16-001259 Clay A. Tidwell vs. Department Of Management Services, Division Of State Group Insurance Status: Closed Recommended Order on Tuesday, May 24, 2016.

Summary: Petitioner did not prove by a preponderance of the evidence that he was entitled to change his dental benefit election during the 2016 plan year without a qualifying status change event.

STATE OF FLORIDA

DIVISION OF ADMINISTRATIVE HEARINGS

CLAY A. TIDWELL,

Petitioner,

vs. Case No. 16 - 1259

DEPARTMENT OF MANAGEMENT

SERVICES, DIVISION OF STATE

GROUP INSURANCE,

Respondent.

_______________________________/

RECOMMENDED O RDER

A formal hearing was held in this case on May 4, 2016, in

Tallahassee, Florida, before Administrative Law Judge Suzanne

Van Wyk of the Division of Administrative Hearings.

APPEARANCES

For Petitioner: Clay Allen Tidwell, pro se

1577 Cinnamon Bear Circle

Tallahassee, Florida 32311

For Respondent: Gavin D. Burgess, Esquire

Department of Management Services

4050 Esplanade Way, Suite 160

Tallahassee, Florida 32399 - 0950

STATEMENT OF THE ISSUE

The issue in this procee ding is whether Petitioner is

entitled to change his dental benefit election in the State

Group Insurance Program for the 2016 plan year.

PRELIMINARY STATEMENT

In a letter dated February 2, 2016, Respondent notified

Petitioner that it had rejected his req uest to change his dental

insurance coverage for the 2016 plan year without a Qualifying

Status Change (QSC) e vent. 1/ In relevant part, the

correspondence provided:

I am writing to let you know that the

Division of State Group Insurance (DSGI) has

made a determination regarding your Level II

Appeal. You are requesting to change your

dental insurance coverage.

In response to your appeal, DSGI requested

detailed information and records from the

People First Service Center, including call

notes. We reviewe d those call notes and

other documentation, along with your letter

and information.

The State Group Health Insurance Plan rules

governing the plan, specifically Rule 60P -

6.0068, Florida Administrative Code, states

that an election made under the Pretax

Pr emium Plan shall be irrevocable during the

Plan Year except when a participant

experiences a Qualifying Status Change (QSC)

event. These rules and section 125 of the

Internal Revenue Code, which applies to

pretax benefit plans, limit our ability to

allow enrollment or coverage changes.

After carefully reviewing your appeal

documents and based upon the facts above, we

must deny your Level II Appeal because you

have not experienced a QSC event that would

allow you to change your dental benefits at

this ti me.

Dissatisfied with RespondentÓs decision, Petitioner timely

requested a formal administrative hearing. On March 3, 2016,

Respondent referred the matter to the Division of Administrative

Hearings (the Division) to assign an A dministrative L aw J udge t o

conduct the final hearing.

The final hearing was held on May 4, 2016, during which

Petitioner testified on his own behalf and introduced the

testimony of Alison Bonnell and Heather Cleary. PetitionerÓs

E xhibits P1 (composite) through P6 were admitted in evidence.

Respondent presented the test imony of Sandie Wade and

Dwayne Purifoy, and introduced E xhibits R1, R3, R4, and R6,

which were admitted in evidence. The undersigned granted

RespondentÓs Motion for Official Recognition of various rules

and statut es governing the State Group Insurance Program, as

well as orders of the Division and sections of the Internal

Revenue Code and the Code of Federal Regulations.

Although a court reporter was present during the final

hearing, no transcript of the proceedi ngs was ordered. Both

parties timely submitted Proposed Recommended Orders, which have

been considered in the preparation of this Recommended Order.

All references herein to the Florida Statutes are to the

2015 version.

FINDING S OF FACT

1. At all times relevant hereto, Petitioner was an

employee of the Department of Management Services (DMS) and was

a participant in the S tate G roup I nsurance P rogram. 2/ Petitioner

was enrolled in dental benefit coverage for the 2015 plan year.

2. Each year during open enrollment, program participants

m a y elect new benefits or change benefits for which they are

enrolled. Open enrollment usually occurs during a two - week

period in the fall of each year.

3. Benefits, including insurance plans, are administered

by a priva te contractor, Northgate Arinso, through an online

system known as ÐPeople First.Ñ

4. Petitioner intended to change his dental insurance

coverage during the open enrollment period for the 2016 plan

year.

5. On October 21, 2015, P etitioner logged on to the

People First website and viewed the ÐChange My BenefitsÑ screen.

Petitioner had researched the various coverages available well

in advance of enrollment, and knew he wanted to enroll in a

preferred provider plan offered by Humana. Petitioner found t he

plan he was seeking and selected ÐnextÑ from prompts on the

computer screen.

6. Petitioner remembers next selecting ÐconfirmÑ from the

screen prompts, and reported that the next, and last, computer

screen he saw was the People First home screen.

7. Petitioner did not review a confirmation of benefits

statement confirming his intended change in dental benefits.

8. Petitioner then viewed the page displaying his current

benefits, which showed the same dental coverage he had for the

2015 plan year.

9. Petitioner asked his co - worker, Alison Bonnell, when

the system would reflect his change in dental coverage, and she

replied that it would not change until January 2016.

10. Petitioner asked his supervisor, Heather Cleary, how

he could view the cha nge he had made. Ms. Cleary, who was new

to DMS, stated she did not know, but suggested Petitioner

contact human resources if he needed assistance.

11. Petitioner made no further inquiries regarding his

dental benefits until January 1, 2016, when he log ged in to

People First and viewed the ÐMy BenefitsÑ page, which showed the

same dental coverage in which he was enrolled for the 2015 plan

year.

12. Petitioner alleges that he effectively changed his

dental coverage for the 2016 plan year, but that, due to an

error in the People First system, his election was not saved.

Petitioner now seeks to change his dental benefit effective for

the 2016 plan year.

13. During open enrollment for the 2016 plan year, the

People First website required all eligible pa rticipants to first

complete a process verifying their mailing and email addresses,

then certifying their dependents.

14. Following completion of that confirmation and

verification process, the system presented participants with the

home screen from wh ich participants could choose from a number

of tabs, including ÐHealth & Insurance.Ñ The Health & Insurance

page provided the following options:

General Benefits Information

Go to the MyBenefits website for your

insurance options.

Your Benefits

Review your current and past benefits.

Insurance Companies

See contact information.

Your DependentsÓ Information

View and update dependentsÓ information.

Change My Benefits

Makes changes with a qualifying event.

Click here for open enrollment .

Benefit Premium History

Review your insurance payment history.

Benefits Materials

View and request insurance forms and

booklets.

Confirmation Statement

View your confirmation statement.

15. If a participant selected ÐChange My Benefits,Ñ the

participant was presente d with a screen to choose the event

triggering enrollment -- new hire or open enrollment. Selecting

Ðopen enrollmentÑ revealed an enrollment summary screen with a

chart listing the categories of Ðhealth,Ñ Ðbasic life,Ñ

Ðoptional life,Ñ Ðdental,Ñ and Ðvision Ñ coverage in the left -

hand column. If the participant was enrolled in one of the

options, the chart listed the name of the plan in which they are

enrolled in the middle column, and , in a column titled Ðmake a

change,Ñ the participant could select Ðcancel Ñ to cancel that

coverage. For all other options, the participant could select

ÐaddÑ in the Ðmake a changeÑ column to enroll in a plan.

16. If a participant selected the option to ÐaddÑ a plan,

they were navigated to a screen which displayed all the cho ices

for that type of coverage, in this case dental coverage. Once a

coverage plan was selected, the program prompted the participant

to Ðcomplete enrollment.Ñ

17. At the bottom of the enrollment summary screen,

participants were presented with the fo llowing statement:

By selecting ÐComplete Enrollment,Ñ I hereby

certify that the information entered is true

and correct and that all dependents listed

above are eligible. I understand that my

elections can only be changed during Open

Enrollment or as the result of a Qualifying

State Change event as defined by the

Internal Revenue Code and/or the Florida

Administrative Code. I agree to notify

People First of any QSC events within the

prescribed time frame and to supply the

appropriate supporting documenta tion upon

request; otherwise, any requested changes

will not be allowed. If any dependent is

determined to be ineligible or I fail to

notify People First of a loss of elibility

or any supporting documentation is not

provided upon request, I understand tha t I

may be liable for any and all claims paid

for any dependent deemed ineligible.

Following this statement was a box in which the participant must

enter his or her password and select ÐComplete Enrollment.Ñ

18. Upon selecting ÐComplete Enrollment,Ñ par ticipant s

w ere notified that a confirmation statement was available in the

People First system for his or her review. A participant must

have returned to the home screen and selected ÐConfirmation

StatementÑ to view the statement to confirm any change in his or

her elections.

19. Petitioner testified that he did not enter his People

First password to complete his enrollment on October 21, 2015.

Rather, Petitioner reported that, because he was redirected to

the People First home screen after selecting th e dental plan

option he was seeking, he was not prompted to complete his

enrollment.

20. Petitioner did not select the ÐConfirmation StatementÑ

tab and review any statements in the system for his account.

21. Petitioner did select the ÐMy BenefitsÑ tab , which

confirmed the same dental coverage which he had selected for the

2015 plan year.

22. Petitioner did not contact the People First service

center for assistance.

23. Dwayne Purifoy has served as operations manager for

Northgate Arinso for 12 year s. Mr. Purifoy oversees the

operation of the People First program.

24. Mr. Purifoy admitted that if the People First program

Ðtimed outÑ during the selection process, the participant would

not receive a notification to that affect, and any changes the

p articipant made would not be saved.

25. The People First program records participant

interactions with the system, including when a participant logs

in, views benefits, and changes benefits. The system record

shows that Petitioner logged in to the ÐChan ge My BenefitsÑ page

on October 21, 2015. The system does not contain a record that

Petitioner changed any of his selected benefits during the open

enrollment period.

26. The preponderance of the evidence supports a finding

that Petitioner, despite his intentions to the contrary, did not

complete a change to his dental benefit election under the S tate

G roup I nsurance Program for the 2016 plan year.

27. Petitioner did not experience any QSC event during the

2016 plan year.

CONCLUSIONS OF LAW

28. The Di vision has jurisdiction over the parties to and

subject matter of this cause, pursuant to section 120.57(1),

Florida Statutes.

29. Enrollment in the state group insurance program is

governed by Florida Administrative Code Rule 60P - 2.002(1), which

provide s:

(1) An employee or state officer may apply

for enrollment in the Health Program [3/] . . . .

(a) During the first sixty (60) calendar

days of state employment or a new term of

office;

(b) During open enrollment;

(c) Within thirty - one (31) days of a

[qualifying status change] of losing other

group health coverage;

(d) Within thirty - one (31) days of a

[qualifying status change] of an increase in

the number of work hours for an employee;

(e) Within thirty - one days prior to

termination of employment and before the

effective date of retirement.

30. Rule 60P - 6.0068 governs changes in participation by

program participants, and provides that Ð[a]n election made

under the Pretax Premium Plan shall be irrevocable during the

Plan Year except when a parti cipant experiences a [qualifying

status change] event.Ñ

31. Petitioner's sole contention in this proceeding is

that he utilized People First to change his dental benefit

election during the open enrollment period for the 2016 plan

year, but, due to an er ror in the program, his change was not

saved. As such, Petitioner requests Respondent immediately

enroll him in the Humana dental benefit plan in which he

intended to enroll.

32. As the party asserting the affirmative of the issue,

Petitioner bears th e burden of demonstrating, by a preponderance

of the evidence, that he took the required steps -- prior to the

expiration of the open enrollment period -- to make his

selections. See Fla. Dep't of Transp. v. J.W.C. Co., Inc. ,

396 So. 2d 7 78, 788 (Fla. 1st DCA 1981) (holding that Ðthe burden

of proof, apart from statute, is on the party asserting the

affirmative of an issue before an administrative tribunalÑ);

§ 120.57(1)(j) , Fla. Stat. (ÐFindings of fact shall be based

upon a preponderance of the evidence, exce pt in penal or

licensure disciplinary proceedings or except as otherwise

provided by statuteÑ); Gross v. Lyons , 763 So. 2d 276, 280 n.1

(Fla. 2000)(explaining that Ð[a] preponderance of the evidence

is defined as the greater weight of the evidence . . . or

evidence that more likely than not tends to prove a certain

propositionÑ)(internal quotations and citations omitted).

33. Pursuant to the F indings of F act contained herein,

Petitioner failed to demonstrate by a greater weight of the

evidence that he correctly utilized the People First system to

change his dental benefit for the 2016 plan year. Even if

Petitioner had proven that the People First system Ðtimed outÑ

while he was attempting to change his benefit election, that

would not support a find ing that Petitioner had successfully

completed the election change. It may not be fair that the

system would not have notified Petitioner of a Ðtime outÑ and

informed him that he needed to start over with his election

process. However, it is not a legal basis on which to require a

change in PetitionerÓs benefit election during the plan year

absent a QSC event.

34. Accordingly, the undersigned must recommend that

Respondent enter a final order denying Petitioner's request to

change his dental coverage election for the 2016 plan year.

35. As admitted by Petitioner at the final hearing, the

open enrollment period for the 2017 plan year is rapidly

approaching, and Petitioner may elect to change his dental

coverage at that time. See Fla. Admin. Code R. 6 0P - 2.002(1).

RECOMMENDATION

Based on the foregoing Findings of Fact and Conclusions of

Law, it is RECOMMENDED that the Department of Management

Services, Division of State Group Insurance, enter a final order

denying Petitioner's request to change his de ntal benefit

coverage in the State Group Insurance Program for the 2016 plan

year.

DONE AND ENTERED this 24th day of May , 2016 , in

Tallahassee, Leon County, Florida.

S

SUZANNE VAN WYK

Administrative Law Judge

Divis ion of Administrative Hearings

The DeSoto Building

1230 Apalachee Parkway

Tallahassee, Florida 32399 - 3060

(850) 488 - 9675

Fax Filing (850) 921 - 6847

www.doah.state.fl.us

Filed with the Clerk of the

Division of Administrative Hearings

this 24th day of May , 2016 .

ENDNOTE S

1/ A QSC event is a Ðchange in employment status, for subscriber

or spouse, family status or significant change in health

coverage of the employee or spouse attributable to the spouseÓs

employment.Ñ Fla. Admin. Code R. 60P - 1.003(17).

2/ Section 110.123, Florida Statutes, provides for the State

Group Insurance Program, a comprehensive package of health

insurance and retirement benefits provided for state employees

in a cost - efficient manner allowing state employees to choose

benefit plans which best suit their individual needs. See

§ 110.123(3), Fla. Stat.

3 / ÐHealth Program,Ñ as that term is used in rule 60P - 2.002(1),

is defined as Ðthe insurance plans offered to eligible

subscribers.Ñ Fla. Admin. Code R. 60P - 1.003(13).

C OPIES FURNISHED:

Gavin D. Burgess, Esquire

Department of Management Services

Suite 160

4050 Esplanade Way

Tallahassee, Florida 32399 - 0950

(eServed)

Clay Allen Tidwell

1577 Cinnamon Bear Circle

Tallahassee, Florida 32311

(eServed)

J. Andrew Atkinson, General Counsel

Office of the General Counsel

Department of Management Services

4050 Esplanade Way, Suite 160

Tallahassee, Florida 32399 - 0950

(eServed)

NOTICE OF RIGHT TO SUBMIT EXCEPTIONS

All parties have the right to submit written exceptions within

15 days from the date of this Recommended Order. Any exceptions

to this Recommended Order should be filed with the agency that

will issue the Final Order in this case.