Oregon Administrative Rules
Chapter 101 - OREGON HEALTH AUTHORITY, PUBLIC EMPLOYEES' BENEFIT BOARD
Division 15 - ELIGIBILITY
Section 101-015-0040 - Policy Term Violations
Universal Citation: OR Admin Rules 101-015-0040
Current through Register Vol. 63, No. 9, September 1, 2024
(1) A PEBB-contracted insurance carrier may remove from coverage and/or deny the claims of a PEBB member due to policy term violations. Removal from coverage for policy term violations is at the discretion of the insurance carrier.
(a) If a policy term violation results in a
termination from the plan or carrier that the violation was committed, it will
not prevent the member from continuing enrollment in other PEBB types of
coverages (e.g., medical, dental, vision, life, etc.), as long as they remain
an employee and eligible for these benefits.
(b) If an eligible employee commits a policy
term violation and loses coverage, PEBB will remove the entire family from the
insurance plan since the benefits are extended to his or her dependents through
the eligible employee. If the eligible employee chooses to, and it is offered,
they can enroll in a different carrier plan (if applicable).
(c) If a dependent commits a policy term
violation, PEBB will remove only the dependent from the insurance plan. If the
eligible employee chooses to and it is offered, they can enroll in a different
carrier plan (if applicable).
(d)
The PEBB member who is removed from a PEBB sponsored insurance plan may appeal
the decision through the carrier that terminated coverage.
(e) When a policy term violation has been
discovered and investigated, the applicable insurance carrier will notify PEBB
and the member with the outcome.
(2) The insurance carrier may do the following when a member has violated a provision of the policy the PEBB member has enrolled in, committed fraudulent activity or misrepresentation:
(a) The insurance carrier may retain the
value of any expenditure it made related to the member who committed the
fraudulent activity or misrepresentation.
(b) The insurance carrier may deny future
enrollments of the individual in accordance with the carrier's
policies.
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
Disclaimer: These regulations may not be the most recent version. Oregon may have more current or accurate information. We make no warranties or guarantees about the accuracy, completeness, or adequacy of the information contained on this site or the information linked to on the state site. Please check official sources.
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