amended at 37 Ill. Reg. 17575, effective October 24, 2013)

 

Section 2106.120  Purpose

 

The purpose of this Part is to provide for administration of an Opt Out Incentive for non‑Medicare annuitants who elect not to participate in the Health Plan provided by Section 8(d-5) and (d-6) of the Act.

 

(Source:  Amended at 37 Ill. Reg. 17575, effective October 24, 2013)

 

Section 2106.130  Definitions of Terms

 

Unless the context otherwise requires, the following words and phrases as used in the Act shall have the following meanings for the purpose of implementing and administering the Opt Out Incentive:

 

"Act" means the State Employees Group Insurance Act [5 ILCS 375].

 

"Annuitant" means a retiree or annuitant who is receiving an annuity from one of the five State retirement systems.

 

"Benefit Choice Period" means a designated time when members may change benefit coverage elections.

 

"CMS" means the Illinois Department of Central Management Services.

 

"Director" means the Director of CMS.

 

"Health Plan" means the health, dental and vision benefits offered by the program to eligible persons.

 

"Major Medical Coverage" refers to policies that provide coverage for most health-related expenses that can be incurred. Coverage included in a major medical insurance policy usually includes prescription drugs; casts and other necessary equipment needed for bone breaks or fractures; x-rays; both outpatient and inpatient services as a result of required medical care; diagnostic tests and examinations; ambulance services; and necessary medical supplies and therapies. This coverage may include deductibles, coinsurance and co-payment requirements.

 

"Member" means an employee, annuitant, retired employee or survivor, as defined in the Act.

 

"Opt Out/In Qualifying Change in Status" means an event that effects eligibility for Health Plan coverage, including but not limited to the following:  member becomes eligible for non-State administered health benefits coverage; marriage; loss or gain of Medicare for any reason; coordination of spouse's open enrollment period; spouse gains or loses non-State administered health benefits.

 

"Opt Out Incentive" means the retiree/annuitant insurance opt out incentive authorized by Section 8(d-5) and (d-6) of the Act, which provides a financial incentive for each annuitant who is not eligible for benefits under the federal Medicare health insurance program who elects not to participate in the Health Plan on or after January 1, 2006 under Section 8(d-5) of the Act and, on or after July 1, 2013, under Section 8(d-6) of the Act.

 

"Program" means the group life insurance, health and other benefits designed and/or contracted for by CMS that are provided under the Act.

 

"SERS" means the State Employees' Retirement System.

 

"Special Enrollment Period" means a designated time period defined by the Director of CMS for certain members to change specific benefit coverage elections when special circumstances occur that affect only those members.

 

(Source:  Amended at 37 Ill. Reg. 17575, effective October 24, 2013)

 

Section 2106.140  Records and Certifications

 

Records and other necessary certifications will be furnished to the Director as may be necessary for the administration of this opt out incentive.  These records and certifications will be retained and provided as necessary by the applicable retirement system and CMS.

 

(Source:  Amended at 37 Ill. Reg. 17575, effective October 24, 2013)

 

Section 2106.150  Severability

 

If any provision of the Act or this Part or application thereof to any person or circumstance is held invalid, such invalidity does not affect other provisions or applications of the Act or this Part that can be given effect without the invalid application or provision.  To this end, the provisions of the Act or this Part are declared to be severable.

SUBPART B: RESPONSIBILITY FOR ADMINISTRATION OF THE OPT OUT INCENTIVE

 

Section 2106.210  CMS Responsibility

 

CMS will be responsible for administering the opt out incentive and shall:

 

a)         Develop and distribute materials and information to members and the retirement systems, including any and all necessary forms with requirements, policies and procedures related to the opt out incentive.

 

b)         Maintain eligibility for the opt out incentive in a centralized, computerized file, properly storing and retrieving confidential information, processing updates and administering security access in accordance with confidentiality laws.

 

c)         Authorize payments to annuitants participating in the opt out incentive.  No partial monthly or retroactive payments will be made.

 

d)         Assist members with opt out incentive questions and/or issues, and respond to oral and written inquiries concerning the opt out incentive.

 

e)         Comply with the federal Health Insurance Portability and Accountability Act (HIPAA), when applicable.

 

f)         Enroll and terminate annuitants in compliance with this Part.

 

g)         Identify and collect opt out incentive payments paid in error to annuitants and deposit the money into the Health Insurance Reserve Fund.

 

(Source:  Amended at 37 Ill. Reg. 17575, effective October 24, 2013)

 

Section 2106.220  Annuitant Responsibility

 

The annuitant shall:

 

a)         Furnish proof of major medical coverage from a source other than CMS at the time of initial application and on an annual basis as required by CMS.

 

b)         Timely report Medicare eligibility changes.

 

c)         Report all eligibility status changes within 60 days after the event, including but not limited to Medicare eligibility.

 

d)         Return to CMS all payments made in error or for fraudulent acts.  Failure to repay payments as required will result in termination of the financial incentive and disallowance of future coverage in the Health Plan.  Fraudulent acts include, but are not limited to, the following:

 

1)         failure to timely report changes and/or Opt Out/In Qualifying Changes in Status;

 

2)         falsifying information in order to receive opt out incentive payments.

 

(Source:  Amended at 37 Ill. Reg. 17575, effective October 24, 2013)

SUBPART C: OPT OUT INCENTIVE REQUIREMENTS AND BENEFITS

 

Section 2106.310  Eligibility Requirements

 

Opt out incentive administration shall be in compliance with Section 8(d-5) and (d-6) of the Act and shall:

 

a)         Allow annuitants who elect not to participate in the Health Plan to receive a financial incentive not to exceed $500 per month if all of the following conditions are met:

 

1)         the annuitant is enrolled in the Health Plan on the effective date of PA 98-0019, at the time of a Special Enrollment Period or subsequent Benefit Choice Periods, or when an Opt Out/In Qualifying Change in Status occurs;

 

2)         the annuitant is not eligible for and/or receiving benefits under the federal Medicare health insurance program (42 USC 1395 et seq.); and

 

3)         the annuitant has 20 or more years of creditable service with the State of Illinois.

 

b)         Allow annuitants who elect not to participate in the Health Plan and meet the requirements of subsections (a)(1) and (a)(2) but fail to meet the requirements of subsection (a)(3) to receive a financial incentive not to exceed $150 per month.

 

c)         Provide for a Special Enrollment Period from November 1 through November 30, 2005 for SERS annuitants enrolled in the Health Plan to elect to participate in the opt out incentive.  The opt out incentive elected by SERS annuitants during this Special Enrollment Period will have an effective date of January 1, 2006.

 

d)         Provide that annuitants who previously elected not to participate in the Health Plan may choose to enroll in the Health Plan during the Benefit Choice Period or with an Opt Out/In Qualifying Change in Status.  Once enrolled, they may take advantage of the opt out incentive during a subsequent Benefit Choice Period or with a subsequent Opt Out/In Qualifying Change in Status.  Annuitants will not be permitted to enroll and opt out during the same Benefit Choice Period or based on the same Opt Out/In Qualifying Change in Status.

 

(Source:  Amended at 37 Ill. Reg. 17575, effective October 24, 2013)

 

Section 2106.320  Participation Limits

 

Opt out incentive participation shall cease when the non-Medicare annuitant:

 

a)         reaches age 65, unless written proof of Medicare ineligibility is submitted to CMS;

 

b)         becomes Medicare eligible for any reason; or

 

c)         elects to participate in the Health Plan.

 

(Source:  Amended at 37 Ill. Reg. 17575, effective October 24, 2013)

 

Section 2106.330  Enrollment

 

Eligible annuitants participating in the Health Plan may enroll in the opt out incentive through September 30, 2013, the annual Benefit Choice Period or with an Opt Out/In Qualifying Change in Status by completing appropriate forms and furnishing proof of eligibility as outlined in Section 2106.310.

 

(Source:  Amended at 37 Ill. Reg. 17575, effective October 24, 2013)