ODS. Healthcare from your head to your toes.

Eligibility

What happens if I lose coverage and regain it later during the year?
How are newborns added to the plan?
What is the dependent stop age for OEBB?
How will ODS handle students or dependents living out of the service area?
How does ODS handle disabled, over age dependents?
Are dependents on active military duty eligible?
Does the OEBB contract cover domestic partners?
Are there any retiree benefits available?
If a member is an active employee and his or her spouse turns 65, is the spouse eligible to stay on the OEBB active plans?
If a member is an active employee and his or her domestic partner turns 65, is the domestic partner eligible to stay on the OEBB active plans?
If a member is an active employee and his or her domestic partner gains Medicare on the basis of a disability, is the domestic partner eligible to stay on the OEBB active plans?
If a member is an OEBB early retiree and he or she goes back to work as an “active” employee, will ODS coordinate benefits between the active coverage and the retiree coverage?

What happens if I lose coverage and regain it later during the year?

The plan eligibility and enrollment rules are defined in divisions 15 and 40 of the OEBB Administrative Rules (OARs).

A lapse in coverage is defined as a break of more than 30 calendar days.

If an OEBB member transfers to a new district or moves to a different ODS plan within same district with no lapse in coverage then all accumulators for deductible, out-of-pocket, plan maximums and dental incentives will transfer to the new plan.
If an OEBB member transfers to a new district or moves to a different ODS plan within same district with a break in coverage then all accumulators for deductible, out-of-pocket, plan maximums and dental incentives will not transfer. The dental maximum will start over and the medical deductible and out-of-pocket will also need to be met again.

How are newborns added to the plan?

Newborns are covered on the plan in accordance with OEBB OAR 111-040-0001. An enrollment form for the addition of a newborn child of an eligible employee or a family member must be furnished to OEBB within 60 days from the date of birth and members must contact their school district to complete the necessary paperwork. When ODS receives the eligibility information from OEBB, any pending claims can be processed.

Addition of the newborn may result in an increase in premium, depending on the current family structure.

What is the dependent stop age for OEBB?

The dependent stop age is 26. Coverage ends the last day of the month of the child’s 26th birthday.

How will ODS handle students or dependents living out of the service area?

If a student or dependent lives outside of the ODS Plus Network service area, the OEBB employee must notify ODS Customer Service prior to the dependent seeking services. The dependent will be placed in an out-of-area status beginning the 1st day of the month following notification.

ODS will extend plan benefits for treatment of an illness or injury, preventive healthcare (including routine physicals and immunizations) and maternity services, as if the care were rendered by in-network physicians or providers. Members are encouraged to see an ODS Travel Network provider in order to avoid balance billing for amounts above the maximum plan allowance. Fees charged by non Travel Network out-of-area physicians and providers of care will be reimbursed at the maximum plan allowance for those services.

How does ODS handle disabled, over age dependents?

Disabled dependents are covered in accordance with OEBB OAR 111-010-0015. If a member has a child or dependent who has sustained a disability rendering him or her physically or mentally incapable of self-support, that child may be eligible for coverage even though he or she is over the dependent stop age. To be eligible, the child must be unmarried and principally dependent on the member for support. The incapacity must have arisen before the child’s 26th birthday. The member must provide ODS with a written physician’s statement confirming that these conditions existed continuously prior to the child’s 26th birthday. Documentation of the child’s medical condition must be reviewed and approved by the ODS medical consultant. Periodic review by the medical consultant also will be required on an ongoing basis.

Disabled children who live in group homes or other facilities, who are still dependent on their parents for support, continue to be eligible for benefits past age 26 if they meet the disability criteria.

ODS will continue to provide coverage as long as the member remains on an ODS plan and the dependent meets the appropriate criteria.

Are dependents on active military duty eligible?

Effective September 23, 2010, dependents under 26 on full-time, active duty in the United States military are eligible. This policy also applies to individuals in the reserve components serving on active duty or full-time training duty. Note that the plan does not cover treatment of any condition caused by or arising out of service in the armed forces of any country or from an insurrection or war.

Does the OEBB contract cover domestic partners?

Registered domestic partners are eligible for coverage. An unregistered domestic partner is eligible for coverage if he or she complies with the Domestic Partner Affidavit provided by the participating district.

Please note: Some participating districts may not offer unregistered domestic partner coverage. Check with your participating district to determine what domestic partner coverage is available.

Are there any retiree benefits available?

Yes. Eligible retired employees and their dependents enrolled in an OEBB benefit plan for active employees can continue participation in any OEBB retiree medical and dental insurance plan or plans available to their Employee Group until becoming eligible for Medicare. The exception is when a member has End Stage Renal Disease (ESRD), in which case the member can remain covered under OEBB’s early retiree plan for 30 months after diagnosed or until age 65.

If a dependent is covered under Medicare and a retiree plan, the member must sign up for Medicare parts A and B. Medicare will be the primary coverage, and ODS will be the secondary coverage. If a member does not sign up for parts A and B, ODS will still pay secondary and estimate the amounts that Medicare would have paid had the member signed up for Medicare.

If a retiree becomes eligible for Medicare coverage, but his or her currently-enrolled eligible dependents are not, these eligible dependents may continue OEBB medical and dental insurance coverage until they no longer meet OEBB eligibility requirements or become eligible for Medicare coverage themselves, whichever occurs first. The eligible individuals must submit an application for enrollment to the retiree plan administrator within 60 days of the retiree’s eligibility for Medicare.

Retirees can continue dental coverage under OEBB beyond age 65 if their former employer allowed retirees to continue dental coverage without being enrolled in a retiree medical plan. Their dependents who are no longer eligible to stay on the OEBB medical plans because of Medicare eligibility also can continue with OEBB dental coverage. This does not apply to vision coverage.

If a member is an active employee and his or her spouse turns 65, is the spouse eligible to stay on the OEBB active plans?

Yes. If a member is actively working (not a retiree) and either the member or his or her spouse turn 65, both are eligible to stay on the active OEBB plans. In this scenario, OEBB coverage would be primary over any Medicare coverage (unless End Stage Renal Disease is applicable, in which case Medicare would be primary after 30 months of eligibility or entitlement to Medicare).

If a member is an active employee and his or her domestic partner turns 65, is the domestic partner eligible to stay on the OEBB active plans?

Yes, however it is important to understand that the primary/secondary payer rules change. Per Medicare, if a domestic partner is entitled to Medicare on the basis of age (turning age 65) and has group health plan coverage based on the current employment status of his/her partner, Medicare is the primary payer of services. The OEBB active coverage pays secondary to Medicare.

If a member is an active employee and his or her domestic partner gains Medicare on the basis of a disability, is the domestic partner eligible to stay on the OEBB active plans?

Yes, the domestic partner is eligible to remain on the OEBB plans. Per Medicare, when the domestic partner is entitled to Medicare on the basis of disability and covered by a large group health plan on the basis of his/her own current employment status or that of a family member (A domestic partner is considered a family member), Medicare is generally a secondary payer. This means that the active OEBB coverage is the primary payer of services and Medicare is secondary.

If a member is an OEBB early retiree and he or she goes back to work as an “active” employee, will ODS coordinate benefits between the active coverage and the retiree coverage?

Yes. The active coverage would be primary, and the retiree coverage would be in the secondary position.