Or. Admin. Code § 101-015-0035

Current through Register Vol. 63, No. 11, November 1, 2024

Section 101-015-0035 - Eligibility Violations

(1) Unintentional Violation:

(a) PEBB will remove from coverage an ineligible PEBB member due to eligibility or enrollment violations. Removal from all benefit plans will be retroactive to the date the individual is determined to have no longer been eligible, or the effective date of coverage if eligibility criteria was never met unless in conflict with federal healthcare reform.

(b) When an eligibility or enrollment violation has been discovered and investigated, PEBB will notify the member and the Agency Human Resource Department with the outcome.

(c) The member may be responsible for any claims paid during the period of time the member was enrolled inappropriately.

(2) Intentional Violation:

(a) The ineligible member shall be removed from coverage by PEBB. The ineligible member's coverage will be retroactively terminated to the date the individual is determined to have no longer been eligible, or the effective date of coverage if eligibility criteria was never met.

(b) PEBB may terminate the eligible employee along with remaining dependents from all plans excluding basic and mandatory plans selected by the agency. This will be a prospective termination lasting for a period of 12 months. The prospective termination will be effective the first day of the following month that the Intentional Violation was discovered.

Or. Admin. Code § 101-015-0035

PEBB 3-2018, temporary adopt filed 02/23/2018, effective 02/23/2018 through 08/21/2018; PEBB 5-2018, adopt filed 08/15/2018, effective 8/15/2018

Statutory/Other Authority: ORS 243.125 & ORS 243.061-302, 659A.060-069, 743.600-602 and 743.707

Statutes/Other Implemented: ORS 243 & ORS 243.061-302, 292.501 and 2007 OL Chap. 99