| (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.
|
| Source Note: 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 beeffectiveDecember 22, 2011, 36 TexReg 8574; amended to be effective September 5, 2016, 41 TexReg 6754 |
