Or. Admin. Code § 111-080-0040 - Eligibility and Policy Term Violations - Definitions
For the purposes of OAR 111-080-0045 and 111-080-0050, the following definitions will apply:
(1)
"Eligibility or Enrollment Violations" means and includes a violation of the
OEBB's eligibility or enrollment rules or policies including fraud or material
misrepresentation. Misstatements, misrepresentations, omissions or concealments
on the part of the OEBB member are not fraudulent unless they are made with
intent to knowingly defraud. OEBB has primary responsibly in investigating such
violations. If an Eligibility Violation is considered a violation of the
insurance carrier's policy, then the violation may also be considered a Policy
Term Violation, and OAR 111-080-0050 would also apply.
(a) "Intentional Violation" is a violation
that has occurred in which OEBB has electronic or written documentation that
the eligible employee took action resulting in a non-eligible member being
enrolled in OEBB benefits.
(b)
"Unintentional Violation" is a violation that has occurred in which the
eligible employee was not aware that such violation had occurred and there is
no evidence of the eligible employee completing a paper form or logging in and
enrolling an ineligible member in OEBB benefits.
(2) "Policy Term Violations" means and
includes a violation of the insurance carrier's policy terms. The insurance
carrier has primary responsibility in investigating such violations.
Notes
Statutory/Other Authority: ORS 243.860 - 243.886
Statutes/Other Implemented: ORS 243.864(1)(a)
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