Ohio Administrative Code Title 3306 - School Employees Health Care Board
Overview of Title 3306: School Employees Health Care Board
Title 3306 of the Ohio Administrative Code (OAC) governs the School Employees Health Care Board (SEHCB), which is responsible for overseeing the health care benefits provided to school employees in Ohio. The SEHCB administers the health care plan for employees of public school districts, educational service centers, charter schools, and certain other educational institutions in the state.
The title outlines the regulations for the operation, governance, and administration of the SEHCB, which is tasked with ensuring that school employees have access to comprehensive, cost-effective health care benefits. This includes health insurance coverage, dental, vision, and other supplemental benefits.
Key Provisions and Articles in Title 3306
1. Article 3306-1 – General Provisions
This article sets out the structure, purpose, and mission of the School Employees Health Care Board:
Establishment of the SEHCB:
The School Employees Health Care Board was established to manage and oversee the health care benefits available to school employees in Ohio. It operates under the authority of the Ohio Revised Code (ORC) and is responsible for developing plans that meet the needs of educational staff while controlling costs.
Mission and Purpose:
The primary mission of the SEHCB is to ensure that school employees receive high-quality, affordable health care coverage. The Board develops health care benefit plans for school employees, negotiates rates with providers, and ensures compliance with state and federal health care regulations.
Definitions:
This section defines key terms related to the administration of health care benefits, such as "school employee," "health care coverage," "eligible dependents," "plan administrator," and "plan benefits." These definitions are essential for understanding the regulations and determining eligibility for various health care plans.
2. Article 3306-2 – Governance of the SEHCB
This article outlines the governance structure of the School Employees Health Care Board:
Composition of the SEHCB:
The SEHCB consists of appointed members, including representatives from school employers, school employee organizations, and the public. The Board's members are responsible for making decisions regarding plan designs, funding mechanisms, and the overall administration of health care benefits.
Board's Powers and Responsibilities:
The Board has broad powers to oversee the administration of the health care plan, including:
Setting premiums and cost-sharing structures for school employees and employers.
Evaluating and selecting health care providers and plan administrators.
Managing the plan’s financial sustainability and making adjustments to keep costs manageable.
Monitoring compliance with state and federal laws, such as the Affordable Care Act (ACA).
Developing and implementing benefit packages for employees, including medical, dental, vision, and mental health services.
Meetings and Decision-Making:
The SEHCB meets periodically to discuss the state of the health care plan, review proposals from providers, and make decisions about plan updates. Meetings are open to the public, and minutes are typically made available to ensure transparency.
3. Article 3306-3 – Health Care Plan Administration
This article outlines the administration and operation of health care benefits:
Health Care Coverage Options:
The SEHCB offers multiple health care plans to eligible school employees, which may include traditional health insurance, managed care plans, and health savings accounts (HSAs). The SEHCB evaluates and selects plans that best meet the needs of employees and their families while ensuring cost-effectiveness.
Eligibility Requirements:
To qualify for health care benefits through the SEHCB, school employees must meet specific eligibility requirements. These include:
Being employed full-time by a qualifying public school, charter school, or educational service center.
Completing the necessary enrollment forms and providing required documentation, such as proof of employment and dependent information.
Dependents Coverage:
School employees can enroll eligible dependents, such as spouses and children, in the health care plans offered through the SEHCB. The criteria for dependent eligibility align with the definitions under federal law and the specific regulations of the SEHCB.
Enrollment Periods:
The SEHCB establishes annual open enrollment periods during which employees can select or modify their health care plans. This period is typically set in the fall and allows employees to make changes to their coverage for the upcoming year.
Plan Management:
The SEHCB is responsible for selecting health insurance providers, negotiating terms and premiums, and ensuring the effective administration of all plans. The Board works with third-party administrators (TPAs) to manage claims processing, customer service, and network management.
4. Article 3306-4 – Funding and Premiums
This article addresses the funding and premium structures for the health care plans:
Premium Calculation and Payment:
Premiums for health care coverage are set by the SEHCB and are based on a variety of factors, including plan type, coverage level (individual vs. family), and the employee’s income or contribution level. The premiums may be shared between school employers and employees, with the specific split determined by the terms of the collective bargaining agreement or other governing agreements.
Cost-Sharing:
Employees typically share the cost of their health care coverage through premiums, deductibles, co-pays, and co-insurance. The SEHCB determines these cost-sharing structures in order to balance affordability for employees with the sustainability of the health care plan.
Funding of the Plan:
The SEHCB is responsible for ensuring that the health care plan is financially sustainable. This may involve establishing reserves to cover future health care costs, reviewing expenditures regularly, and adjusting premiums or benefits to maintain financial balance.
Employer Contributions:
In addition to employee contributions, school employers contribute to the cost of health care premiums. The Board sets guidelines for these contributions, which may vary by school district or educational institution based on their agreements with employees.
5. Article 3306-5 – Plan Benefits and Coverage
This article focuses on the benefits and coverage provided through the SEHCB:
Medical Benefits:
The SEHCB provides a range of medical benefits, including preventive care, doctor visits, emergency care, hospitalization, surgeries, prescription drugs, and mental health services. Coverage options and details about specific benefits are outlined for employees when they enroll in the plan.
Dental and Vision Coverage:
In addition to medical benefits, the SEHCB may offer dental and vision care coverage. This can include routine exams, cleanings, and services related to eye health, such as glasses or contact lenses.
Mental Health and Wellness:
Mental health services, including therapy, counseling, and substance abuse treatment, are often included in the health care benefits offered by the SEHCB. These services help support the emotional well-being of school employees.
Prescription Drug Coverage:
Prescription drugs are typically covered under the SEHCB’s health plans. Employees may have access to a formulary, which lists covered medications, and may pay varying amounts for medications depending on the tier and plan chosen.
Preventive and Wellness Services:
The SEHCB may provide coverage for preventive care, such as annual wellness exams, vaccinations, screenings for chronic conditions, and other services that support overall health and prevent illness.
Specialty Benefits:
Some plans may offer additional benefits such as maternity care, fertility treatment, chiropractic care, and other services designed to meet the diverse health care needs of school employees.
6. Article 3306-6 – Compliance and Reporting
This article outlines the compliance and reporting requirements for the SEHCB:
Legal Compliance:
The SEHCB must comply with all applicable federal and state laws, including the Affordable Care Act (ACA), Health Insurance Portability and Accountability Act (HIPAA), and other health care regulations that govern employee benefits. This includes ensuring that the health care plan meets minimum coverage requirements and reporting to relevant authorities.
Annual Reporting:
The SEHCB must provide annual reports detailing the health care plan’s financial status, including premium rates, claims costs, and utilization statistics. These reports are typically submitted to the Ohio Department of Education and other relevant oversight bodies.
Data Security and Privacy:
The SEHCB must adhere to privacy regulations, such as HIPAA, ensuring that sensitive health information about employees is protected from unauthorized access.
7. Article 3306-7 – Appeals and Dispute Resolution
This article outlines the appeals and dispute resolution processes:
Claims Disputes:
If a school employee believes a claim has been improperly processed or denied, they can file an appeal with the SEHCB. The appeals process provides a mechanism for reviewing claims and ensuring fair treatment under the health care plan.
Independent Appeals:
In some cases, employees may be able to request an independent review by an external party if they are dissatisfied with the initial outcome of their appeal.
Dispute Resolution Procedures:
The SEHCB establishes guidelines for resolving disputes between the Board and plan participants, including mediation, arbitration, or other resolution mechanisms.
Purpose and Goals of Title 3306
The primary goals of Title 3306 are:
Provide Affordable Health Care Benefits:
To ensure that school employees in Ohio have access to comprehensive, affordable health care coverage that meets their needs and protects their well-being.
Maintain Financial Sustainability:
To ensure that the health care plan is
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