Appendix_7_6_RFP_31786-00186_Eligibility_Criteria_REVISED.pdf

Appendix 7.6 RFP 31786-00186

Provision Description Eligibility Criteria STATE

Employee:

1) An individual employed by the employer who is regularly scheduled to work not less than thirty (30) hours per week;

2) An individual who has received a seasonal appointment and who meets the requirements set forth in TCA 8-27-204(a)(3); or

3) All other individuals required by applicable state or federal law.

Participation Requirements

Employee participation in the State Sponsored Group Basic Health Program is not required to participate in the State Group Disability Insurance Plan. Participation by those enrolled in the State Group Disability Insurance Plan is on a calendar year basis.

Transfer from Prior Contract(s)

Members enrolled in Short-term disability plan at the end of the prior contract shall be automatically enrolled in this Short-term disability plan, subject to the award of the new contract, if premiums are current and the individual does not make a change during the State’s Annual Enrollment Period or other defined election period.

Central state government and state higher education members enrolled in Long-term disability at the end of the prior contract shall be automatically enrolled in this Long-term disability plan (LTD-N), subject to the award of the new contract. State offline agency members enrolled in Long-term disability at the end of the prior contract shall be automatically enrolled in this Long-term disability plan (LTD-C), subject to the award of the new contract, if premiums are current and the member does not make a change during the State’s Annual Enrollment Period or other defined election period.

Members in an elimination period or receiving claim benefits from the prior contractor shall remain enrolled with the prior contractor until the end of claim benefits and the Member returns to active work with the State. At the time the Member returns to active work with the State, the Member shall be automatically enrolled in the State Long Term Disability Insurance Plan (enrollment in LTD-N for central state government and state higher education employees) and enrollment in LTD-C for state offline agency employees) and given the opportunity to enroll in the Short Term Disability Insurance Program without medical underwriting.

Mid-Year Enrollment An eligible central state government or, state higher education or state offline Employee experiencing one of the events below may apply for new enrollment in the Short-term disability plan.

The Employee must submit medical evidence of insurability to the Contractor for review. An eligible state offline employee experiencing one of the events below may also apply for new enrollment in the Long-term disability plan and medical evidence of insurability is not required.

Without regard to the dates or circumstances on which an individual would otherwise be able to enroll in this Disability Plan, central state government and, state higher education and state offline Employees, as defined in this Eligibility Criteria, are permitted to enroll in short-term disability coverage (and state offline employees can enroll in long-term disability coverage) under this Disability Plan if the Employee meets one of the conditions stated in Section A or B below:

(A) Loss of Eligibility for Other Coverage.

(1) An Employee, otherwise eligible to enroll in this disability benefit plan, may be enrolled through this Mid-Year Enrollment provision, provided that they:

(a) Declined coverage in a state-sponsored disability insurance plan when it was previously offered during their initial eligibility period, or during a subsequent Annual Enrollment Period;

(b) Had coverage under any group disability insurance plan at the time the state-sponsored coverage was previously offered; and

(c) Experience a loss of eligibility for the other disability insurance coverage for reasons including the following (but not for a failure to pay premiums or termination for cause):

•Death;

•Divorce;

•Legal separation;

•Cessation of Dependent status;

•Termination of employment (voluntary and non-voluntary);

•Employer’s discontinuation of contribution to insurance coverage (total contribution, not partial);

•Reduction in number of work hours of employment;

(2) If an Employee satisfies all three requirements of A(1) above, the Employee is eligible for Mid-Year Enrollment to this Disability Plan.

(3) All Mid-Year Enrollment requests due to Loss of Eligibility for Other Coverage and required supporting documentation must be submitted to and received by ABC/BA within sixty (60) calendar days of the loss of eligibility for other coverage.

(4) The effective date of coverage due to Loss of Eligibility for Other Coverage shall be according to the section “Coverage Start Date for Mid-Year Enrollments” below.

(B) Acquisition of New Dependents.

(1) When an Employee acquires a new Dependent by marriage, birth, adoption, or placement for adoption, the Employee may be enrolled by Mid-Year Enrollment.

(2) All enrollment applications based upon the acquisition of a new Dependent and required supporting documentation must be submitted to and received by ABC/BA within sixty (60) calendar days of the acquisition date.

(3) The effective date of coverage for a Mid-Year Enrollment for acquiring a new Dependent shall be according to the section “Coverage Start Date for Mid-Year Enrollments” below.

(4) Substantiation of Acquiring a New Dependent. If requesting enrollment based on acquiring a new Dependent, the Employee/Retiree must submit appropriate documentation as listed on the enrollment application to substantiate the following:

• The date of birth of a child;

• The date of the adoption or the order placing the child in custody for adoption;

• The date of guardianship specified by the order granting guardianship and requiring financial support and insurance coverage;

• The date of marriage

Coverage Start Date for Mid- Year Enrollments

For any amount for which Employee is not required to give evidence of insurability, such insurance will take effect on the first day of the month following the date of the request, if the Employee is Actively at Work on that date.

For any amount for which Employee is required to give evidence of insurability and Contractor determines that

Employee is insurable, such insurance will take effect as follows:

• the first day of the calendar month following the date Contractor states in Writing, if approved prior to the 15th day of the month and if Employee is Actively at Work on that date, or

• the first day of the second calendar month following the date Contractor states in Writing, if approved on or after the 15 th day of the month and if Employee is Actively at Work on that date.

Underwriting

Guaranteed

Issue

Underwritten

Enrollment in the STD or LTD insurance plan shall be guaranteed issue by the Contractor without medical underwriting to:

1) Eligible central state government and, state higher education and state offline Employees employed on and after January 1, 2027, who enroll in the Short-term disability program within thirty (30) days of the employee’s hire date.

2) Eligible central state government and state higher education Employees who are automatically enrolled in long-term disability (LTD-N) on and after January 1, 2027.

3) Eligible state offline agency Employees who enroll in long-term disability (LTD-C) on and after January 1, 2027, within thirty (30) days of the employee’s hire date

Enrollment in Short-term disability shall occur if the applicant is approved by the Contractor based upon medical underwriting criteria for:

Eligible employees who did not enroll within thirty (30) days of the employee’s hire date

a. Eligible employees applying during a Mid-Year enrollment period; or

b. Eligible employees applying during the State’s annual enrollment.

Cancellation Central state government and, state higher education and state offline Members may cancel short-term disability coverage during the annual enrollment period for the beginning of the next calendar year or at any time during the year by submitting a notice 30-days in advance of the desired cancellation date.

State offline Members may cancel long-term disability coverage (LTD-C) during the annual enrollment period for the beginning of the next calendar year or at any time during the year by submitting a notice 30-days in advance of the desired cancellation date.