Or. Admin. Code § 101-020-0025 - Removing an Ineligible Individual from Benefit Plans
(1) All eligible employees have 30 days from
the date a spouse, domestic partner, or dependent child loses eligibility to
remove the individual from PEBB coverage. The individual will be removed from
plans the last day of the month in which eligibility was lost.
(2) An employee's failure to report a spouse,
domestic partner, or dependent child's loss of eligibility within 30 days of
the event is an intentional misrepresentation of a material fact of enrollment
by the employee. PEBB will rescind all coverage back to the last day of the
month and plan year when eligibility was lost. Under COBRA regulations
ineligible individuals removed more than 60 days from the eligibility loss date
will receive a COBRA unavailability letter due to the employee's late
notification.
(a) At an agency's discretion,
an employee may become liable to repay the agency for premiums paid by the
agency while the individual was ineligible.
(b) An employee may become liable for
repayment of insurance claims incurred and paid by a plan for the ineligible
individual according to contract agreements between PEBB and the plan.
(c) An employee may face
disciplinary action by an agency. Example: Ann's divorce is final on June 6.
Ann submits her update form to her agency October 10. The agency forwards the
update forms to PEBB. PEBB terminates the ineligible individual's coverage the
last day of the month that the divorce was final. The ex-spouse will receive a
COBRA unavailability letter.
(3) Premium refunds to agencies:
(a) Premium refunds for rescinded coverage
may be available according to PEBB's contract agreement with each
plan.
(b) An agency will not receive
a premium equivalent refund from a PEBB self-insured plan for an ineligible
individual whose coverage is rescinded.
(3) A plan may remove from coverage or deny the claims
of an eligible employee, a family member, domestic partner, or domestic
partner's dependent child because of fraud, intentional misrepresentation of a
material fact, eligibility violations, or policy term violations. Violations
include but are not limited to, fraud, material misrepresentation, or
concealment. When a plan removes an employee from coverage for violations:
(a) The employee may choose, as a midyear
plan change, an alternative plan to replace the terminated plan. If no
alternative plan is available, there is no coverage.
(b) The plan may retain all premiums paid and
has the right to recover from the employee, the benefits paid as a result of
such wrongful activity that are in excess of the premiums.
(c) The plan may deny future enrollments of
the individual.
(4) When
discovered, PEBB may rescind coverage for individuals identified as ineligible
to the end of the month that eligibility is lost, whether or not requested by
the employee within the 30 day period.
Notes
Statutory/Other Authority: ORS 243.061 - 302
Statutes/Other Implemented: ORS 243.061-302, 659A.060-069, 743.600-602 & 743.707
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