Eligibility

WAITING PERIOD
You and your Dependents (see Definitions) are eligible for coverage as specified under 'Waiting Period" in the "Definitions" chapter.

OPEN ENROLLMENT PERIOD
Certain provisions of your Open Enrollment Period may be modified by your particular School District. If you have Open Enrollment Period questions, contact your School District’s business or personnel office.

Each component employer may allow eligible employees to enter the Plan during an annual open enrollment period. This period shall be from November 1 through November 30 and become effective the following January 1, unless the employer has notified the Consortium that an alternate time period has been selected and has been communicated to its employees.

An individual entering the Plan during the open enrollment period shall not be considered a late enrollee.

EMPLOYEE ELIGIBILITY
Minimum requirements for determination of eligibility shall be established by each individual district and BOCES subject to the following:

An individual who is employed by more than one participating employer shall only be allowed to enroll under one employer.

DEPENDENT ELIGIBILITY
Subject to all conditions of the term "Dependent” as defined in the "Definitions" section, the following section provides additional guidance:

A. Spouse means an individual to whom the employee is legally married in accordance with the laws of the state of residence; effective July 1, 2005, same-sex only domestic partners may be covered. Please refer to Appendix C for the Plan’s domestic partner policy

B. An unmarried child under 19 years of age must be dependent upon his parent(s) for at least 50% of the child's support and maintenance.

C. An unmarried child 19 years of age or older but under 25 years of age and who is a full time student at an accredited secondary or preparatory school, college, university or other educational institution must be dependent upon his parent(s) for at least 50% or more of the child's support and maintenance.
Time spent in service with a branch of the United States military, not to exceed 4 years, may be deducted from the age of a student dependent in determining his eligibility for enrollment.

D. With the exception of an employee's natural born children, adoptive children, proposed adoptive children or stepchildren, the dependent must reside permanently in the employee's home. Residence of a temporary nature or limited duration, as in the case of an exchange student, is not sufficient to provide eligibility for coverage.

E. An enrolled dependent child who reaches age 19 and whose birthday occurs during the summer vacation following graduation from high school shall continue to be covered if it is anticipated that he will be enrolled in an accredited educational institution as a full-time student at the end of the vacation
period.

F. A handicapped child as defined under "Dependent” in the "Definitions" section.

G. Any person who does not specifically meet one of the criteria outlined in this section shall not be an eligible dependent.

H. Any person who is on active duty in the armed forces of any country shall not be an eligible dependent

DECLINATION OF HEALTH BENEFITS
An individual who declines coverage at the time he initially becomes eligible or declines coverage during the annual enrollment period, shall be required to wait until the next Open Enrollment Period Effective Date to become covered under the Plan. This shall include, but not be limited to, an employee who declines coverage in favor of an employee’s "buy out" option or to avoid paying the employee's share of the health benefits premium.

Certain changes in your status may enable you to enroll in the Plan at times other than the annual open enrollment period. Where an employee, retiree or dependent rejected initial enrollment in the Plan, he may later enroll if each of the following conditions are met:

The employee, retiree or dependent was covered under another plan at the time coverage was initially offered, and;

Eligibility for coverage was lost and coverage was terminated for one of the following reasons:

• continuation coverage required by Federal or State law was exhausted; or
• termination of employment; or
• death of the spouse; or
• legal separation, divorce or annulment; or
• reduction in the number of hours of employment; or
• contract holder (e.g. employer) contributions toward the payment of premium for the other plan were terminated.

Coverage must be applied for within 30 days of termination.

EMPLOYEE COVERAGE
If an employee applies for enrollment within one month of the date of FIRST eligibility, the employee's coverage may become effective on the first day of the month following the month in which the employee applies for coverage.

A. If an employee requests that coverage begin on the first date of employment, the employer may, at its discretion, comply with the employee's request provided the employee applies for coverage on or before the date of employment.

B. The participating employer may, at its discretion, also require the employee to satisfy a period of employment before coverage for the employee and any eligible dependents becomes effective; however, this employment period must be applied on a uniform basis for all new employees and may not exceed six months. The effective date of coverage will be the first day of the month following the month during which the employee satisfies the required period of employment. An employee who is hired on, or otherwise acquires eligibility on, the first day of a month may count that month in establishing his effective date of coverage.

An employee who fails to apply for enrollment during the one month period following the date of his first eligibility must then wait for the annual enrollment period to apply for coverage.

DEPENDENT COVERAGE

A. If an employee applies for Family coverage at the same time as Individual coverage, the effective date of Family coverage will be the same as the employee's.

B. If an employee applies for Family coverage within 31 days of the date an eligible dependent is first acquired; the effective date of Family coverage will be the first day of the month following the month in which Family coverage is requested. If the request is made on the first day of the month and is within
31 days of acquiring the dependent, then coverage may become effective that day.

1. If this change is due to marriage and the employee requests that Family coverage begins on the date of marriage, the employer may comply with the employee's request provided application is made on or before the date of marriage.

2. If this change is due to the birth or adoption of a child and the employee requests that Family coverage begins on the date of birth or adoption, the employer shall comply with the employee's request provided application is made within 31 days of the date of birth or adoption.

C. If an employee who has only Individual coverage requests a change to Family coverage more than 31 days after the acquisition of an eligible dependent, then the employee must wait until the annual enrollment period to apply for Family coverage; however, if the new dependent is a newborn infant, then coverage shall become effective from the date the employer is notified of the birth or adoption.

D. If an employee who has family coverage requests to add an additional dependent more than 31 days after acquisition of the new dependent, coverage shall become effective no earlier than the first day of the calendar month following the month in which the request is made.

LOSS OF ELIGIBILITY BY STUDENT DEPENDENTS

A. In the event of a student’s graduation, coverage will be terminated on the last day of the month in which graduation takes place.

B. In the event of a student dependent’s marriage, coverage will cease on the date of marriage. Please refer to the section titled, “Continuation of Coverage (COBRA) and Extended Benefits”.

C. In the event that a student loses eligibility because of his parent’s loss of eligibility, the student’s coverage will cease at the time the parent’s coverage ceases. Please refer to the section titled, “Continuation of Coverage (COBRA) and Extended Benefits”.

D. In the event that a student (without military service) attains age 25, his coverage shall cease on the last day of the month in which he reaches age 25. Please refer to the section titled, “Continuation of Coverage (COBRA) and Extended Benefits”.

In the event that a student has had his eligibility extended by virtue of military service, coverage will cease on the last day of such extension unless eligibility ceases at an earlier date for one of the above reasons.

E. Medical Leave of Absence: In the event that a student is granted a medical leave by his educational institution, coverage may be extended for a maximum of one (1) year from the month in which the student withdraws from classes, plus any time before the start of the next regular semester. The Consortium must be notified within sixty (60) days of the leave commencing. Adequate documentation shall be required.

F. If a student drops out midterm for any reason other than a medical leave of absence, coverage shall cease on the date of withdrawal from classes. Please refer to the section titled, “Continuation of Coverage (COBRA) and Extended Benefits”.

CHANGES FROM FAMILY COVERAGE

A. An enrollee may change from Family coverage to Individual coverage at any time. Adjustment of the employer’s and employee's contribution toward the cost of coverage shall not take effect until the first day of the month following the month of the request to change to Individual coverage.

B. If, and only if, the sole dependent of an enrollee is also an eligible employee or retiree of a participating employer, but not already covered as an employee or retiree, Family coverage may be changed to two Individual coverages. This coverage change shall take effect on the first day of the month following the
month of the change request.

C. If the spouse of an employee enrolled for Family coverage is also an employee or retiree of a participating employer, but not already covered as an employee or retiree, enrollment may be transferred from the currently enrolled spouse to the dependent spouse only during the annual, open enrollment period.

RETIREMENT

A. An employee or retiree of a participating employer is eligible to continue coverage in retirement if he:

1. has had at least ten (10) years of full-time service, not necessarily continuous, with the employer from which he is retiring; (An employer may, at its discretion, reduce the required number of years necessary to be eligible for coverage in retirement); and

2. has vested for benefits from a retirement system administered by the State of New York; and

3. is at least 55 years of age.

B. An employee or retiree is also eligible to continue coverage during retirement, regardless of age or length of service with the participating employer, if granted a service connected disability retirement by a retirement or pension plan or system administered and operated by the State of New York due to an injury, illness or disease that resulted from his service with the participating employer.

C. Employees who have qualified for Social Security disability payments are considered to be retired for health benefits purposes, regardless of age, provided that they have had at least 10 years of service with the participating employer. Proof of Social Security status will be required.

DEATH OF ENROLLEE - SURVIVOR COVERAGE

A. In the event of the death of an employee or retiree enrolled for Individual coverage, coverage will terminate on the date of death.

B. In the event of the death of an employee or retiree enrolled for Family coverage, the coverage of any surviving dependents must be continued in accordance with the Federal COBRA continuation coverage rules. The employer shall make a contribution toward the cost of this coverage, for a period of at least 3 months, at the same percentage the employer had been making immediately preceding the death of the employee. After 3 months, the full cost of coverage shall be paid by the surviving spouse or dependents, unless the participating employer establishes administratively or through contract negotiations, a contribution less than 100% for surviving spouses and/or dependents.

1. If the deceased employee or retiree was enrolled for Family coverage and had completed ten (10 years of active service or as an employee having had completed the years of service required to
become eligible for vesting in the Teachers’ Retirement System or Employees’ Retirement System prior to death, then the spouse of the deceased employee may continue coverage as long as the spouse remains unmarried and dependent children may continue coverage for as long as the children would have been eligible had the enrollee lived. The surviving spouse and/or dependents shall pay the full cost of coverage (i.e. the employer’s and employee's share). A participating
employer may choose to reduce the above ten (10) year requirement. In addition, a participating employer may share in the cost of the surviving spouse's and/or dependent’s coverage.

2. Regardless of the length of service, if the death of an active employee enrolled for Family coverage results from a work incurred injury, the surviving dependents may be eligible to continue coverage
as dependent survivors. To be eligible, the survivors must be entitled to accidental death benefits payable by a retirement system or pension plan administered by the state or civil division thereof, or to death benefits provided under the Worker's Compensation law. The surviving spouse and/or dependents shall pay the full cost of coverage (i.e. the employer’s and employee's share).

C. To enroll as a surviving dependent or spouse, the spouse or dependent must inform the business or personnel office of the applicable employer within 90 days of the employee's death. No application made after the 90 day period will be accepted. Since application must be made while coverage is still in effect, the dependent survivor(s) will retain the enrollee's original effective date of coverage.

D. The survivor(s) will be issued new identification cards containing the name of the surviving spouse. If there is no spouse and only dependent children are being enrolled, the name of the oldest child will be entered on the card.

E. When the dependent survivors are required to pay the full cost of coverage and only one or two survivors are eligible to continue health benefits, one or two Individual enrollments can be established rather than a Family enrollment. If there are three or more survivors and a Family enrollment is established, a change to two Individual enrollments can be subsequently established at any time if only two of these survivors continue to be eligible.

VESTING FOR BENEFITS

A. Employees who terminate their employment before age (55) may continue their health benefits if they have;

1. satisfied the minimum requirements established by their retirement system for vesting receipt of their retirement allowance (this need not be done officially); and

2. met the minimum requirements of the employer, other than age, for continuation of health benefits into retirement; and

3. terminated employment within five (5) years of the date on which they (a) are entitled to receive a retirement allowance or (b) become age fifty five (55).

B. Eligible employees who wish to continue coverage as enrollees in the program during vested status, must pay both the employer and employee share of the cost of coverage (i.e. the full cost of coverage) from the date their employment terminates until the date they become eligible to receive a retirement allowance from an approved retirement system. After that date, they are only responsible for the retiree's share of payments, if any. All required payments by vestees must be made to the employer where they were formerly employed.

C. Vestees, who wish to continue coverage into their retirement, must continue health insurance coverage as an enrollee or as a dependent of an enrollee while in vested status. This may include coverage as the spouse of an enrollee of a participating employer different than that of the vestee. Further, if the vestee maintains continuity of coverage as a dependent of an enrollee, he may continue vestee status beyond that date that he initially becomes eligible to receive a retirement allowance from an approved retirement system. A vestee whose coverage lapses will not be permitted to reinstate coverage, either during vested status or after retirement.

D. Once an employee has established eligibility to continue health benefits coverage as a vestee through one participating employer, that eligibility shall not be impaired by subsequent employment and/or enrollment through another participating employer, except when the employee establishes eligibility for
coverage as a vestee or retiree through the second, or subsequent employer.