Rule 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.Ga. Comp. R. & Regs. R. 111-4-1-.09
O.C.G.A. Secs. 20-2-881, 20-2-911, 45-18-1et seq., IRS Code Section 125. Patient Protection and Affordable Care Act (PPACA).
Original Rule entitled "Termination of Coverage" adopted. F. Apr. 18, 2005; eff. May 8, 2005.Repealed: New Rule of same title adopted. F. Jan. 22, 2007; eff. Feb. 11, 2007.Amended: F. Jan. 26, 2011; eff. Feb. 16, 2011.