Rule 478-2-.04. Eligibility

1. (1) Active State Employees. Employees who are actively at work, on approved leave with pay other than personal sickness or disability, or on suspension with pay may participate in the Flexible Benefit Plan if the employee is a regular full-time employee who works a minimum of thirty (30) hours per week and whose duties are expected to require at least nine (9) months of service. Contingent workers of the Labor Department, employees who are working on a temporary, seasonal, or intermittent basis, and employees working in sheltered workshop operated by a county family and children services, mental health subdivisions or other employing entities are not eligible to participate in the Program. Eligible employees are as follows:

   1. (a) a member of the General Assembly or a full-time employee of the General Assembly;
   2. (b) a person who works full time and receives his or her compensation in a direct payment from a state department, agency, community service board, authority, or institution of State government, exclusive of the Board of Regents of the University System of Georgia;
   3. (c) a person who works full time and receives his compensation from a county department of family and children services or a county department of health;

2. (2) Active Educational System Employees. Active Educational System Employees include a member of any local board of education, public school teachers and public school employees as defined in Georgia Official Code Annotated Sections 20-2-880 and 20-2-910. Employees, who are not considered temporary or emergency employees, and who are actively at work or on approved leave with pay, other than sick or disability, may participate in the Flexible Benefit Plan if the employee receives pay from one of the educational institutions that has elected to participate in the Plan and who meets the work requirements, as follows:

   1. (a) Persons serving in a certificated position and who work at least 17.5 hours per week;
   2. (b) Employees who work at least 17.5 hours per week for a county or regional library;
   3. (c) Persons serving a non-certificated position and who work at least 20 hours per week or 60% of the time normally required for these positions, if that's more than 20 hours per week; and
   4. (d) Persons eligible for the Public School Employees Retirement System and who work at least fifteen (15) hours per week or 60% of the time normally required for these positions. if that is more than fifteen (15) hours per week, and
   5. (e) Any person, other than an employee in a professionally certified capacity ort position, employed not less than half time and compensated in a charter school in this state established pursuant to either Article 31 or Article 31A of Title 20, Chapter 2 of the Official Code of Georgia Annotated, if such charter school elects to participate in the flexible benefit plan upon initial approval of its charter or, if such charter school is an existing charter school, upon renewal of its charter.
3. (3) Employees on Leave without Pay. Active employees who are eligible to participate in the Flexible Benefits Program may continue all insurance options in which enrolled by paying the required after-tax premium during a period of "approved leave of absence without pay" for a period up to twelve (12) months, subject to the conditions in these regulations. An employee will be considered to have one (1) continuous period of leave without pay if the employee returns to work for a period of time, and fails to have three (3) or more consecutive payroll deductions or reductions during the return to work.
4. (4) Employees on Suspension without Pay. Employees who are eligible to participate in the Flexible Benefits Program may continue all insurance options in which enrolled by paying the require d after tax premiums during a period of "suspension without pay" for a period of up to twelve (12) months, subject to the conditions in these regulations.
5. (5) Employees on Military Leave. Military leave is the period of time during which an employee is ordered to military duty or the period, as provided by law, during which an employee is attending military training. Employees who are eligible to participate in the Flexible Benefits Program may continue the coverages and options, consistent with policy and contractual limitations of each benefit option. If payroll deductions are not applicable, the employee shall remit the premiums and contributions to the Third-Party Administrator through the direct bill process.
6. (6) Employees on Military Reservist Activation Leave. Military Reservist Activation Leave is the period of time during which an employee is activated on an emergency basis. Employees who are eligible to participate in the Flexible Benefits Program may continue the coverages and options, consistent with policy and contractual limitations of each benefit option. If payroll deductions are not applicable, the employee shall remit the premiums and contributions to the Third-Party Administrator through the direct bill process.

7. (7) Employees on Reduced Working Hours Due to a Disability. Employees who are eligible to participate in the Flexible Benefits Program, but due to disability are placed on reduced working hours by the employing entity, may continue the options for which enrolled by paying the required after-tax premiums during the period of reduced working hours. The premium payments for coverage shall not exceed twelve (12) calendar months, and will be subject to the following condition:

   1. (a) Notification to the Employing Entity. The employing entity shall require documentation as necessary to provide certification that the employee is physically or mentally incapable of working the required hours to be considered full-time.
   2. (b) Documentation and Approval. Appropriate documentation may include but is not limited to certification from a qualified medical practitioner that outlines the disability and the timeframe for which the employee is required to remain on reduced working hours. The employing entity may require periodic recertification of the disabling condition and circumstances in order to substantiate the period of coverage continuation. The employing entity shall notify the Third-Party Administrator of the employee's approval for reduced working hours.
8. (8) Spouse. An Active Employee shall be entitled to enroll the Employee's spouse upon employment, during open enrollment, or Qualifying Life Event.
9. (9) Dependent Child. An Active Employee shall be entitled to enroll eligible dependent children upon employment, during Open Enrollment, or Qualifying Life Event.

10. (10) Disabled Dependents. Dependent children who are disabled before age 26, and incapable of self-sustaining employment by reason of mental incapacity or physical disability, are eligible for coverage if:

    1. (a) The disabled child is already a participant and turning age 26. To maintain eligibility, the employee must submit documentation of the disability within 31 days of the child reaching age 26; or
    2. (b) The child was disabled before age 26 and is enrolling as a newly eligible dependent. The employee must provide proof of the child's disability and submit the DOAS/HRA Disabled Dependent Certification Form within 31 days of enrollment in order for the disabled dependent child to enroll in flexible benefits.
    3. (c) Active employees may enroll their disabled dependents who were disabled prior to age 26 during Open Enrollment if they submit the proof of the disability within 31 days of the enrollment.
    4. (d) The completion and approval of the disability certification with the State Health Benefit Plan does not satisfy the requirements for the Flexible Benefits Plan Disability certification process.

11. (11) Dependent Verification. The Plan shall require each Participant wishing to add a Dependent to coverage to affirm their Dependency status and show proof of Dependent status.

    1. (a) Dependency status shall be verified at the following times:

       1. i. At initial enrollment in the Plan;
       2. ii. During any Qualifying Life Event;
       3. iii. During each open enrollment period (but if Participant is merely continuing to cover a current Dependent(s) then affirmation that such Dependent continues to be a Dependent shall be sufficient; and
       4. iv. During any Dependent Verification audit as determined by the Administrator.
    2. (b) The completion and approval of the Dependent Verification audit with the State Health Benefit Plan does not satisfy the Flexible Benefits Plan Dependent Verification process.

12. (12) Retired Employees Enrolled in the Dental Option. Employees who were eligible to participate and were enrolled as an active employee in the dental option of the Flexible Benefits Program at the time of retirement on or after April 1, 1997, shall be eligible to continue the dental coverage and option in which enrolled if:

    1. (a) The employee is eligible to immediately receive an annuity from the Employees Retirement System, Legislative Retirement System, Teachers Retirement System, Public School Employees Retirement System, or the Judicial Retirement System.
    2. (b) A retired employee shall be entitled to continue dental coverage for the spouse upon Retirement, provided the spouse was enrolled in dental coverage prior to the employee's retirement.
13. (13) Surviving Spouse of an Employee Enrolled in a Dental Option. The surviving spouse of a deceased employee may continue dental coverage provided the spouse is immediately eligible to receive a monthly benefit from the Employees Retirement System, Legislative Retirement System, Teachers Retirement System, Public School Employees Retirement System, or the Judicial Retirement System. The spouse may elect coverage as a surviving spouse, or if an active employee, through payroll reduction but cannot elect double or dual coverage under this provision.

14. (14) Surviving Spouse of a Retired Employee Enrolled in a Dental Option. The surviving spouse of a retired employee may continue dental coverage provided the retired employee and spouse were enrolled in the dental option and the spouse is immediately eligible to receive a monthly benefit from the Employees Retirement System, Legislative Retirement System, Teachers Retirement System, Public School Employees Retirement System, or the Judicial Retirement System.

    1. (a) Restrictions on Surviving Spouse. The spouse may elect coverage as a surviving spouse, or if an active employee, through payroll reduction, but cannot elect double or dual coverage under this provision.
    2. (b) Surviving Eligible Dependent Children. The surviving spouse may elect to continue coverage for surviving eligible dependent children already enrolled in the dental option.
15. (15) Continuation of Coverage for a Dependent Child of a Deceased Employee. Upon the death of an active or retired employee, an eligible dependent child who was covered under the family dental coverage and is the principal beneficiary under one of the retirement systems may continue coverage consistent with these regulations and the insurance contracts. The dependent child may not be covered under this provision if he or she is a covered dependent child under another active or retired employee, or is eligible as an active employee.
16. (16) Extended Beneficiaries. Persons who meet the definition of Extended Beneficiaries are eligible to participate in the dental and vision options and health care flexible spending account by paying the required after tax premiums or contributions as established by the Council.

17. (17) Judicial Reinstatement of Employees. Employees who were eligible to participate in the Flexible Benefits Program who are reinstated to employment by the State Personnel Board or the judiciary shall have coverage reinstated for themselves and any eligible dependents in accordance with the following:

    1. (a) If the employment reinstatement occurs within twelve (12) months of discharge and back-pay for continuous employment is awarded, all retroactive premiums for the insurance options must be collected and claims incurred during the period may be filed for processing. Retroactive contributions for the health care flexible spending account may be waived by the Administrator; retroactive contributions for dependent care flexible spending account are not to be made.
    2. (b) If the employment reinstatement occurs following a period longer than twelve (12) months after discharge and back-pay for continuous employment is awarded, coverage for the employee and previously covered dependents will be reinstated upon the employee's return to work or in accordance with judicial review. Medical underwriting and late entrant penalties will not apply for any reinstated coverages.
    3. (c) If employment reinstatement occurs either within or in excess of twelve (12) months of discharge and retroactive pay is not awarded, coverage may be reinstated with the employee's return to work. Medical underwriting and late entrant penalties will not apply for any reinstated coverages.

Authority: O.C.G.A. §§ 45-18-50, 45-18-52(a), 45-18-54.

History. Original Rule entitled "Eligibility" was filed on September 25, 1986; having become effective August 6, 1986, as specified by the Board.

Amended: F. Jan. 29, 1991; eff. July 1, 1990, as specified by the Board.

Amended: F. Feb. 14, 1991; eff. Jan. 10, 1991, as specified by the Board.

Amended: F. Apr. 22, 1997; eff. Apr. 9, 1997, as specified by the Board.

Amended: F. Nov. 15, 2005; eff. Oct. 26, 2005, as specified by the Board.

Amended: F. Mar. 11, 2026; eff. Feb. 3, 2026, as specified by the Board.