8.21 – Group Medical Insurance

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Details

Scope: NMSU System

Source: ARP Chapter 8 | HR-Benefits

Rule Administrator:

Last Updated: 06/27/2016

Related

Cross-Reference:

Revision History:

2017 Recompilation, formerly Rule 7.15.05
06/27/16 Change in Benefits approved by Board of Regents
06/21/16 Change in Benefits approved by Chancellor
10/21/15 former Policy 7.15.05 replicated by Board of Regents Rule as initial 7.15.05
06/20/13 Amendment to Policy 7.15.05 approved by Board of Regents

A. Eligibility


The university offers group medical insurance for all eligible employees.

  1. Effective July 1, 2016, eligible employees are defined as those employees working at least .75 FTE in a regular, nine-month, or term appointment position.
  2. Optional dependent coverage is also available to eligible employees.
  3. Nine -month regular employees will receive full benefits, except for unemployment compensation, during the off employment period provided they return to employment the following academic year.
  4. Eligible employees also include any employee continuously enrolled in this benefit from June 30, 2016.
  5. Employees working in a position less than a .75 FTE; temporary employees; graduate assistants; other student employees; and Cooperative Extension Service employees with federal appointments are not eligible to participate in the group policy.

 

B. Effective Date of Coverage


Coverage is optional and is available from the date of eligible employment.  Coverage is effective the first pay period after 30 days of employment. Coverage may begin on the first or sixteenth day of the month. Employees must complete and return an enrollment form to the Office of Human Resource Services department within 31 calendar days of their regular date of employment to receive this benefit.

 

C. Enrollment Procedures


Coverage is not automatic.  Within the first 31 calendar days of employment, each eligible employee must either enroll in or waive coverage under the policy by completing an enrollment form.  Details of coverage and provisions of the medical plan are available in the plan Benefit Summary.

 

D. Premium Payments


Premium payments are made by payroll deduction.  The university pays a percentage of the premium for the employee and, if the employee’s dependents are enrolled in the plan, a percentage of their dependent premium also.  Premium payments begin the pay period in which coverage begins. Note: A full fiscal year of premiums (July-June) will be deducted over 18 paychecks (August – May) for 9 month faculty/staff.

 

E. Coverage Changes


An employee is responsible for requesting changes to insurance coverage by completing and submitting appropriate forms in order to adjust premiums.  When an employee experiences a change in status, the employee has 31 calendar days from the date of the status change to contact the Office of Human Resource Services to make coverage changes.

  1. A change in status includes, but is not limited to:
    1.  Marriage
    2. Divorce
    3. Childbirth or adoption
    4. Loss of prior coverage or gain of new coverage
    5. Dependent no longer meeting insurance eligibility rules due to age
  2. All status changes which result in an insurance coverage and/or premium change will be effective the day following the date of the change in status, except in the following cases:
    1. For a newborn or placement of child(ren) through adoption – the coverage becomes effective the date of birth or date of placement.
    2. For divorce or legal separation – the change is effective the day the legal documents are filed with the appropriate court.
    3. For dependent children who lose eligibility due to age – the change is effective at the end of the month in which the dependent reaches 26 years of age.
  3. All changes that affect premiums will result in a full premium being deducted for the pay period in which the change takes place.

 

F. Coverage during Disability


If any employee is terminated because of total disability, coverage may be continued in certain circumstances.  Refer to the COBRA section of the medical plan Benefit Booklet for details.

 

G. Coverage after Retirement


  1. Employees hired on or after July 1, 2016 are not eligible for the retiree health insurance benefit.
  2. An employee who was hired before July 1, 2016 and who officially retires from the university and receives a monthly benefit from the Educational Retirement Board immediately upon termination of employment (those eligible under the Alternative Retirement Plan must meet eligibility rules and immediately begin receiving a benefit) may elect to continue medical insurance after retirement, providing the employee had been covered under the plan for the prior 10 consecutive years and worked in a regular employment status.
  3. Time while enrolled as an employee or as a spouse of an active employee will be counted toward the 10 years, provided there is no gap in coverage during the 10 year period.
  4. Coverage as the spouse of a retiree will not be credited toward the 10 years.
  5. The university continues to pay a percentage of the premium. When a retiree or dependent becomes age 65 and/or eligible for Medicare, all medical coverage will be moved to the Medicare Carve-Out Plan, which includes a Medicare Part D prescription plan.  If the retiree or dependent enrolls in a Medicare Part D prescription plan outside the university retiree plan, they will no longer be eligible to access prescription or medical coverage through the retiree medical plan.
  6. The university reserves the right to unilaterally increase, decrease or discontinue coverages, plan provisions, and premiums.
  7. Details regarding coverage, eligibility and restrictions are available through the Office of Human Resources.

 

H. Dependent Coverage after Retirement


  1. Dependents of employees hired on or after July 1, 2016 are not eligible for the retiree health plan.
  2. The following rules shall apply with respect to dependents of retirees who are eligible for the retiree health insurance benefit described above:
    1. Spouses and dependent children of eligible retirees covered at the time of retirement may continue coverage after retirement.
    2. New spouses of retirees acquired after retirement may be added to the plan under certain circumstances. In order to add a new spouse, an enrollment form must be completed.  The new spouse may not be added until 1 year after the date of marriage; the retiree must still be living and have medical insurance coverage at the end of the 1 year waiting period and must enroll the new spouse within 31 days of the 1 year marriage anniversary.  New spouse coverage begins the first day of the month following the 1 year waiting period, provided the appropriate forms have been completed and received by Benefit Services.  There will be no university contributions to the new premium, and the retiree will be responsible for paying 100 percent of the premium for the new spouse’s coverage.  The new spouse will be eligible for surviving spouse benefits.
    3. New dependent children acquired after retirement may not be added to the plan, unless he child is a newborn or a newly adopted child.
    4. A retiree who rescinds retirement, returns to full-time employment, and later retires, may only continue coverage for dependent children who have been covered as a dependent for at least 10 years. Time covered under the retiree as an active employee will count toward the 10 years.
    5. If coverage is discontinued by the retiree for self or any covered dependent (including spouse), retiree and/or dependent may never re-enroll.
    6. Surviving spouse of a deceased retiree may continue coverage until re-marriage if he/she pays 100 percent of the premium.
    7. Surviving dependent children of a deceased retiree may continue coverage until they no longer meet the rule of a dependent child under the medical plan by paying 100 percent of the premium. If coverage is terminated or dependents are removed from the plan for any reason, enrollment in the plan at a later date is prohibited.

 

I. Coverage during Leave without Pay (LWOP)


During periods of leave without pay, medical insurance may be continued at the option of the employee.

  1. Continued coverage will not exceed the length of time agreed upon with the individual vendor agreements.
  2. Arrangements for timely payment of premiums must be made with the Office of Human Resource Services and the Office of University Accounts Receivable. If the employee is on LWOP for a full pay period the employee is responsible for both the university’s and employee’s portions of premium (except FMLA LWOP, Professional LWOP and Educational LWOP).
  3. Failure to make full payment of premiums may result in cancellation of coverage. If coverage is not continued or is cancelled during any leave without pay period, the employee will be required to re-apply for coverage through the open enrollment process or with a qualifying event.  This does not apply if the employee was approved for FMLA, in which case, the employee may be reinstated immediately upon return to work, provided the employee requests coverage from the Office of Human Resource Services within 31 days from the date of return.

 

J. Coverage after Termination (12-Month Faculty and Staff)


Coverage ceases at midnight on the 15th day of the month if employment terminates between the 1st and 15th day of the month, provided the applicable premium for the pay period has been paid.  If an employee terminates employment between the 16th and last day of the month, coverage ceases at midnight on the last day of the month, provided the applicable premium for the pay period has been paid.  The policy contains continuance in compliance with state and federal law.  Complete information on these procedures is available in the Office of Human Resource Services.

 

K. Coverage after Termination (9-Month Faculty and Staff)


When employees or faculty members do not return the next academic year, only dental and medical coverage will remain in effect until June 30th. All other insurances stop at the end of the pay period in which their regular employment ends. See the health insurance carrier’s Benefit Booklet for details.

 

L. Medical Plan Provisions


Details on the medical plan provisions are contained in the medical insurance carrier’s Benefit Booklet.