34 Tex. Admin. Code § 81.11 - Cancellation of Coverage and Sanctions
(a) A
participant's coverage will end on the earliest of:
(1) the last day of the month in which
insurance required contributions for a participant's coverage are paid in full;
(2) the last day of the month in
which a participant becomes ineligible for coverage;
(3) the last day of the month, or other date
as specified by ERS, in which ERS instructs the relevant carriers and
administering firms to end a participant's coverage; or
(4) the effective date of a participant's
expulsion from participation in the GBP or specific coverage plans as provided
under §1551.351 of the Act.
(b) In addition to the dates described in
subsection (a) of this section, an employee's coverage will end on the earliest
of:
(1) the last day of the month in which
the employee's employment ends; or
(2) the last day of the month in which the
employee retires, unless the employee is eligible for coverage as a retiree.
(c) In addition to the
dates described in subsection (a) of this section, a dependent's coverage will
end:
(1) on the last day of the month in
which the employment or retirement of the member who enrolled the dependent
ends;
(2) on the last day of the
month in which the dependent ceases to be an eligible dependent as defined in
§
81.1 of this chapter (relating to
Definitions); or
(3) for qualified
medical child support court-ordered dependent GBP health coverage only:
(A) on the last day of the month in which the
dependent ceases to be an eligible dependent as defined in §
81.1 of this chapter; or
(B) the court order is invalidated
or terminates.
(d) Cancellation of coverage for a surviving
spouse or surviving dependent of a deceased member.
(1) If a surviving spouse or surviving
dependent of a deceased member becomes an employee eligible for GBP coverage,
the coverage based on the status of surviving spouse or surviving dependent
will be cancelled as of the eligibility date of the employee coverage. If the
surviving spouse ceases to be an employee, the surviving spouse may re-enroll
in GBP coverage based on the status of surviving spouse. If the surviving
dependent ceases to be an employee, the surviving dependent may re-enroll in
GBP coverage based on the status of surviving dependent for as long as he/she
is an eligible dependent.
(2) If a
surviving spouse or surviving dependent of a deceased member cancels coverage
that was based on the status of surviving spouse or surviving dependent, he/she
may not re-enroll in GBP coverage, except as provided in paragraph (1) of this
subsection.
(e)
Required notice when a dependent loses eligibility for coverage. A member is
required to notify his/her benefits coordinator or ERS in writing within 31
days from the date the member's dependent loses eligibility for coverage. If
the member fails to comply with this notification requirement, the member and
dependent may be subject to sanctions pursuant to §1551.351 of the Act and
subsection (f) of this section.
(f)
Sanctions for Insurance Program Violations.
(1) ERS may rescind any insurance coverage or
impose one or more sanctions described by the Act against any person,
including, but not limited to, any current or former participant, employee,
annuitant, dependent or insurance claimant who commits any of the violations
enumerated in the Act.
(2) Any
person with a grievance regarding eligibility, payment of a claim or other
matters for which an appeal is permitted involving the GBP may submit a written
request to the executive director to make a determination on the matter in
dispute. Any person who disputes a rescission of coverage, a denial of benefits
or sanctions imposed in connection with a determination made under the Act, may
appeal the determination in accordance with §
81.9 of this chapter (relating to
Grievance Procedures). A timely appeal of a determination made pursuant to the
Act shall not stay the imposition of sanctions. At the time such a
determination is made pursuant to the Act, no further claims will be paid until
the ERS decision is final. Upon final agency action, all eligible claims, if
any, will be processed subject to any offsets for overpayments.
(3) Any hearing provided pursuant to this
section shall be a contested case under Government Code, Chapter 2001, and be
conducted in the manner prescribed by law and by Chapter 67 of this title
(relating to Hearings on Disputed Claims).
(4) Any person expelled from the GBP may not
be insured under any benefits plan offered by the GBP for a period determined
by ERS.
(5) If a person's insurance
coverage is rescinded, it may be rescinded to the date of the inception of the
coverage or from the date of the prohibited conduct as found in the
determination made in accordance with the Act.
(6) ERS also may deny any claim filed to
obtain benefits from the insurance coverage in a manner prohibited under the
Act.
Notes
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