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1 2022 Benefits Administrator ManualBenefits Administrator Manual SCPEBA 122021 | Expires 12312022 1 Table of contents General information .. 12 How to use this manual .. 13 EBS .. 13 Contact PEBA .. 14 When you call PEBA on behalf of a subscriber .. 14 Requests for proof of insurance .. 14 Forms on the web .. 14 Training and resources .. 14 Using the online system .. 16 Terms .. 18 Employee Benefits Services (EBS) .. 18 Signing up .. 18 EBS homepage .. 19 Manage Subscribers .. 19 Inquiry .. 19 Manage .. 20 Enrollment File Upload .. 24 Life Ins SOH .. 25 Manual transactions .. 25 Manage Groups .. 26 Enrollment reports .. 26 Accounting reports .. 26 Balance .. 26 Contacts .. 26 SLTD Salary Entry .. 26 Online Bill Pay .. 27 BA Console .. 28 Suspended tab .. 28 Acknowledgement tab .. 28 Approval tab .. 28 Current EBS tab .. 29 RFR (Request for Review) tab .. 29 Status.

2 29 Benefits Administrator Manual SCPEBA 122021 | Expires 12312022 2 Tips .. 31 MyBenefits .. 31 Using MyBenefits .. 31 Making special eligibility changes .. 31 Making open enrollment changes .. 32 Active subscribers .. 33 Employee eligibility rules and procedures .. 36 Determining eligibility for benefits .. 36 Measurement periods .. 36 Administrative periods .. 37 Stability periods .. 38 Notes on employee eligibility .. 38 Procedures to elect 20-hour threshold .. 39 Assisting a benefits-eligible employee .. 39 Required information .. 39 Available benefits .. 39 Where to find more information .. 40 Refusal of coverage .. 40 Explain enrollment 41 Explain effective dates .. 41 Tobacco 41 MoneyPlus enrollment .. 42 Effect of MoneyPlus on other retirement plans .. 42 Review MoneyPlus features .. 43 Health Savings Account enrollment .. 45 GEA TRICARE Supplement Plan enrollment.

3 46 Assisting a newly eligible variable-hour, part-time or seasonal employee .. 46 Assisting a permanent, part-time 47 Process for medical emergencies .. 48 National Medical Support 49 Rules and procedures for late entrants .. 50 Health plans .. 50 Dental .. 50 Vision care .. 50 Benefits Administrator Manual SCPEBA 122021 | Expires 12312022 3 Life insurance .. 50 Supplemental Long Term Disability .. 51 Changes in status and special eligibility 51 Gain of other group coverage .. 51 Gain of Medicare coverage .. 52 Gain of Medicaid coverage .. 52 Loss of other group coverage .. 53 Loss of TRICARE coverage .. 54 MoneyPlus change in status rules .. 54 Completing the enrollment for a change in status .. 55 Coverage changes for permanent, part-time teachers .. 55 Other coverage changes .. 56 Optional Life .. 56 Dependent Life .. 58 Supplemental Long Term Disability.

4 59 MoneyPlus .. 59 Health Savings Accounts (HSAs) .. 59 Beneficiary changes .. 60 Open enrollment for active subscribers .. 60 Dental coverage .. 61 Open enrollment procedures and helpful hints .. 61 New employees or transfers hired October 2-December 31 .. 61 Unpaid leave or reduction in hours .. 62 Employees with unpaid leave or reduction of hours .. 62 Premiums while on unpaid leave .. 63 SLTD and life insurance benefits while on unpaid 64 Continuing MoneyPlus while on unpaid leave .. 64 Continuing a Health Savings Account while on unpaid leave .. 65 Military leave .. 65 Family and Medical Leave Act (FMLA) .. 66 Workers compensation .. 67 Affordable Care Act reporting requirements .. 68 Transfers and terminations .. 69 Assisting a transferring employee .. 71 Benefits Administrator Manual SCPEBA 122021 | Expires 12312022 4 Transferring out (losing employer).

5 71 Transferring in (gaining employer) .. 72 Transfers new employer created or lateral transfer .. 75 Transfers dual employment .. 75 76 General rules for terminating active employees .. 76 Other termination information .. 77 Life insurance .. 77 Long term 77 MoneyPlus .. 77 Health Savings Account .. 78 Reinstating coverage after termination .. 78 Affordable Care Act reporting requirements .. 78 COBRA subscribers .. 79 What is COBRA? .. 81 Who is the COBRA administrator? .. 81 Required COBRA notices .. 81 Mailing requirements for all COBRA notices .. 81 Important note for National Medical Support Notices (NMSN) .. 82 Initial COBRA Notice .. 82 First required notice .. 82 60-day COBRA notification requirement for spouses and children .. 82 COBRA qualifying events and notices .. 82 Qualified beneficiaries .. 82 Second required notice .. 83 18-month COBRA qualifying events.

6 84 Procedures for determining COBRA eligibility .. 85 COBRA election period .. 86 COBRA Termination Notice .. 86 Third required notice .. 86 Other coverage may end COBRA eligibility .. 86 Initial premium payment period .. 87 Administrative fee for optional employers .. 88 Benefit changes .. 88 Benefits Administrator Manual SCPEBA 122021 | Expires 12312022 5 COBRA procedures for the Medical Spending Account .. 88 Procedures at termination .. 88 Affordable Care Act reporting requirements .. 89 COBRA quick reference .. 89 Retiree subscribers .. 90 Requirements for retiree insurance .. 92 Assisting an eligible retiree .. 92 Retiree packet information .. 92 Administrative information .. 92 Important retirement information .. 93 Health insurance .. 93 Dental insurance .. 94 Vision insurance .. 94 Life insurance .. 94 Long term 95 MoneyPlus .. 95 Health Savings Account.

7 96 Assisting a new retiree with enrollment .. 96 Completing the Retiree NOE .. 96 Changing coverage in retirement .. 96 Retiree returns to work .. 97 Life insurance .. 97 Medicare .. 97 Affordable Care Act reporting requirements .. 98 Survivors .. 99 General rules about survivor coverage .. 101 If survivor was not covered at the time of subscriber s death .. 101 If survivor was covered at the time of subscriber s death .. 101 Assisting a survivor .. 101 If the deceased was an active employee subscriber .. 101 Procedures to continue coverage as a survivor .. 102 Premium waiver rules .. 102 Premiums .. 103 Which SSN/BIN to use for claims .. 104 Benefits Administrator Manual SCPEBA 122021 | Expires 12312022 6 Optional Life benefits for survivors .. 104 When survivor coverage ends .. 104 Spouse .. 104 Gaining eligibility through participating employer .. 105 Children.

8 105 Spouses and children .. 106 Spouses: special eligibility requirements and changes in status .. 108 Both spouses employed by participating employers .. 108 Spouse is retiree subscriber .. 108 Marriage .. 108 Spouse of foreign national employee .. 109 Separated spouse .. 109 Former spouse/divorce .. 109 Death of covered spouse .. 110 Dependent Life-Spouse coverage .. 110 Eligibility requirements .. 110 Children: special eligibility requirements and changes in status .. 110 Child younger than age 26 .. 111 Incapacitated child .. 115 Child in full-time military service .. 116 Child turns age 26 .. 116 Dependent Life-Child coverage .. 116 Full-time students .. 116 Dependent Non-confinement Provision .. 117 Eligibility for MoneyPlus spending accounts .. 117 COBRA notification by subscriber required .. 117 Adoption Assistance Program .. 117 Adoption assistance is subject to taxes.

9 118 Disability subscribers .. 119 Training .. 121 Workplace Possibilities .. 121 Eligibility .. 121 Applying for disability benefits .. 121 Assisting a disabled employee .. 122 Benefits Administrator Manual SCPEBA 122021 | Expires 12312022 7 Optional Life .. 123 Basic Long Term Disability and Supplemental Long Term Disability .. 123 MoneyPlus .. 125 Claims and appeals .. 126 State Health Plan claims .. 128 Tips for filing claims .. 128 State Health Plan claims for services outside the .. 128 Coordination of benefits .. 128 Accident questionnaires .. 129 Other health/dental 129 Mental health and substance use claims .. 129 Dental Plus and Basic Dental claims .. 130 Tips for filing claims .. 130 State Vision Plan claims .. 130 In-network claims .. 130 Out-of-network claims .. 130 Denials and appeals .. 130 Life insurance claims .. 130 Submitting the claim.

10 131 Retirees .. 131 Claims payments .. 132 Accidental death benefit .. 132 Suicide .. 132 Other benefits .. 132 Dependent Life .. 133 Denials and appeals (Optional Life and Dependent Life).. 133 Long term disability claims .. 133 Basic Long Term Disability .. 133 Supplemental Long Term Disability .. 133 MoneyPlus claims and reimbursement .. 135 Medical Spending Account and Dependent Care Spending Account reimbursements .. 135 Health Savings Account reimbursements .. 137 Administrative or eligibility appeals .. 137 Appeals related to claims or authorization of benefits .. 139 Benefits Administrator Manual SCPEBA 122021 | Expires 12312022 8 Third-party claims administrators .. 139 Accounting and billing .. 141 General accounting rules .. 143 Collecting premiums for mid-month changes .. 143 Unpaid leave rules .. 143 Issuing credits .. 143 Retroactivity .. 143 Billing statements.