N.Y. Comp. Codes R. & Regs. tit. 4 § 74.2

Current through Register Vol. 46, No. 45, November 2, 2024

Section 74.2 - Eligibility

(a) Employees.

(1) An employee shall be eligible for coverage under the plan for himself and for his dependents, if any, subject to the provisions of this Part and of the appropriate contracts applicable to employees and their dependents.

(2) No employee may be covered under this plan until he has completed six months of service following date of last entry into the service of the State or a participating employer. Each appointment, or election, or reinstatement following a break in service, shall be considered a new entry into service.

(3) Coverage for any employee and his dependents shall cease without notice upon termination of his status as an employee as defined in section 74.1 of this Part. The status of any person as an employee shall be deemed to terminate upon his severance from the payroll for any reason, including retirement, except that for the purpose of continuing his coverage under the plan, the status of such person as an employee shall be deemed to continue during any period of authorized leave without pay or during any other period of separation from the payroll for which the employer continues contributions on behalf of the employee and his dependents. For the purpose of this plan, employees in vested status, on preferred lists or on seasonal layoff are not considered to be on leave without pay.

(4) Notwithstanding the foregoing, coverage under the plan for any person whose status as an employee terminates shall continue through the last day of the calendar month in which his employment ceases. Coverage of his enrolled dependents shall continue for the same period.

(5) Notwithstanding any other provisions of this Part, if the regular work schedule of an employee has been not less than half-time per week for at least one year and then is reduced to less than half-time per week under circumstances not expressly excepted under section 74.1(c) of this Part, the president may, in his or her discretion and upon the request of the employer, deem such person's status as an employee to continue for a period not exceeding one year for the purpose of continued coverage under the plan. Thereafter, if the regular work schedule of such employee continues to be less than half-time per week, the president may, from time to time, review the case and, in his or her discretion, grant extensions not exceeding one year each during which such person's status as an employee may be deemed to continue.

(6) In the event both husband and wife elect coverage under the plan as employees as defined in section 74.1 of this Part, there shall be coordination of benefits.

(7) Notwithstanding any other provisions of this Part in the event of the death of an employee, the coverage hereunder of his dependents shall continue through the last day of the calendar month in which death occurs.

(b) Cessation of eligibility upon termination of the plan. Upon the termination of the plan by the State, the coverage and eligibility for coverage of its employees shall cease as of the end of the last period for which the required contributions have been paid to the insurance carrier.

(c) Disqualification. The president may disqualify from participation in the dental insurance plan and from receiving benefits thereunder any employee who has secured or attempted to secure participation in the dental insurance plan or benefits under the plan for himself or another by fraud, deception or a false statement of a material fact, or who has accepted benefits for himself or another knowing he was not entitled thereto. No person shall be disqualified or denied benefits pursuant to this subdivision unless he is first given a written statement of the reasons therefor and afforded an opportunity to make an explanation and submit facts in opposition to such action. Such employees may be restored to eligibility for coverage under the plan only on approval of the president and subject to such conditions as may be imposed by the president, including repayment of sums expended for benefits obtained by fraud, deception or false statement of a material fact, or accepted by the employee with knowledge that he was not entitled thereto.

N.Y. Comp. Codes R. & Regs. Tit. 4 § 74.2