Ga. Comp. R. & Regs. R. 111-4-1-.09 - Termination of Coverage
(1)
Termination from Employment.
Termination from employment includes resignation, abandonment of job,
release from job, forfeiture of job, and all other types of termination. Health
benefit Coverage shall terminate at the end of the month following the month of
the last date of employment that was transmitted to the Administrator unless
continued under the provision of Extended Coverage. This date will normally be
the end of the month following the month in which separation or termination of
employment occurred.
(2)
Employment Layoff. Employment layoff means that the Employer has
formalized a reduction in staff plan and the Employee will no longer be
employed by one of the Employing Entities. Health Benefit Coverage shall
terminate at the end of the month following the month of the last date of
employment that was transmitted to the Administrator, unless continued under
the provisions of Extended Coverage. The Coverage termination date will
normally be the end of the month following the month in which the layoff
occurred.
(3)
Reduction of
Hours. A reduction in hours worked may result in loss of eligibility to
continue health benefit Coverage.
(a) If for
any reason the number of worked hours is reduced for a covered State Employee
to less than thirty (30) hours per week, Coverage shall terminate at the end of
the month following the month in which the reduced hours took effect; unless
continued under the provisions of Extended Coverage.
(b) If for any reason the number of worked
hours is reduced for a covered Teacher to less than half-time or a minimum of
seventeen and one-half (17 1/2) hours per week, Coverage shall terminate at the
end of the month following the month in which the reduced hours took effect;
unless continued under the provisions of Extended Coverage.
(c) If for any reason the number of worked
hours is reduced for a covered Public School Employee to less than sixty (60)
percent of that required to perform the position duties, Coverage shall
terminate at the end of the month following the month in which the reduced
hours took effect; unless continued under the provisions of Extended Coverage.
However, the sixty (60) percent cannot be less than twenty (20) hours if the
Member is a participant in the Teachers Retirement System and less than fifteen
(15) hours if the member is a participant in the Public School Employees
Retirement System.
(4)
Failure to Return from an Approved Leave of Absence Without Pay.
If an Employee on an Approved Leave of Absence Without Pay fails to
return to Active employment, Coverage will terminate at the earlier of the end
of the month for which the Leave Without Pay was approved or the end of the
month for which a valid Premium payment has been received. Failure to return to
Active employment from an Approved Leave of Absence Without Pay will be
considered termination of employment for the purposes of Extended Coverage
eligibility.
(5)
Legal
Separation or Divorce. Coverage for a legally separated or divorced
Spouse will terminate at the end of the month in which the separation papers
were approved by a court of competent jurisdiction or in which the divorce
decree is approved by the court of competent jurisdiction unless continued as
an Extended Beneficiary.
(6)
Dependent Child. Coverage for an eligible Dependent child shall
terminate at the end of the month in which the child reaches age twenty-six
(26) unless a Qualified Medical Child Support Order (QMCSO) or other court
order bears an earlier expiration date or Coverage is continued under the
provisions for a Totally Disabled Child or an Extended Beneficiary.
(7)
Failure to Remit Premium.
Failure to remit the billed Premium amount in full within thirty (30)
calendar days following the end of the month for which Coverage has been paid
will result in suspension of benefit payments and will constitute forfeiture of
eligibility to continue Coverage while on Approved Leave of Absence Without Pay
or Extended Coverages of any kind. Coverage will not be reinstated for payments
received thirty (30) calendar days following termination of Coverage for
insufficient payment, unless an administrative error has been made. Failure to
remit Premium will constitute a declination of eligibility to continue coverage
as an Extended Beneficiary without further notice by the
Administrator.
(8)
Expiration
of Approval Leave of Absence Without Pay. Coverage will terminate at the
end of the month following expiration of the Approved Leave of Absence Without
Pay period unless the leave is extended by the appropriate organizational
official and such extension is approved by the Administrator or the Employee
returns to work, or the Employee extends coverage under the provisions of
Extended Coverage. Coverage may be terminated earlier than the expiration of
such leave when the Failure to Remit Premium provisions of these regulations
apply.
(9)
Expiration of
Coverage as a Pending Retiree. Health benefit Coverage will terminate at
the end of the month following determination that the Retiree is not
immediately eligible to receive an annuity under a state supported
participating retirement system operated for Employees, unless the Retiree is
eligible to continue Coverage under the Extended Coverage provisions of these
regulations. Pending Retirees appealing a denial of retirement benefits may
continue up to the maximum period outlined in Section
111-4-1-.07.
(10)
Expiration of Extended Beneficiary
Coverage Privileges. Health benefit Coverage for Extended Beneficiaries
will terminate at the end of the month in which the earliest of the following
conditions occur:
(a) The full Premium amount
is not paid within the time allowed under these regulations;
(b) The maximum Coverage period permitted
under these regulations is exhausted;
(c) The Extended Beneficiary becomes enrolled
in Medicare benefits;
(d) The
Extended Beneficiary becomes covered under another group health care plan by
reason of employment or marriage, and pre-existing condition exclusions are not
applied under the new coverage;
(e)
Cancellation of contract with an organization with whom the Board of Community
Health is authorized to contract;
(f) The State Health Benefit Plan is
terminated.
(11)
Deceased Enrolled Member. Coverage shall terminate no later than
the end of the month of death of a Member enrolled in employee only Coverage.
Coverage shall terminate no later than the end of the month following the month
of death of a Member when the Coverage includes Dependents. The Employing
Entity, retirement system or deceased's estate shall remit the appropriate
Premium. A surviving Beneficiary may continue coverage as outlined in
111-4-1-.04, the Extended Coverage
provisions of these regulations.
(12)
Discontinuation of Coverage
Outside Open Enrollment. Coverage shall terminate no earlier than the
end of the month following receipt of the request to discontinue Coverage
outside the annual Open Enrollment period. Requests to discontinue Coverage
must be approved by the Administrator. The Administrator may require
documentation of other Coverage.
(13)
Suspension of Benefits Due to
Nonpayment. If an Employing Entity fails to remit Premiums or
documentation or fails to reconcile bills in the manner required by the Plan,
the Plan may suspend benefit payments for Enrolled Members of the Employing
Entity.
Notes
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