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2018 Benefits Eligibility State of Florida Employees and Retirees

Read this section to increase your understanding of the rules that govern this program, including important deadlines, changes allowed during the plan year, and dependent eligibility. We cover eligible state employees, retirees, surviving spouses, former employees who continue insurance through COBRA, and eligible dependents.

Employee Eligibility

To be eligible to participate in the State Group Insurance Program (program), you must be a full-time or part-time employee as defined in s.110.123(2)(c) and (f), Florida Statutes. Upon hire, your position or expected hours of service will determine if you are eligible to participate in the program.

  • Full-time – includes salaried career service and select exempt service/senior management service (SES/SMS) positions working 0.75 full-time equivalency (FTE) or more and Other Personal Services (OPS) employees expected to work an average of 30 or more hours per week. Employees in these positions are eligible to participate in all plans offered under the program upon hire (exception: OPS employees are not eligible for optional life).
  • Part-time – includes salaried career service and SES/SMS positions working less than 0.75 FTE. Employees in these positions are eligible to participate in all plans offered under the program upon hire but pay a pro-rated share of the health and life insurance employer premium based on the FTE plus their employee share.

OPS employees expected to work less than 30 hours per week on average are not eligible to participate in the program upon hire.

Seasonal – includes positions for which the customary annual employment is six months or less and begins each year at approximately the same time of year, such as summer or winter. Employees in these positions are not eligible to participate in the program upon hire.

Eligibility is determined at the point of hire, and eligibility for subsequent plan years is determined using a look-back measurement method. The look-back measurement method is based on IRS final regulations under the ACA. Its purpose is to provide greater predictability for eligibility determinations. Effective October 3, 2014, the State of Florida began using a 12-month look-back measurement method to determine who is a full-time employee for purposes of program eligibility.

The 12-month look-back measurement method involves three different periods:

1. Measurement Period – counts hours of service to determine eligibility     

a. New Hire Measurement Period

If you are not a full-time employee at the point of hire, your hours of service from the first day of the month followingyour date of hire to the last day of the twelfth month of employment will be measured.  

An example: Assume you are hired October 5, 2018, and you are not employed full time. Your i nitial measurement period will run from November 1, 2018, through October 31, 2019. 

If your hours worked during the new hire measurement period average 30 hours or more per week, you are eligible to enroll in the program with an effective date of December 1, 2019.  

b. Open Enrollment Measurement Period 

  • If you have been employed long enough to work through a full (12 months) measurement period, you are considered an ongoing employee. Your hours of service are measured during the open enrollment measurement period. This period runs from October 3 through the following October 2 of each year and will determine eligibility for the plan year that follows the measurement period.
  • If you are a new employee who is reasonably expected to work an average of 30 hours or more per week upon hire, you are eligible. Eligibility will continue until your hours are measured during the next or second (depending on your date of hire) open enrollment measurement period to determine eligibility for the next plan year.y
  • An example:Assume you are hired January 5, 2018, in an OPS position and are expected to work an average of at least 30 hours per week. You are eligible to enroll in the program at your point of hire and will continue program eligibility through December 31, 2019. You will then be measured on October 3, 2019, to determine your eligibility for the 2020 plan year. 

2. Stability Period – follows a measurement period. Your hours of service during the measurement period determine whether you are a full-time employee who is eligible for coverage during the stability period. As a general rule, your status as a full-time employee or a non-full-time employee is “locked in” for the stability period, regardless of how many hours you work during the stability period as long as you remain an employee of the State of Florida.  

There are exceptions to this general rule for employees who experience certain changes in employment status. For ongoing employees, the stability period lasts 12 consecutive months. Newly hired full-time employees may have a stability period longer than 12 months depending on their date of hire.

3.  Administrative Period – the time between the measurement period and the stability period when administrative tasks, such as determining eligibility for coverage and facilitating enrollment, are performed. If you are determined to be eligible, a benefits package showing your available options, costs and effective dates will be mailed to the mailing address on file in People First, the system of record.

Special rules apply when employees are rehired by the State of Florida. If you are an OPS employee who experiences a break in service of at least 13 weeks (26 weeks for employees of academic institutions), you will be treated as a new hire upon your return. If you return to state employment in fewer than 13 weeks (26 weeks for employees of academic institutions), you will automatically be enrolled in the plans you had before you left employment.

The rules for the look-back measurement method are very complex, and this is a general overview of how the rules work. More complex rules may apply to your situation. The State of Florida intends to follow the IRS final regulations (including any future guidance issued by the IRS) when administering the look-back measurement method. If you have any questions about this measurement method and how it applies to you, call the People First Service Center at 866-663-4735 weekdays from 8 a.m. to 6 p.m. Eastern time.

Retiree Eligibility

You are eligible to continue health and life insurance if you were a state officer or state employee and you:

1. Retire under a State of Florida retirement system or a state optional annuity or state retirement program or go on disability retirement under the State of Florida retirement system, as long as you were covered under health and life insurance at the time of your retirement and you begin receiving retirement benefits immediately after you retire; or

2 . Retire under the Florida Retirement System Investment Plan, and you

  • Meet the age and service requirements to qualify for normal retirement as set forth in s. 121.021(29), Florida Statutes; or have attained the age specified by s. 72(t)(2)(A)(i), Internal Revenue Code, and you have 6 years of creditable service; and
  • Take an immediate distribution; and
  • Maintained continuous coverage under the program from termination until receiving your distribution (you must contin-ue health insurance coverage through COBRA until you take your immediate distribution); or

3. Retired before January 1, 1976, under any state retirement system and you are not eligible to receive any Social Security benefits.

If you do not continue health insurance coverage at retirement or drop retiree coverage after retiring, you will not be allowed to elect state health insurance at a later date as a retiree.

If you are a retiree that returns to active employment as a full-time equivalent (FTE) or other personnel services (OPS) employee and you are enrolled in health insurance coverage at the time of retirement, you will automatically be enrolled in active employee health insurance coverage. When you later terminate employment or return to retirement you will be allowed to continue retiree coverage, provided you have had continuous coverage under the program.

To learn more, see the benefits package for new retirees.

COBRA Eligibility

The Consolidated Omnibus Budget Reconciliation Act (COBRA) allows qualified participants to continue coverage of health, dental, and vision benefits through their employer’s group insurance plan for limited periods of time under certain circumstances, including the following:
  • Voluntary or involuntary job loss.
  • Reduction in hours worked.
  • Transition between jobs.
  • Death.
  • Divorce.
  • Other life events.
People First will mail a COBRA package to you or your dependents to your address on record in People First when one of these events is reported. COBRA enrollees pay the entire monthly premium plus a 2 percent administrative fee. You and/or your dependents lose eligibility for COBRA when you become eligible for other group insurance, including Medicare, or if you fail to pay the premium by the last day of the coverage month.

Dependent Eligibility 

The following dependents are eligible for coverage:

  • Your spouse – the person to whom you are legally married.
  • Your child – your biological child, child with a qualified medical support order, legally adopted child, or child placed in the home for the purpose of applicable state and federal laws through the end of the calendar year in which the child turns age 26.
  • Your stepchild – the child of your spouse for as long as you remain legally married to the child’s parent through the end of the calendar year in which the child turns age 26. 
  • Legal guardianship – a child for whom you have legal guardianship in accordance with an Order of Guardianship pursuant to applicable state or federal laws or a child for whom you are grant court-ordered temporary or other custody through the end of the calendar year in which the child turns age 26.
  • Your foster child – a child that has been placed in your home by the Department of Children and Families Foster Care Program or the foster care program of a licensed private agency through the end of the calendar year in which the child turns age 26.
  • Newborn child of a covered dependent (health insurance only) – a newborn child of an enrollee’s eligible child who is covered under state group health insurance at the time of the newborn child’s birth. Coverage ends at 18 months or when the parent of the child terminates coverage, whichever is earlier.
  • Eligible children of an enrollee’s surviving spouse through the end of the calendar year in which the child turns age 26.
  • Children of law enforcement, probation, or correctional officers who were killed in the line of duty and who are attending a college or university beyond their 18th birthday.
  • Children over the age of 26 with intellectual or physical disabilities if – 
          -They were enrolled before they turned 26 and remain covered or they were over the age of 26 at the time of the enrollee’s initial enrollment; and
          - They are incapable of self-sustaining employment because of the intellectual or physical disability; and
          -They are dependent on the enrollee for care and financial support.
  • Children between the ages of 26 and 30 (health insurance only) – eligibility begins the year after an eligible child turns 26 and ends on December 31 the year he or she turns 30. To be eligible and remain eligible, the child must be unmarried, have no dependents, not be enrolled in other health insurance coverage, and must either be a resident of Florida or be a full-time or part-time student.

NOTICE: As prohibited by the rules of the program, the following acts will be treated as fraud or misrepresentation of material fact:

  • Falsifying dependent information.
  • Falsely certifying ineligible persons as eligible.
  • Falsifying dependent documentation.
  • Falsely enrolling ineligible persons in coverage.yyFalsifying the occurrence of QSC events.
  • Falsifying QSC event documentation.

Such acts will require you to reimburse the plan for any fraudulent claims incurred or, if you’re still within the COBRA election window, for paying COBRA premiums for any months that ineligible persons were covered.

Dependent Eligibility Verification 

Dependent Eligibility Verification Audit. During the 2017 Legislative Session, the Florida Legislature directed the Division of State Group Insurance (DSGI) to conduct an audit to ensure that dependents covered under the State Group Insurance Program meet eligibility requirements. The audit will begin on December 1, 2017, and applies to nearly 93,000 subscribers with approximately 193,000 actively enrolled dependents.

What does this mean to me?  During the audit, you may be requested to provide documentation of your dependent(s) eligibility. It is important that you comply with any request from the audit vendor. If you do not send legible documents within the requested timeframe or if the documents provided do not support eligibility, insurance coverage will be terminated for the dependent(s).

What should I do now?  If you are covering an ineligible dependent, an amnesty period will occur now through November 30, 2017.  This means that if you remove ineligible dependents from coverage before December 1, 2017, you will be held harmless for past claims for the ineligible dependent(s). You may remove ineligible dependents at any time by calling People First at 866-663-4735 or online during Open Enrollment from October 16, 2017 through November 3, 2017.  

Where do I find more information?  More information will be provided in your Open Enrollment package which you will receive in October 2017. You may also visit the Dependent Eligibility Verification webpage. The webpage provides detailed descriptions of eligible dependents.
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