State Codes and Statutes

State Codes and Statutes

Statutes > North-carolina > Chapter_135 > GS_135-45_12

§ 135‑45.12.  Cessationof coverage.

(a)        Coverage under thisPlan of an employee and his or her surviving spouse or eligible dependentchildren or of a retired employee and his or her surviving spouse or eligibledependent children shall cease on the earliest of the following dates:

(1)        The last day of themonth in which an employee or retired employee dies. Provided such survivingspouse or eligible dependent children were covered under the Plan at the timeof death of the former employee or retired employee, or were covered onSeptember 30, 1986, any such surviving spouse or eligible dependent childrenmay then elect to continue coverage under the Plan by submitting writtenapplication to the Claims Processor and by paying the cost for such coveragewhen due at the applicable fees. Such coverage shall cease on the last day ofthe month in which such surviving spouse or eligible dependent children die,except as provided by this Article.

(2)        The last day of themonth in which an employee's employment with the State is terminated asprovided in subsection (c) of this section.

(3)        The last day of themonth in which a divorce becomes final.

(4)        The last day of themonth in which an employee or retired employee requests cancellation ofcoverage.

(5)        The last day of themonth in which a covered individual enters active military service.

(6)        The last day of themonth in which a covered individual is found to have knowingly and willfullymade or caused to be made a false statement or false representation of amaterial fact in a claim for reimbursement of medical services under the Plan.The Executive Administrator and Board of Trustees may make an exception to theprovisions of this subdivision when persons subject to this subdivision havehad a cessation of coverage for a period of five years and have made a full andcomplete restitution to the Plan for all fraudulent claim amounts. Nothing inthis subdivision shall be construed to obligate the Executive Administrator andBoard of Trustees to make an exception as allowed for under this subdivision.

(7)        The last day of themonth in which an employee who is Medicare‑eligible selects Medicare tobe the primary payer of medical benefits. Coverage for a Medicare‑eligiblespouse of an employee shall also cease the last day of the month in whichMedicare is selected to be the primary payer of medical benefits for theMedicare‑eligible spouse. Such members are eligible to apply forconversion coverage.

(8)        The last day of themonth in which a covered individual is found to be ineligible for coverage.

(b)        Coverage under thisPlan as a dependent child ceases when the child ceases to be a dependent childas defined by G.S. 135‑45.1 except, coverage may continue under this Planfor a period of not more than 36 months after loss of dependent status on afully contributory basis provided the dependent child was covered under thePlan at the time of loss of dependent status.

(c)        Coverage under thePlan as a surviving dependent child whether covered as a dependent of asurviving spouse, or as an individual member (no living parent), ceases whenthe child ceases to be a dependent child as defined by G.S. 135‑45.1,except coverage may continue under the Plan on a fully contributory basis for aperiod of not more than 36 months after loss of dependent status.

(d)        Termination ofemployment shall mean termination for any reason, including layoff and leave ofabsence, except as provided in subdivisions (a)(1) and (2) of this section, butshall not, for purposes of this Plan, include retirement upon which theemployee is granted an immediate service or disability pension under andpursuant to a State‑supported Retirement System.

(1)        In the event oftermination for any reason other than death, coverage under the Plan for anemployee and his or her eligible spouse or dependent children, provided theeligible spouse or dependent children were covered under the Plan attermination of employment may be continued for a period of not more than 18months following termination of employment on a fully contributory basis.Employees who were covered under the Plan at termination of employment may becontinued for a period of not more than 18 months or 29 months if determined tobe disabled under the Social Security Act, Title II, OASDI or Title XVI, SSI.

(2)        In the event ofapproved leave of absence without pay, other than for active duty in the armedforces of the United States, coverage under this Plan for an employee and hisor her dependents may be continued during the period of such leave of absenceby the employee's paying one hundred percent (100%) of the cost.

(3)        If employment isterminated in the second half of a calendar month and the covered individualhas made the required contribution for any coverage in the following month,that coverage will be continued to the end of the calendar month following themonth in which employment was terminated.

(4)        Employees paid forless than 12 months in a year, who are terminated at the end of the work yearand who have made contributions for the non‑work months, will continue tobe covered to the end of the period for which they have made contributions,with the understanding that if they are not employed by another State‑coveredemployer under this Plan at the beginning of the next work year, the employeewill refund to the ex‑employer the amount of the employer's cost paid forthem during the non‑paycheck months.

(5)        Any employeereceiving benefits pursuant to Article 6 of this Chapter when the employee hasless than five years of retirement membership service, or an employee on leaveof absence without pay due to illness or injury for up to 12 months, isentitled to continued coverage under the Plan for the employee and any eligibledependents by the employee's paying one hundred percent (100%) of the cost.

(e)        A legally divorcedspouse and any eligible dependent children of a covered employee or retiredemployee may continue coverage under this Plan for a period of not more than 36months following the first of the month after a divorce becomes final on afully contributory basis, provided the former spouse and any eligible dependentchildren were covered under the Plan at the time a divorce became final.

(f)         A legallyseparated spouse of a covered employee or retired employee may continuecoverage under this Plan for a period not to exceed 36 months from theseparation date on a fully contributory basis, provided the separated spousewas covered under the Plan at the time of separation and provided the coveredemployee's or retired employee's actions result in the loss of coverage for theseparated spouse. Eligible dependent children may also continue coverage ifcovered under the Plan at time of separation, provided the employee's orretired employee's actions result in the loss of coverage for the dependent children.

(g)        Whenever thissection gives a right to continuation coverage, such coverage must be electedwithin the time allowed by applicable federal law.

(h)        Continuationcoverage under this Plan shall not be continued past the occurrence of any oneof the following events:

(1)        The termination ofthe Plan.

(2)        Failure of a Planmember to pay monthly in advance any required premiums.

(3)        A person becomes acovered employee or a dependent of a covered employee under any group healthplan and that group health plan has no restrictions or limitations on benefits.

(4)        A person becomeseligible for Medicare benefits on or after the effective date of thecontinuation coverage.

(5)        The person wasdetermined to be no longer disabled, provided the 18‑month coverage was extendedto 29 months due to having been determined to be disabled under the SocialSecurity Act, Title II, OASDI or Title XVI, SSI.

(6)        The person reachesthe maximum applicable continuation period of 18, 29, or 36 months.

(i)         Noticerequirements concerning continuation coverage shall be developed by theExecutive Administrator and Board of Trustees.

(j)         The spouse and anyeligible dependent children of a covered employee may continue coverage underthe Plan on a fully contributory basis for a period not to exceed 36 monthsfrom the date the employee becomes eligible for Medicare benefits which resultsin a loss of coverage under the Plan, provided that the spouse and eligibledependent children were covered under the Plan at the time the employee became eligiblefor Medicare benefits which results in a loss of coverage under the Plan.  (1981 (Reg. Sess., 1982), c.1398, s. 6; 1983, c. 922, ss. 17, 19‑21; 1985, c. 732, ss. 13, 34; 1985(Reg. Sess., 1986), c. 1020, ss. 19, 29(m)‑(x); 1987, c. 738, s. 29(o); 1989,c. 752, s. 22(p); 1991, c. 427, s. 42; 1995, c. 278, s. 2; 1997‑512, ss.32‑35; 2000‑184, s. 4; 2008‑168, ss. 1(a), 3(a), (q); 2008‑187,s. 49.5; 2009‑16, s. 3(f).)