§ 135-45.4. Effective dates of coverage.

NORTH CAROLINA STATUTES AND CODES

§ 135-45.4. Effective dates of coverage.

§ 135‑45.4. Effectivedates of coverage.

(a) Employees andRetired Employees.

(1) Employees andretired employees covered under the Predecessor Plan will continue to becovered, subject to the terms hereof.

(2) Employees notenrolling or not adding dependents when first eligible may enroll later on thefirst of any following month, but will be subject to a twelve‑monthwaiting period for preexisting conditions except as provided in subdivision(a)(3) of this section. The waiting period under this subdivision is subject toapplicable federal law.

(3) Employees notenrolling or adding dependents when first eligible in accordance with G.S. 135‑45.3may enroll later on the first of any following month but will be subject to a12‑month waiting period for a preexisting health condition, exceptemployees who elect to change their coverage in accordance with rules adoptedby the Executive Administrator and Board of Trustees for optional alternativeplans offered under the Plan.

(4) Members of theGeneral Assembly, beginning with the 1985 Session, shall become first eligiblewith the convening of each Session of the General Assembly, regardless of aMember's service during previous Sessions. Members and their dependentsenrolled when first eligible after the convening of each Session of the GeneralAssembly will not be subject to any waiting periods for preexisting healthconditions. Members of the 1983 Session of the General Assembly, not alreadyenrolled, shall be eligible to enroll themselves and their dependents on orbefore October 1, 1983, without being subject to any waiting periods forpreexisting health conditions.

(b) Waiting Periods andPreexisting Conditions.

(1) New employees anddependents enrolling when first eligible are subject to no waiting period forpreexisting conditions under the Plan.

(3) Retiring employeesand dependents enrolled when first eligible after an employee's retirement aresubject to no waiting period for preexisting conditions under the Plan.Retiring employees not enrolled or not adding dependents when first eligibleafter an employee's retirement may enroll later on the first of any followingmonth, but will be subject to a 12‑month waiting period for preexistingconditions except as provided in subdivision (a)(3) of this section.

(4) Employees anddependents enrolling or reenrolling within 12 months after a termination ofenrollment or employment that were not enrolled at the time of this previoustermination, regardless of the employing units involved, shall not beconsidered as newly‑eligible employees or dependents for the purposes ofwaiting periods and preexisting conditions. Employees and dependentstransferring from optional prepaid alternative plans available under the Plan;employees and dependents immediately returning to service from an employingunit's approved periods of leave without pay for illness, injury, educationalimprovement, workers' compensation, parental duties, or for military reasons;employees and dependents immediately returning to service from a reduction inan employing unit's work force; retiring employees and dependents reenrolled inaccordance with G.S. 135‑45.4(b)(3); formerly‑enrolled dependentsreenrolling as eligible employees; formerly‑enrolled employeesreenrolling as eligible dependents; and employees and dependents reenrolledwithout waiting periods and preexisting conditions under specific rules adoptedby the Executive Administrator and Board of Trustees in the best interests ofthe Plan shall not be considered reenrollments for the purpose of thissubdivision. Furthermore, employees accepting permanent, full‑timeappointments who had previously worked in a part‑time or temporaryposition and their qualified dependents shall not be covered by waiting periodsand preexisting conditions under this division provided enrollment as apermanent, full‑time employee is made when the employee and hisdependents are first eligible to enroll.

(5) To administer the 12‑monthwaiting period for preexisting conditions under this that Article, the Planmust give credit against the 12‑month period for the time a person wascovered under a previous plan if the previous plan's coverage was continuous toa date not more than 63 days before the effective date of coverage. As used inthis subdivision, a "previous plan" means any policy, certificate,contract, or any other arrangement provided by any accident and health insurer,any hospital or medical service corporation, any health maintenanceorganization, any preferred provider organization, any multiple employerwelfare arrangement, any self‑insured health benefit arrangement, anygovernmental health benefit or health care plan or program, or any other healthbenefit arrangement. Waiting periods for preexisting conditions administeredunder this Article are subject to applicable federal law.

(1) Dependents ofemployees and retired employees who have family coverage under the PredecessorPlan will continue to be covered subject to the terms hereof.

(2) Employees who havedependents may apply for family coverage at the time they enroll as provided insubdivisions (a)(2) and (a)(3) of this section and such dependents will becovered under the Plan beginning the same date as such employees.

(3) Employees andretired employees may change from one category of coverage to a differentcategory of coverage without a waiting period for preexisting conditions, and,as applicable, dependents will be covered under the Plan the first of the monthor the first of the second month following the dependent's eligibility forcoverage, provided written application is submitted to the Health BenefitsRepresentative within 30 days of becoming eligible.

(4) Employees or retiredemployees who wish to change to employee only coverage shall give writtennotice to their Health Benefits Representative within 30 days after any changein the status of dependents, (resulting from death, divorce, etc.) that requiresa change in contract category. The effective date will be the first of themonth following the dependent's ineligibility event. If notification was notmade within the 30 days following the dependent's ineligibility event, thedependent will be retroactively removed the first of the month following thedependent's ineligibility event, and the coverage category change will be thefirst of the month following written notification, except in cases of death, inwhich case the coverage category change will be made retroactive to the firstof the month following the death.

(5) Employees not addingdependents when first eligible may enroll later on the first of any followingmonth, but dependents will be subject to a 12‑month waiting period forpreexisting health conditions except as provided in subdivision (a)(3) of thissection.

(6) Employees or retiredemployees who wish to change to employee only coverage even though theirdependents continue to be eligible, shall give written notification to theirHealth Benefits Representative. Except as otherwise required by applicablefederal law, the date of this category change will be the first of the monthfollowing written notification or any first of the month thereafter as desiredby the employee.

(7) The effective datefor newborns or adopted children will be date of birth, date of adoption, orplacement with adoptive parent provided member is currently covered underemployee and family or employee and child coverage. If the member wishes to adda newborn or adopted child and is currently enrolled in employee only coverage,the member must submit application for coverage and a coverage type changewithin 30 days of the child's birth or date of adoption or placement. Effectivedate for the coverage category change is the first of the month in which thechild is born, adopted, or placed. Adopted children may also be covered thefirst of the month following placement or adoption.

(d) Categories ofCoverage Available. There are four categories of coverage which an employeeor retiree may elect.

(1) Employee Only. Coversenrolled employees only. Maternity benefits are provided to employee only.

(2) Employee and Child. Covers enrolled employee and all eligible dependent children. Maternitybenefits are provided to the employee only.

(3) Employee and Family. Covers employee and spouse, and all eligible dependent children. Maternitybenefits are provided to employee or enrolled spouse.

(4) Employee and spouse.Covers employee and spouse only. Maternity benefits are provided to theemployee or the employee's enrolled spouse.

(e) Notwithstanding anyother provision of this section, no coverage under the Plan shall becomeeffective prior to the payment of premiums required by the Plan.

(f) Firefighters,rescue squad workers, and members of the National Guard are subject to the sameterms and conditions of this section as are employees. Eligible dependents offirefighters, rescue squad workers, and members of the National Guard aresubject to the same terms and conditions of this section as are dependents ofemployees.

(g) Differentcategories of coverage may be offered for optional alternative plans orprograms.

(h) If any provision ofthis section is in conflict with applicable federal law, federal law shallcontrol to the extent of the conflict. (1981 (Reg. Sess., 1982), c. 1398, s. 6; 1983, c.499; c. 761, ss. 252‑255; c. 867, s. 4; c. 922, s. 5; 1985, c. 400, ss.5, 6; 1985 (Reg. Sess., 1986), c. 1020, ss. 5(b), 20; 1987, c. 857, s. 13;1991, c. 427, ss. 10‑12; 1996, 2nd Ex. Sess., c. 18, s. 28.23(b); 1997‑512,ss. 28‑31, 40; 1999‑237, s. 28.29(g); 2007‑323, s. 28.22A(h);2008‑168, ss. 1(a), 3(a), (h); 2009‑16, ss. 3(d), 5(a); 2009‑281,s. 1.)