Section 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.34 Tex. Admin. Code § 81.11
The provisions of this §81.11 adopted to be effective September 1, 1985, 10 TexReg 2321; amended to be effective May 19, 1992, 17 TexReg 3252; amended to be effective September 2, 1993, 18 TexReg 5594; amended to be effective September 6, 1996, 21 TexReg 8182; amended to be effective February 16, 1998, 23 TexReg 1099; amended to be effective September 16, 1999, 24 TexReg 7276; amended to be effective September 13, 2001, 26 TexReg 6962; amended to be effective December 31, 2003, 28 TexReg 11612; amended to be effective May 3, 2006, 31 TexReg 3588; amended to be effective January 4, 2007, 31 TexReg 10811; amended to be effective March 15, 2010, 35 TexReg 2202; amended to be effectiveDecember 22, 2011, 36 TexReg 8574; Amended by Texas Register, Volume 41, Number 36, September 2, 2016, TexReg 6755, eff. 9/5/2016