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Eligibility

Eligibility Requirements


Following are the requirements for employee eligibility of insurance:

  • The employee must be employed with Laurens County School District 55 in a permanent and full-time basis working 30 or more hours per week.

  • Part-time employees may be eligible based on their position.
  • The employee must complete appropriate election forms within 31 days of the date of employment or status change.
  • Enrollment deadline is 31 days from the hire date.  

 Effective Date

  • Coverage of the state health plan begins on the first day of the following month after the hire date of employee.   
  • Example: Hired on January 12, 2016, coverage begins February 1, 2016.

Open Enrollment is held each year in October for a January 1st benefit effective date. Please note that the dental plan is only available during open enrollment in odd-numbered years for a January 1st benefit effective date.

  • Spouse and children younger than 26 are - eligible dependents may be added to coverage
  • No pre-existing conditions for health plans

State Standard Health Plan and Savings Plan

  • Worldwide access to network hospitals/physicians through the Blue Card Program.

Making Changes to Insurance Program

  • Eligible employees may make certain changes to benefits during designated enrollment periods and within 31 days of a family status change or special eligibility situation. 

Special Eligibility Situations

Click here for the Special Eligibility Situations Quick Reference - The quick reference describes changes subscribers can make when a special eligibility situation occurs. Unless otherwise noted, all changes must be made within 31 days of the event. 

Marriage - If you, as a covered subscriber, wish to add a spouse because you marry, you can do so by completing an NOE and submitting a copy of your marriage license within 31 days of the date of your marriage. You may enroll yourself and your spouse and eligible children/stepchildren to your health, dental, vision and life insurance by submitting a completed Notice of Election form and proper documentation of dependent eligibility to your benefits office. You may also enroll in or increase your Optional Life by up to $50,000 and enroll in or change contributions to Medical or Dependent Care Spending account.
   

A subscriber can enroll his spouse, without medical evidence, in $10,000 or $20,000 in Dependent Life-Spouse coverage with 31 days of the marriage. Subscribers can also enroll eligible dependent children in Dependent Life-Child coverage within 31 days of the marriage.

Legal Separation - If you and your covered spouse separate, your spouse may remain on your health, Dental/Dental Plus, State Vision Plan and Dependent Life-Spouse coverage until the divorce is final.

If you do not participate in the MoneyPlus pretax premium feature, you can remove your spouse from your coverage when you separate. If you remove your spouse from one of these programs: health, dental or vision coverage, you must also remove him from the other two programs.

Divorce - If you divorce, you must remove your spouse and former stepchildren from your coverage by completing an NOE and submitting a complete copy of the divorce decree within 31 days of the date stamped on the divorce decree. Coverage for your divorced spouse and former stepchildren will end the last day of the month after the divorce decree is stamped. If you fail to drop your divorced spouse or former stepchildren within 31 days of the date the court order or divorce decree is stamped by the court, the change in coverage is effective the first of the month after your signature on the NOE dropping your former dependents.

Adding Children - Eligible children may be added by completing an NOE within 31 days of the qualifying event.

  • Date of birth (effective on date of birth)
  • Marriage of the subscriber to the child’s parent (effective on the date the marriage)
  • Adoption or placement for adoption (effective on the date of adoption or placement for adoption)
  • Placement of a foster child (effective on the date of placement)
  • Loss of other coverage (effective on the date of loss of coverage)
  • The Health Insurance Portability and Accountability Act (HIPAA) requires SC PEBA Insurance Benefits to notify you of a very important provision in its health insurance plan. You have the right to enroll in SC PEBA Insurance Benefits health insurance plans under its “special enrollment provision” if you acquire a new dependent or if you decline coverage under SC PEBA Insurance Benefits’ health insurance plans for yourself or an eligible dependent while other coverage is in effect and later lose that other coverage for certain qualifying reasons. The newly eligible child must be offered health, Dental/Dental Plus and State Vision Plan coverage. The subscriber and all other previously enrolled family members may change health plans. A child who is eligible, but not newly eligible, cannot be added at this time. However, a spouse may be added.  

Appeals - If you are dissatisfied after an eligibility determination has been made, you may ask SC PEBA Insurance Benefits to review the decision.

  • If you are an employee, a Request for Review should be submitted through your benefits office. Your BA may write a letter or use the Request for Review form, which is available online at the SC PEBA Insurance Benefits website. If the request is denied, you may appeal by writing to the SC PEBA Insurance Benefits Appeals Committee within 90 days of notice of the decision.
Health Insurance Cards 

Tobacco User Certification

  • Tobacco User Certification Form 
  • Enrolling in a health plan will require certification as a tobacco or non-tobacco user. If only the employee is enrolled and use tobacco, there will be an additional $40 per month surcharge added to the health premium. If dependents are covered (even if only one out of the group uses tobacco), an additional $60 per month surcharge will be added to the health premium.

Transferring Employee

Enrolling as a Transferring Employee

  • As an active employee, SC PEBA Insurance Benefits considers you a transfer if you change employment from one participating group to another with no break in insurance coverage or with a break of employment of no more than 15 calendar days.
  • A transfer is not a new hire for insurance purposes.  The employee must remain enrolled in the same insurance benefits in which he/she was enrolled at the former employer.

Additional information

  • Members are encouraged to notify Medi-Call during the first trimester of a pregnancy and to participate in the Maternity Management Program; however, the State Health Plan no longer financially penalizes a member for failure to do so. Please note that members are required to pre-authorize any hospital admission.  This includes hospitalization related to having a baby.  Failure to do so will result in the insured being financially penalized,  For details, see the 2019 Insurance Benefits Guide.
 

 

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