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 31 calendar days.

• If an OEBB member transfers to a new district or moves to a different Moda Health plan within same the 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 Moda Health plan within same the 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.

Newborns are covered on the plan in accordance with OAR 111-040-0001. An enrollment form for the addition of a newborn child of an eligible employee must be furnished to OEBB within 60 days from the date of birth. Members will need to contact their entity to complete the necessary paperwork. When Moda Health 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.

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

If a student or dependent lives outside of the service area, the OEBB member must update the dependent’s address in the MyOEBB system 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.

Moda Health will extend plan benefits for out-of-area status dependents 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 a Moda Health 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 based on the maximum plan allowance for those services.

Dependents enrolled on a Synergy or Summit plan offering residing within the state of Oregon but outside of their plan's network service area should use a Connexus network provider. They will be responsible for using their pre-selected Medical Home provider when they return to the Synergy or Summit service area.

Disabled dependents are covered in accordance with 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 Moda Health 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 Moda Health 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.

Moda Health will continue to provide coverage as long as the member remains on a Moda Health plan and the dependent meets the appropriate criteria.

Dependents under age 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.

Yes; domestic partners by affidavit and same sex domestic partners that have entered into a "Declaration of Domestic Partnership" that is recognized under Oregon law are eligible for coverage. A domestic partner by affidavit is eligible for coverage if he or she complies with criteria in OAR 111-010-0015 and returns a signed and completed Domestic Partner Affidavit to their entity.

Please note: Some participating districts may not offer opposite sex domestic partner coverage. Check with your entity to determine what domestic partner coverage is 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 Moda Health will be the secondary coverage. If a member does not sign up for parts A and B, Moda Health 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.

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).

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. Domestic Partners who become eligible for Medicare should elect Medicare part B coverage.

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.

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