Eligibility Violations

(1) Unintentional Violation: (A) OEBB will remove from coverage an ineligible OEBB 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, OEBB will notify the member and the Educational Entity with the outcome. If the outcome includes rescission of coverage, OEBB will give a 30 day notice of such rescission prior to terminating coverage retroactively to the date the member was no longer eligible for benefits. (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 OEBB. 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) OEBB may terminate the eligible employee along with remaining dependents from all plans excluding basic and mandatory plans selected by the educational entity. 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. Statutory/Other Authority: ORS 243.860 – 243.886 Statutes/Other Implemented: ORS 243.864(1)(a) History: OEBB 12-2011, f. & cert. ef. 6-22-11 OEBB 8-2011(Temp), f. & cert. ef. 2-15-11 thru 8-13-11 OEBB 16-2010, f. & cert. ef. 12-10-10