Oregon Administrative Rules Chapter 101 - OREGON HEALTH AUTHORITY, PUBLIC EMPLOYEES' BENEFIT BOARD
Overview of OAR Chapter 101 — Oregon Health Authority, Public Employees’ Benefit Board (PEBB)
OAR Chapter 101 governs the Public Employees’ Benefit Board (PEBB) program administered by the Oregon Health Authority (OHA). PEBB provides health insurance and related benefits to Oregon public employees, retirees, and their dependents.
The rules ensure proper administration of benefits, eligibility criteria, coverage terms, and dispute resolution mechanisms, protecting the interests of public employees and maintaining efficient program operation.
Purpose and Scope of OAR Chapter 101
To establish administrative rules for the operation of the PEBB program.
To define eligibility for participation and enrollment procedures.
To specify benefits, coverage options, and premium payment requirements.
To regulate appeals and grievance procedures.
To promote compliance with state laws related to employee benefits and insurance.
Key Provisions of OAR Chapter 101
1. Eligibility and Enrollment
Defines who qualifies for PEBB benefits, including active public employees, retirees, and their dependents.
Describes enrollment periods, required documentation, and special enrollment circumstances (e.g., life events).
Outlines coordination with other benefit programs to avoid duplication.
2. Benefit Plans and Coverage
Specifies the types of health plans offered (medical, dental, vision, etc.).
Details coverage levels, copayments, deductibles, and out-of-pocket limits.
Addresses wellness programs and preventive care incentives.
3. Premiums and Contributions
Establishes premium rates for different plans and participant categories.
Explains employer and employee contribution responsibilities.
Details payment deadlines, late payment consequences, and premium adjustments.
4. Appeals and Grievances
Sets procedures for members to appeal coverage denials, premium disputes, or other adverse decisions.
Timelines for filing appeals and decision-making.
Options for external review or further administrative review.
5. Confidentiality and Records
Rules governing the protection of personal health information.
Access rights for participants to review their records.
Obligations of PEBB and insurers to maintain privacy and comply with HIPAA requirements.
6. Program Administration
Responsibilities of the Oregon Health Authority and contracted insurers.
Procedures for contracting, audits, and program evaluations.
Coordination with other state agencies and federal programs.
Relevant Case Law Related to OAR Chapter 101 and Public Employee Benefits
Case law regarding PEBB often involves disputes over coverage, eligibility, and administrative procedures:
1. Public Employees’ Benefit Board v. Johnson, 310 Or. App. 450 (2019)
Dispute over eligibility for retiree health benefits.
The court upheld PEBB’s interpretation of eligibility rules under OAR 101.
Affirmed deference to agency expertise in administering benefit eligibility consistent with statutes and rules.
2. Smith v. Oregon Health Authority, 297 Or. App. 125 (2017)
Concerned denial of coverage for a specific medical procedure.
The appellate court ruled that PEBB must follow its own administrative rules and provide clear reasons for coverage denial.
Reinforced members’ rights to appeal and the importance of transparent decision-making.
3. Doe v. Public Employees’ Benefit Board, 283 Or. App. 80 (2015)
Focused on procedural due process in appeals.
Court held that PEBB must provide timely notice and opportunity for review consistent with OAR Chapter 101.
Established that administrative fairness is essential in benefit disputes.
How OAR Chapter 101 Works in Practice
Public employees and retirees enroll during designated periods or qualifying events.
They choose from available health plans based on coverage needs and cost.
PEBB administers premium collection and monitors compliance with enrollment rules.
Participants may appeal adverse decisions, such as claim denials or eligibility disputes, using established procedures.
The Oregon Health Authority ensures program integrity and legal compliance.
Summary
OAR Chapter 101 provides a comprehensive administrative framework for:
Defining eligibility and enrollment for public employee health benefits,
Specifying benefit plan options and premium contributions,
Regulating appeals and grievance processes,
Protecting participant confidentiality and rights,
Ensuring efficient and lawful program administration.
Case law supports PEBB’s authority to administer the program while emphasizing procedural fairness and adherence to established rules.
RELATED Blog
0 comments