Part IV.
Employees Retirement System of Texas
Chapter 81.
Insurance
34 TAC §§81.1, 81.5, 81.7, 81.11
The Employees Retirement System of Texas (ERS) adopts on
an emergency basis amendments to §§81.1, 81.5, 81.7, and 81.11,
concerning the Uniform Group Insurance Program (UGIP). Section 81.1 is amended
to remove long and short term disability insurance premiums from the definition
of "insurance premium expenses" covered by the premium conversion plan; §81.5
is amended to permit certain retirees not covered by optional life insurance
or dependent life insurance at the time of retirement an opportunity to apply
for minimum retiree optional life insurance and dependent life insurance coverage.
Section 81.5 is also amended to permit both parents to carry dependent life
and accident insurance on a child if both parents are participants in the
UGIP; and §81.7 is amended to make participation in the premium conversion
plan mandatory and automatic, to make coverage of an adopted child effective
on the date of placement for adoption, to make coverage in the life and accident
plans begin at the date of birth and to clarify the definition of a qualifying
life event for premium conversion purposes; and §81.11 is amended to
reflect amendments made in §81.7.
These sections are being adopted on an emergency basis in order to have
UGIP policies and procedures relating to eligibility, enrollment, and premium
conversion in place before the beginning of annual summer enrollment that
begins on July 1, 1999. Additionally, the ERS is in the process of implementing
a new, comprehensive employee benefits software platform providing on-line
access and interactive capabilities. The adoption of these sections on an
emergency basis will permit the integration of the proposed changes with the
implementation of the new employee benefits software in order to achieve a
smooth transition in conjunction with summer enrollment and the start of the
new plan year.
The amendments are adopted under Insurance Code, Article 3.50-2,
§4.
No other statutes are affected by these proposed amendments.
§81.1.Definitions.
The following words and terms, when used in this chapter, shall have
the following meanings, unless the context clearly indicates otherwise.
(1)
Accelerated Life Benefit - An amount of Term Life Insurance
requested by the insured employee and approved by the carrier to be paid in
advance of the employee's or covered dependent's actual death in accordance
with the terms of the Group Term Life Plan, as permitted by Article 3.50-6,
Texas Insurance Code. Accelerated Life Benefit payment can be requested only
upon diagnosis of a terminal condition and only once during the lifetime of
the employee or covered dependent. A terminal condition is a non-correctable
health condition that with reasonable medical certainty will result in the
death of the insured within 12 months.
(2)
Act - The Texas Employees Uniform Group Insurance
Benefits Act, Chapter 79, Acts of the 64th Legislature, 1975, as amended (the
Insurance Code, Article 3.50-2).
(3)
Active duty - The expenditure of time and energy
in the service of the State of Texas. An employee will be considered to be
on active duty on each day of a regular paid vacation or regular paid sick
leave or on a non-working day, if the employee was on active duty on the last
preceding working day.
(4)
AD&D - Accidental death and dismemberment.
(5)
Age of employee - The age to be used for determining
optional term life and voluntary AD&D insurance premiums will be the employee's
attained age as of the employee's first day of active duty within a contract
year.
(6)
Annuitant - A person as defined in the Act.
(7)
Basic plan - The program of group insurance determined
by the trustee in which every full-time employee or retiree is automatically
enrolled, unless participation is specifically waived.
(8)
Board or trustee - The board of trustees of the Employees
Retirement System of Texas.
(9)
Committee or GBAC - The Group Benefits Advisory Committee
as established by the Act, §18.
(10)
Contract year - A contract year begins on the first
day of September and ends on the last day of the following August.
(11)
Department - Commission, board, agency, division,
institution of higher education, or department of the State of Texas created
as such by the constitution or statutes of this state.
(12)
Dependent - The spouse of an employee or retiree
and unmarried children under 25 years of age, including:
(A)
the natural child of an employee/retiree;
(B)
a legally adopted child (including a child living with
the adopting parents during the period of probation);
(C)
a stepchild whose primary place of residence is the employee/retiree's
household;
(D)
a foster child whose primary place of residence is the
employee/retiree's household and who is not covered by another governmental
health program;
(E)
a child whose primary place of residence is the household
of which the employee/retiree is head and to whom the employee/retiree is
legal guardian of the person;
(F)
a child who is in a parent-child relationship to the employee/retiree,
provided the child's primary place of residence is the household of the employee/retiree,
the employee/retiree provides the necessary care and support for the child,
and if the natural parent of the child is 21 years of age or older, the natural
parent does not reside in the same household;
(G)
a child who is considered a dependent of the employee/retiree
for federal income tax purposes and who is a child of the employee/retiree's
child;
(H)
an eligible child, as defined in this subsection, for whom
the employee/retiree must provide medical support pursuant to a valid order
from a court of competent jurisdiction; or
(I)
any such child, regardless of age, who lives with or whose
care is provided by an employee or retiree on a regular basis if such child
is mentally retarded or physically incapacitated to such an extent as to be
dependent upon the employee or retiree for care or support, as the trustee
shall determine. Mentally retarded or physically incapacitated means any medically
determinable physical or mental condition which prevents the child from engaging
in self-sustaining employment, provided that the condition commences prior
to such child's attainment of age 25, the child was eligible and covered under
the plan immediately prior to reaching age 25, and that satisfactory proof
of such condition and dependency is submitted by the employee/retiree within
31 days following such child's attainment of age 25. As a condition to the
continued coverage of a child as a mentally retarded or physically incapacitated
dependent beyond the age of 25, the carrier or health maintenance organization
shall have the right to require periodic certification of the child's physical
or mental condition
,
but not more frequently than annually following
the child's attainment of age 25.
(13)
Eligible to receive an annuity - Refers to
a person who, in accordance with the Act, meets all requirements for retirement
from a state retirement program or the Optional Retirement Program.
(14)
Employee - Any appointive or elective state officer
or employee in the service of the State of Texas, including an employee of
an institution of higher education as defined in the Act, except
a person
[
(A)
who is retired or retires and is an annuitant as defined
in the Act;
(B)
who receives his compensation for services rendered to
the State of Texas on a warrant issued pursuant to a payroll certified by
a department or by an elected or duly appointed officer of this state;
(C)
who receives payment for the performance of personal services
on a warrant issued pursuant to a payroll certified by a department and drawn
by the state Comptroller of Public Accounts [
(D)
who is appointed
,
subject to confirmation of
the senate
,
as a member of a board or commission with administrative
responsibility over a statutory agency having statewide jurisdiction whose
employees are covered by the Act;
(E)
who is a member of the governing body of an institution
of higher education;
(F)
who is a member of the State Board of Education;
(G)
who receives compensation for services rendered to an institution
of higher education on a warrant or check issued pursuant to a payroll certified
by an institution of higher education or by an elected or duly appointed officer
of this state, and who is eligible for participation in the Teacher Retirement
System of Texas; or,
(H)
who receives compensation for services rendered to an institution
of higher education but is not permitted to be a member of the Teacher Retirement
System of Texas because the person is solely employed by an institution of
higher education that, as a condition of employment, requires the person to
be enrolled as a student in the institution of higher education in graduate-level
courses and who is employed by the institution at least 20 hours a week.
(15)
Employing office - For a retiree covered by
this program, the office of the Employees Retirement System
of Texas
in Austin, Texas or the retiree's last employing
department
[
(16)
Evidence of insurability - Such evidence required
by a qualified carrier for approval of coverage or changes in coverage pursuant
to the rules of §81.7(h) of this title (relating to Enrollment and Participation).
(17)
Extended sick leave without pay - The status of
an employee who is certified monthly by an agency administrator to be absent
from duty as a result of a disabling condition which prevents the employee
from performing the employee's usual duties
, and
who has not received
a refund of retirement contributions based upon the most recent term of employment.
Such leave is limited to a maximum period of duration in the current Appropriations
Act.
(18)
Former COBRA unmarried child - a child of an employee
or retiree who is unmarried; whose UGIP coverage as a dependent has ceased;
and who upon expiration of continuation coverage under the Consolidated Omnibus
Budget Reconciliation Act
, Public Law 99-272,
(COBRA) reinstates
UGIP coverage.
(19)
HealthSelect of Texas - The statewide point-of-service
plan of health coverage fully self-insured by the Employees Retirement System
of Texas and administered by a qualified carrier or HMO.
(20)
HealthSelect Plus - The optional managed care plan
of health coverage fully self-insured by the Employees Retirement System of
Texas and administered by a qualified carrier or HMO on a regular basis.
(21)
HMO - A health maintenance organization approved
by the board to provide health care benefits to eligible participants in the
program in lieu of participation in the program's HealthSelect of Texas plan
or HealthSelect Plus plan.
(22)
Insurance premium expenses - Any out-of-pocket premium
incurred by a participant, or by a spouse or dependent of such participant,
as payment for coverage provided under the Program that exceeds the state's
or institution's contributions offered as an employee benefit by the employer.
The types of premium expense covered by the
premium conversion
plan include out-of-pocket premium for group term life, health (including
HMO premiums),
AD&D,
[
(23)
Leave without pay - The status of an employee who
is certified by a department administrator to be absent from duty
for
an entire calendar month, who does not receive any compensation for that month,
and
who has not received [
(24)
ORP - The Optional Retirement Program as provided
in the Government Code, Chapter 830.
(25)
Placement for adoption - A person's
assumption and retention of a legal obligation for total or partial support
of a child in anticipation of the person's adoption of such child.
(26)
Preexisting condition - Any injury or
sickness, for which the employee received medical treatment, or services,
or took prescribed drugs or medicines during the three-month period immediately
prior to the effective date of such coverage. However, if the evidence of
insurability requirements set forth in §81.7(h) of this title must first
be satisfied, the three-month period for purposes of determining the preexisting
conditions exclusion will be the three-month period immediately preceding
the date of the employee's completed application for coverage.
(27)
Premium conversion plan - A separate
plan, under the Internal Revenue Code, §79 and §106, adopted by
the board of trustees and designed to provide premium conversion as described
in §81.7(f) of this title.
(28)
Program - The Texas Employees Uniform
Group Insurance Program as established by the board.
(29)
Retiree - A retired employee who is eligible,
under the terms of the Act, for benefits under this program and retired employees
who, as of August 31, 1992, were eligible participants in a group insurance
program administered by an institution of higher education.
(30)
Salary - The salary to be used for determining
optional term life and disability income limitations will be the employee's
regular salary, including longevity, shift differential, hazardous duty pay,
and benefit replacement pay, received by the employee as of the employee's
first day of active duty within a contract year. No other component of compensation
shall be included. Non-salaried elective and appointive officials or members
of the legislature may use the salary of a state district judge or their actual
salary as of September 1 of each year.
(31)
System - The Employees Retirement System
of Texas.
(32)
TRS - The Teacher Retirement System of
Texas.
§81.5.Eligibility.
(a)
Full-time employees. A full-time employee, elected officer,
or appointed officer of the State of Texas is eligible for
automatic
coverage [
(b)
Part-time employees. A part-time employee
or other
employee who is not eligible for automatic coverage becomes eligible for coverage
upon application to participate in the program, subject to the provisions
of §81.7(b) of this title (relating to Enrollment)
[
(c)
Retirees. [
(1)
A retiree is eligible for health and dental
coverage on the day he or she becomes an annuitant.
(2)
A retiree is eligible for optional
life insurance and dependent life insurance coverage if the retiree was enrolled
in such coverage on the day before becoming an annuitant. Except as provided
in paragraph (3) of this subsection, a retiree may not increase the amount
of life insurance for which the retiree was enrolled on the day before becoming
an annuitant, but may cancel life insurance coverage at any time. Canceled
life insurance coverages may never be reinstated. A retiree is not eligible
for disability or AD&D coverage.
(3)
A covered retiree whose effective
date of retirement is on or after September 30, 1999, and who was not enrolled
in optional life insurance or dependent life insurance coverage on the day
before becoming an annuitant, becomes eligible for minimum retiree optional
life insurance and dependent life insurance coverage on the date the retiree
becomes an annuitant. Submission of evidence of insurability acceptable to
the system shall be required for enrollment in such coverage.
(4)
A covered retiree who was not enrolled
in dependent life insurance coverage on the day before becoming an annuitant
becomes eligible for dependent life insurance coverage of a newly acquired
dependent on the first day of the month following the date on which the individual
becomes a dependent of the retiree.
(5)
[
Unless otherwise specifically
authorized, persons who become insured as retirees will be ineligible for
coverage as active employees as long as they remain eligible for coverage
as retirees.
(6)
[
A retiree whose extended
life insurance benefits are terminated is eligible for retiree life insurance
coverage on the first day of the month following the extended life insurance
benefits termination date.
(d)
Dependents of employees and retirees. [
(1)
The dependents of an employee or retiree
are eligible for coverage on the same day that the employee or retiree becomes
eligible. Except as otherwise provided in this paragraph, a newly acquired
dependent is eligible for coverage on the first day of the month following
the date on which the individual becomes a dependent of a covered employee
or retiree. The employee or retiree must be enrolled for a particular coverage
before the employee's or retiree's dependents are eligible for that type of
coverage. An eligible child for whom a covered employee or retiree is court
ordered to provide medical support becomes eligible for health coverage upon
receipt by the department of a valid court order. A newborn natural child
is eligible automatically on the date of birth. A newly adopted child is eligible
automatically on the date of placement for adoption.
(2)
Except as otherwise provided in this
paragraph, double coverage is not permitted for any participant in the program.
(A)
A dependent may not be simultaneously covered
for basic term life and dependent term life. A family member who is covered
as an employee or retiree is not eligible to be covered as a dependent in
the program. Except as provided in subparagraph (B) of this paragraph, a dependent
may not be covered by more than one employee or retiree for the same coverage.
(B)
A child who is an eligible dependent of
two participants in the program may be enrolled in dependent life insurance
coverage and accidental death and dismemberment coverage by both participants.
(e)
Former COBRA unmarried children. [
(1)
A former COBRA unmarried child is eligible
to continue the health and dental insurance coverages in which the child was
enrolled upon expiration of the child's continuation coverage under COBRA.
(2)
A former COBRA unmarried child continuing
health insurance coverage under the provisions of this subsection is eligible
for dental insurance coverage if such coverage was not in effect upon the
expiration of the child's continuation coverage under COBRA.
(f)
Surviving dependents.
(1)-(3)
(No change.)
(4)
A surviving spouse
or
[
(5)
A surviving spouse and eligible dependents,
and a surviving dependent child, continuing health insurance coverage under
the provisions of this subsection are eligible for dental insurance coverage
if such coverage was not in effect on the date of death of the deceased employee
or retiree.
(g)-(k)
(No change.)
§81.7.Enrollment and Participation.
(a)
Full-time employees and their dependents.
(1)
A new employee who is eligible under the Act for automatic
insurance coverage shall be enrolled in the basic plan of health and life
insurance unless, on or before the date on which the employee begins active
duty, the employee completes and signs an enrollment form to elect other coverages
or to decline any and all coverages. Coverage of an employee under the basic
plan, and other coverages selected as provided in this paragraph, become effective
on the date on which the employee begins active duty.
[
(2)
To enroll eligible dependents, to
elect to enroll in an approved HMO or in HealthSelect Plus, and to elect optional
coverages, the employee shall complete and sign an enrollment form within
30 days after the date on which the employee begins active duty. Coverages
selected on or before the date on which the employee begins active duty become
effective on the date on which the employee begins active duty. Coverages
selected within 30 days after the date on which the employee begins active
duty become effective on the first day of the month following the signature
date on the enrollment form. An enrollment form completed and signed after
the initial period for enrollment as provided in this paragraph is subject
to the provisions of subsection (h) of this section.
[
(3)
Except as otherwise provided in this section,
an employee may not change coverage during a contract year.
[
(4)
An eligible employee who enrolls in the program
is eligible to participate in premium conversion and shall be automatically
enrolled in the premium conversion plan. The employee shall be automatically
enrolled in the plan for subsequent plan years as long as the employee remains
on active duty.
[
[
(5)
[
[
(6)
[
A newborn natural child
will be covered immediately and automatically from the date of birth in the
health plan in effect for the employee or retiree.
A newly adopted child
will be covered immediately and automatically from the date of placement for
adoption in the health plan in effect for the employee or retiree. To continue
coverage for more than 30 days after the date of birth or placement for adoption,
an enrollment form for health coverage must be submitted within 30 days after
the date of birth or placement for adoption.
[
[
(7)
[
The effective date
of a newborn natural child's life and AD&D insurance will be the
date of birth, if the child is born alive, as certified by an attending physician.
The effective date of a newly adopted child's life and AD&D insurance
will be the date of placement for adoption
[
(8)
[
Health insurance coverage
of an
[
(9)
[
The effective date of
HealthSelect of Texas coverage for an employee's or retiree's dependent, other
than a newborn natural child
or newly adopted child
, will be as
stated in paragraph
(5)
[
(b)
Part-time employees. A part-time employee
or other
employee who
is not automatically covered [
(c)
Retirees and their dependents.
(1)
Provided the required premiums are paid or deducted, an
employee's health, dental and term life insurance coverage (including eligible
dependent coverages) may be continued upon retirement [
(2)
A retiree may enroll in health, dental, and life
insurance coverages for which the retiree is eligible, including dependent
coverages, by completing and signing an enrollment form before, on, or within
30 days after, the retiree's effective date of retirement. Except as otherwise
provided in this paragraph and paragraph (4) of this subsection, coverage
becomes effective on the first day of the month following the effective date
of retirement. A change in coverage for which the retiree applies after initial
enrollment as a retiree, but within 30 days after the effective date of retirement,
becomes effective on the first day of the month following the date of the
application. An application received after the initial period for enrollment
as provided in this paragraph is subject to the provisions of subsection (h)
of this section.
[
(3)
A retiree who becomes eligible for
optional life insurance coverage or dependent life insurance coverage as provided
in §81.5(c)(3) of this title (relating to Eligibility) may apply for
approval of such coverage before, on, or within 30 days after, the effective
date of retirement by providing evidence of insurability acceptable to the
system.
(4)
[
Enrollments and applications
to change coverage become effective as provided in paragraph (2) of this subsection
[
(5)
All other enrollment rules stated
in subsections (a), (g), and (l) of this section apply to retirees.
(d)
Surviving dependents. [
(1)
A surviving dependent eligible to continue
health and dental insurance coverage as provided in §81.5(f) of this
title (relating to Eligibility) may apply to continue such coverage upon written
notification of eligibility to apply. Application shall be made on, or within
30 days after, written notification of eligibility to apply. Coverage becomes
effective on the first day of the month following the date of death of the
deceased employee or retiree.
(2)
A surviving spouse who is receiving
an annuity shall make premium payments by deductions from the annuity as provided
in §81.3(d)(2)(A) of this title (relating to Administration). A surviving
spouse who is not receiving an annuity may make payments as provided in §81.3(d)(2)(B)
of this title.
(e)
Former COBRA unmarried children. A former COBRA unmarried
child must provide an application
to continue health and dental insurance
[
(f)
Premium conversion plans.
(1)
An eligible employee participating in the
program is deemed to have elected to participate in the premium conversion
plan and to pay insurance premium expenses with pre-tax dollars as long as
the employee remains on active duty.
[
(2)
(No change.)
(g)
Special rules for additional or alternative coverages.
(1)
(No change.)
(2)
An eligible participant in the
program
[
(3)
An eligible participant in the
program
[
(4)-(6)
(No change.)
[
(h)
Changes in coverage
after the initial period for enrollment
[
(1)
Changes for Qualifying Life Event.
[
(A)
Subject to the provisions of paragraphs
(3) and (4) of this subsection, a participant shall be allowed to change coverage
during a plan year if a qualifying life event occurs as provided in this paragraph
and the change in coverage is consistent with the qualifying life event.
(B)
A qualifying life event occurs when a participant
experiences one of the following changes:
(i)
change in marital status;
(ii)
change in dependent status;
(iii)
change in employment status;
(iv)
change of address that results in loss
of benefits eligibility;
(v)
change in Medicare or Medicaid status;
(vi)
significant cost of benefit or coverage
change imposed by a third party provider; or
(vii)
change in coverage ordered by a court.
(C)
A participant who loses benefits eligibility
as a result of a change of address shall change coverage as provided in paragraphs
(6)-(9) of this subsection.
(D)
A participant may apply to change coverage
on, or within 30 days after, the date of the qualifying life event.
(E)
Except as otherwise provided in subsections
(a)(6) and (a)(8) of this section, the change in coverage is effective on
the first day of the month following the date of the qualifying life event.
(F)
The plan administrator may require documentation
in support of the qualifying life event.
(2)
Effects of change in cost of benefits to the
premium conversion plan. There shall be an automatic adjustment in the amount
of premium conversion plan dollars used to purchase optional benefits in the
event of a change, for whatever reason, during an applicable period of coverage,
of the cost of providing such optional benefit to the extent permitted by
applicable law and regulation. The automatic adjustment shall be equal to
the increase or decrease in such cost. A participant shall be deemed by virtue
of participation in the plan to have consented to the automatic adjustment.
(3)
An eligible participant who wishes to add or increase
coverage, add eligible dependents to HealthSelect of Texas, or change coverage
from an HMO [
(4)
The evidence of insurability provision applies only
to:
(A)
employees who wish to enroll in Elections III or IV Optional
Term Life insurance;
(B)
employees who wish to enroll in or increase Optional Term
Life insurance, Short Term Disability, or Long Term Disability
after
the initial period for enrollment
[
(C)
employees, retirees, or eligible dependents who wish to
enroll in HealthSelect of Texas
after the initial period for enrollment
[
(D)
employees enrolled in the program whose coverage was dropped
or canceled, except as
otherwise
provided in
subsection (k)
[
(E)
retirees who wish to enroll in optional
life insurance coverage or dependent life insurance coverage as provided in
subsection (c)(3) of this section.
(5)
An employee or retiree who wishes to add eligible
dependents to the employee's or retiree's HMO or HealthSelect Plus coverage
may do so:
(A)
during the annual enrollment period (coverage will become
effective on September 1); or
(B)
upon the occurrence of a qualifying life event as
provided in paragraph (1) of this subsection
[
(6)
A participant who is enrolled in an approved
HMO and who permanently moves out of the HMO service area shall make one of
the following elections, to become effective on the first day of the month
following the date on which the participant moves out of the HMO service area:
[
(A)
enroll in another approved HMO for which
the participant and all covered dependents are eligible;
(B)
enroll in HealthSelect Plus, if the participant
and all covered dependents are eligible; or
(C)
if the participant and all covered dependents
are not eligible to enroll in either an approved HMO or HealthSelect Plus,
either:
(i)
enroll in HealthSelect of Texas without
providing evidence of insurability; or
(ii)
enroll in an approved HMO or in HealthSelect
Plus, if the participant is eligible, and drop any ineligible covered dependent,
unless not in compliance with §81.11(a)(2) of this title (relating to
Termination of Coverage).
(7)
A participant who is enrolled in HealthSelect
Plus and who permanently moves out of the HealthSelect Plus service area,
shall make one of the following elections, to become effective on the first
day of the month following the date on which the participant moves out of
the HealthSelect Plus service area:
[
(A)
enroll in an approved HMO for which the
participant and all covered dependents are eligible; or
(B)
if the participant and all covered dependents
are not eligible to enroll in an approved HMO, either:
(i)
enroll in HealthSelect of Texas without
providing evidence of insurability; or
(ii)
enroll in an approved HMO for which the
participant is eligible and drop any ineligible covered dependent, unless
not in compliance with §81.11(a)(2) of this title (relating to Termination
of Coverage).
(8)
When a covered dependent of a participant
permanently moves out of the participant's HMO service area, the participant
shall make one of the following elections, to become effective on the first
day of the month following the date on which the dependent moves out of the
HMO service area:
[
(A)
drop the ineligible dependent, unless not
in compliance with §81.11(a)(2)(relating to Termination of Coverage);
(B)
enroll in an approved HMO or HealthSelect
Plus, if the participant and all covered dependents are eligible; or
(C)
enroll in HealthSelect of Texas without
providing evidence of insurability if the participant and all covered dependents
are not eligible to enroll in an approved HMO or HealthSelect Plus.
(9)
When a covered dependent of a participant
permanently moves out of the HealthSelect Plus service area, the participant
shall make one of the following elections, to become effective on the first
day of the month following the date on which the dependent moves out of the
HealthSelect Plus service area:
[
(A)
drop the ineligible dependent, unless not
in compliance with §81.11(a)(2)(relating to Termination of Coverage);
(B)
enroll in an approved HMO if the participant
and all covered dependents are eligible; or
(C)
enroll in HealthSelect of Texas without
providing evidence of insurability, if the participant and all covered dependents
are not eligible to enroll in an approved HMO.
[
[
[
[
[
(10)
[
An eligible participant
will be allowed an annual opportunity to make changes
in
[
(A)
A participant
[
(i)
change from one HMO to another HMO;
(ii)
change from an HMO to HealthSelect Plus;
(iii)
change from HealthSelect Plus to an HMO
(iv)
change from HealthSelect of Texas to HealthSelect Plus;
(v)
change from HealthSelect of Texas to an HMO;
(vi)
change from HealthSelect Plus to HealthSelect of Texas;
(vii)
select in-area or out-of-area coverage in HealthSelect
of Texas based on an out-of-area residential zip code and an in-area work
zip code;
(viii)
enroll in a dental plan;
(ix)
change dental plans;
(x)
enroll eligible dependents in an HMO, HealthSelect Plus,
or dental coverage;
(xi)
enroll eligible dependents in HealthSelect of Texas, without
evidence of insurability, if the participant is enrolled in HealthSelect of
Texas and does not reside in any HMO service area;
(xii)
enroll themselves and their eligible dependents in an
eligible HMO, in HealthSelect Plus (if they are eligible), and in a dental
plan from a declined or canceled status;
and
[
(xiii)
decrease or cancel coverage, unless prohibited
by §81.11(a)(2) (relating to Termination of Coverage)
[
(B)
Surviving dependents and former COBRA unmarried children
are not eligible for the provisions in subparagraph (A)(vii), [
(C)
Such opportunity will be scheduled prior to September 1
of each year at times announced by the system. Coverage selected during the
annual enrollment period will be effective September 1. An employee who re-enrolled
after the close of the annual opportunity but prior to September 1 of the
same calendar year shall have until August 31 of that calendar year to make
changes as allowed above to be effective September 1. [
[
(11)
[
A participant
who is a retiree or a surviving dependent, or who is in a direct pay status,
may decrease or cancel any coverage at any time unless such coverage is health
insurance coverage ordered by a court as provided in §81.5(d) (relating
to Eligibility).
[
[
[
(i)
Preexisting conditions exclusion. The preexisting conditions
exclusion shall apply to employees who enroll in
disability
[
[
[
(j)
(No change.)
(k)
Reinstatement in the program.
(1)
Except as provided in subsection (h)(1) of this section,
an employee who terminates employment and returns to active duty within the
same contract year shall reinstate the coverages in effect on the date employment
was terminated. Except as provided in subsection (h)(1), coverage becomes
effective on the date on which the employee returns to active duty. To reinstate
canceled coverages, submission of evidence of insurability acceptable to the
carrier will not apply.
[
(2)
Except as provided in paragraphs (3) - (5) of
this subsection and subsection (h)(1) of this section, an employee whose coverages
were canceled during a period of leave without pay shall, upon return to active
duty, be enrolled in the basic plan without evidence of insurability, provided
the employee is eligible for the full state contribution. Except as provided
in subsection (h)(1), coverage becomes effective on the date on which the
employee returns to active duty.
[
(3)
Except as provided in subsection (h)(1) of this
section, an
[
(4)
Except as provided in subsection (h)(1) of this
section, an employee
[
(5)
Except as provided in subsection (h)(1) of this
section, an employee whose coverages were canceled
[
[
(l)
Continuation coverage in special circumstances.
(1)
(No change.)
(2)
Continuation of health, dental, and life coverages
for employees in a leave without pay status.
(A)
An employee in a leave without pay status may continue
the types and amounts of health, life, and dental coverages in effect on the
date the employee entered that status for a maximum period of up to 12 months.
The maximum period may be extended for up to 12 additional months for a total
of 24 continuous months, provided the extension is certified by the department
to be for educational purposes. The employee must pay premiums directly as
defined in §81.3(d)(2)(B)(i) of this title (relating to Administration).
Disability income coverage for an employee in a leave without pay status will
be suspended beginning on the first day of the month in which the employee
enters the leave without pay status and continuing for those months in which
the employee remains in that status. Suspended disability income coverage
for an employee returning to active duty from a leave without pay status will
be reactivated effective on the
date on which
[
(B)
(No change.)
(3)-(11)
(No change.)
§81.11.Termination of Coverage.
(a)
Cancellation of coverage.
(1)
[
(2)-(5)
(No change.)
(b)-(d)
(No change.)
Filed with the Office of the Secretary of State,on
June 17, 1999.
TRD-9903639
Sheila W. Beckett
Executive Director
Employees Retirement System of Texas
Effective date: June 17, 1999
Expiration date: September 15, 1999
For further information, please call: (512) 867-7125
persons
] performing personal services for the State of
Texas or
an institution
[
institutions
] of higher education
as
an
independent
contractor
[
contractors
]:
upon the state treasurer
] against appropriations made by the Texas legislature from any state
funds or against any trust funds held by the state [
treasurer
]
or who is paid from funds of an official budget of a state department, rather
than from funds of the General Appropriations Act;
agency
]; for an active employee, the employee's employing
department
[
agency
].
accidental death and dismemberment,
]
and
dental, [
and long and short term disability,
]
but
do
[
does
] not include out-of-pocket premium for
long or short term disability or
dependent term life.
compensation or
] a refund of retirement
contributions based upon the most recent term of employment.
and premium conversion
] on the first day he or
she begins active duty with the state. For an elected or appointed officer,
the first day of active duty shall be the day he or she takes the oath of
office.
is subject
to the same eligibility rules as a full-time employee
].
A retiree is eligible for health and dental
coverage on the day he or she becomes an annuitant. A retiree is eligible
for optional life insurance coverage only if the retiree was enrolled in optional
life insurance coverage on the day before becoming an annuitant. A retiree
is eligible for dependent life insurance coverage only if the retiree was
enrolled in dependent life insurance coverage on the day before becoming an
annuitant. Retirees may not increase the amount of life insurance for which
they have been enrolled, but may cancel life coverage at any time. Canceled
life insurance coverages may never be reinstated. A retiree is not eligible
for disability or accidental death and dismemberment coverage.
]
(1)
]
(2)
]
The dependents
of an employee or retiree are eligible for coverage on the same day that the
employee or retiree becomes eligible. A newly acquired dependent is eligible
for coverage on the date the individual becomes a dependent of a covered employee
or retiree. The employee or retiree must be enrolled for a particular coverage
before the employee's or retiree's dependents are eligible for that type of
coverage. An eligible child for whom a covered employee or retiree is court
ordered to provide medical support becomes eligible for health coverage upon
receipt by the department of a valid court order. A newborn child is covered
automatically on the date of birth. A retiree's dependents are eligible for
dependent life insurance coverage only if that coverage was in effect the
day before the retiree became eligible for retiree life insurance; however,
where the retiree was precluded from adding dependent life coverage because
eligible dependents were either active employees or covered as dependents
of an active employee, the retiree may add dependent life coverage upon an
eligible dependent's termination of employment other than by retirement. The
request to add this coverage must be submitted within 30 days following the
date the dependent terminates employment other than by retirement. A dependent
may not be simultaneously covered for basic term life and dependent term life.
A family member who is covered as an employee or retiree is not eligible to
be covered as a dependent in the program. A dependent may not be covered by
more than one employee or retiree for the same coverage. Double coverage is
not permitted for any participant in the program.
]
A former COBRA unmarried
child is eligible for the health and dental coverages in which they were enrolled
upon expiration of the child's continuation coverage under the Consolidated
Omnibus Reconciliation Act (COBRA), Public Law 99-272.
]
of
] a
dependent child of a paid law enforcement officer employed by the state or
a custodial employee of the institutional division of the Texas Department
of Criminal Justice who suffers a violent death in the course of performance
of duty is eligible to continue or enroll in health and dental coverages.
A surviving spouse or natural or adopted children eligible under this section
may enroll within 90 days from the date of death. Other eligible dependent
children may continue health and dental coverages in effect on the date of
death.
A new employee,
other than a part-time state agency employee, will automatically be enrolled
in the basic plan of health and life insurance, effective on his or her first
day of active duty. Any employee, who is eligible and enrolled in the program,
is eligible to participate in premium conversion and shall be enrolled automatically
in the premium conversion plan. To enroll eligible dependents, elect to enroll
in an approved HMO or in HealthSelect Plus, elect optional coverages, and/or
elect not to participate in premium conversion, the employee must complete
an enrollment form on the first day of active duty or within 30 days from
that date. The employee may decline any and all coverages in the program or
participation in premium conversion by completing an enrollment form on or
before the first day of active duty.
]
An enrollment
form for coverages or premium conversion election to be effective on the day
the employee begins active duty must be completed and signed on or before
that day. Coverages or premium conversion elections for which the enrollment
form is completed and signed after the first day of active duty and within
30 days after that day will be effective on the first day of the month following
the signature date on the enrollment form. Enrollment forms completed and
signed after the first 31 days will be governed by subsection (h) of this
section.
]
An
employee's election to or not to participate in the premium conversion plan
shall be irrevocable for the plan year, unless there is a change in family
status as defined in subsection (h)(1) of this section and the change is consistent
with the event.
An employee who continues to remain eligible to
participate in premium conversion shall be enrolled automatically for subsequent
plan years unless the employee specifically declines participation in writing
during the annual enrollment period or under the family status rules.
]
(5)
An employee who is ineligible to
participate, or who is eligible and elects not to participate, in premium
conversion and who becomes or remains eligible to participate in a subsequent
plan year will continue to not participate in premium conversion unless the
employee completes a new enrollment form during the annual enrollment period
or under the change in family status rules and elects to participate.
]
(6)
]
Coverages for dependents
of an employee will be effective on the same day the employee's coverage becomes
effective if an enrollment form is completed and signed on or before the effective
date of the employee's coverage. If the enrollment form is completed and signed
within 30 days after the employee's effective date, the dependent's coverage
will be effective on the first day of the month following the signature date
on the enrollment form.
] Coverage for a newly eligible dependent, other
than a dependent referred to in paragraphs
(6) or (8)
[
(7)
and (9)
] of this subsection, will be effective on the
first day
of the month following the
date the person becomes a dependent if an
enrollment form is completed and signed on or within 30 days after the date
the
person
[
dependent
] first becomes
a dependent
[
eligible
]. If the enrollment form is completed and signed
after the initial period for enrollment as provided in this paragraph,
[
more than 30 days after the employee's effective date or the date the
dependent is first eligible, as the case may be,
] the enrollment form
will be governed by the rules in subsection (h) of this section. [
The
requirement that an enrollment form must be completed and signed within 30
days after a dependent first becomes eligible is waived if the level of health,
dental, and/or life coverages were in effect prior to the acquisition of the
newly eligible dependent; however, an enrollment form must be completed before
verification of coverage will be provided to the carrier(s)
].
(7)
]
(A)
If there are no other dependents covered
at the time of birth, the newborn natural child will be automatically covered
in the same health plan in which the employee or retiree is then covered.
Unless not in compliance with subsection (h) of this section, to continue
coverage for more than 30 days after the date of birth, an enrollment form
for health coverage must be submitted within 30 days after the date of birth.
]
(B)
If health, dental, and/or life coverages
for dependent children were already in effect, an application to add a subsequent
newborn natural child must be completed before verification of coverage for
the newborn dependent will be provided to the carrier.
]
(8)
]
14th day after the
date of birth, unless the newborn natural child is then confined to a hospital
or other institution for medical care; in which case, the newborn natural
child's life and AD&D insurance coverage will become effective on the
day after the day the newborn natural child is released from the hospital
or institution
]. The effective date of all other eligible dependents'
life and AD&D insurance coverages will
be
[
become effective
] as stated in paragraph
(5)
[
(6)
] of this subsection
[
, unless the dependent is confined in a hospital or other institution
for medical care at the date of eligibility; in which case, the life and AD&D
insurance coverage will become effective on the day after the day the dependent
is released from the hospital or institution
].
(9)
]
An
] eligible child for whom a covered employee or
retiree is
court-ordered
[
court ordered
] to provide
medical support becomes
effective on the date on which the department
receives a valid copy of the court order
[
eligible for health coverage
upon receipt by the department of a valid court order
].
(10)
]
(6)
] of this subsection [
, unless the dependent is confined in a hospital or other institution for
medical care at the date of eligibility; in which case, HealthSelect of Texas
coverage will be effective on the day after the day the dependent is released
from the hospital or institution
].
but
] must complete
an application form provided by the Employees Retirement System
of Texas
, authorizing necessary deductions for premium payments for elected
coverage [
and electing to participate or not to participate in premium
conversion
]. This form must be submitted to the Employees Retirement
System
of Texas
through his or her employing
department
[
agency
] on
, or within 30 days after, the date on which the
employee begins active duty
[
or before the employee's first day
of active duty in order for coverage to be effective on that day. If not submitted
on the first day of active duty, but within 30 days thereafter, coverage will
be effective on the first day of the month following the date of application
]. All
other
rules for enrollment stated in subsection (a)
of this section, other than the rule as to automatic coverage, apply to
such
[
a part-time
] employee.
provided the employee
was insured in the program for such benefits immediately preceding the first
day he or she becomes an annuitant
]. The life insurance will be reduced
to the maximum amount which the retiree is permitted to retain under the insurance
contract as a retiree. All other coverages in force for the active employee,
but not available to the retiree, will automatically be discontinued concurrently
with the commencement of retirement status.
If a retiree was not covered as an active employee
immediately prior to becoming an annuitant, the retiree will be automatically
enrolled in the basic retiree plan. Coverage for an eligible dependent of
a retiree will be effective on the same day the retiree's coverage becomes
effective if an application is received on or before the retiree's effective
date of coverage. Applications received after the first 31 days will be governed
by subsection (h) of this section.
]
(3)
]
An application to delete optional life coverages or to change
health coverage will be effective on the day the member becomes an annuitant
if the application is postmarked or received by the Employees Retirement System
on or before the effective date of retirement,
] unless other coverages
are in effect at that time. If other coverages are in effect at that time,
[
the deletion or change in
] coverage
becomes
[
will become
] effective on the first day of the month following the date
of approval of retirement by the Employees Retirement System of Texas; or,
if cancellation of the other coverages preceded the date of approval of retirement,
the first day of the month following the date the other coverages were canceled.
[
If the application is received after the date the member becomes an
annuitant, but within 30 days after the date the member becomes an annuitant,
the deletion or change of coverage will become effective the first day of
the month following the date the application for deletion or change is received,
unless other coverages are in effect at that time. If other coverages are
in effect at that time, the deletion or change in coverage will become effective
on the first day of the month following the date of approval of retirement
by the Employees Retirement System of Texas; or, if cancellation of the other
coverages preceded the date of approval of retirement, the first day of the
month following the date the other coverages were canceled. All other enrollment
rules stated in subsections (a), (g), and (l) of this section apply to retirees.
]
A surviving spouse and dependents
of a deceased employee who, at the time of death, had at least ten years of
service credit, including three years of service as an eligible employee with
a Uniform Group Insurance Program participating department, and who met the
program eligibility requirements in accordance with the Act may continue coverage
as provided in §81.5(f) of this title (relating to Eligibility). A surviving
spouse and dependents of a deceased retiree may continue coverage as provided
in §81.5(f) of this title. A surviving spouse who is receiving an annuity
shall make premium payments by deductions from the annuity as provided in
§81.3(d)(2)(A) of this title (relating to Administration). A surviving
spouse who is not receiving an annuity may make payments as provided in §81.3(d)(2)(B)
of this title. The surviving spouse or eligible dependents must apply to continue
coverage for himself or herself and dependents within 30 days after notification
in writing of eligibility to make application.
]
for
] coverage
on, or within 30 days after,
[
within 30 days from
] the date the notice of eligibility was mailed by
the system. Coverage
becomes effective on the first day
[
will begin the first
] of the month following the month in which continuation
coverage ends. Premium payments may be made as provided in §81.3(d)(2)(B)
(relating to Administration).
Pursuant to the premium conversion
plan, a participant may elect to pay certain insurance premium expenses for
health, disability, accidental death and dismemberment, dental, and group
term life with pre-tax dollars.
] The plan is intended to be qualified
under the Internal Revenue Code, §79 and §106.
Program
] and eligible dependents may participate in an approved
HMO if they reside in the approved service area of the HMO and are otherwise
eligible under the terms of the
contract
[
letter of agreement
] with the HMO.
Program
] and eligible dependents may participate in HealthSelect
Plus if they reside in
an
[
the
] approved service area
of HealthSelect Plus.
(7)
An employee who, during the annual
enrollment period prior to the beginning of a plan year or within 30 days
from their first active duty date, makes an application to increase insurance
coverage under the Program (the premium for which will exceed the State of
Texas' and the institution's total contributions for premium costs) may elect
not to participate in premium conversion by completing and submitting an enrollment
form during the annual enrollment period or within 30 days from the first
active duty date.
]
beyond the first 31 days of eligibility
].
The
premium conversion plan's affect on ability to change insurance coverage.
An employee participating in the premium conversion plan may not change coverages
during the plan year, unless there is a change in family status and the change
is consistent with the event. A change in family status includes marriage,
divorce, death of a dependent; birth or adoption; termination or gaining employment
by a dependent; change from full-time to part-time or part-time to full-time
employment status by employee or dependent; significant change in health insurance
coverage attributable to dependent gaining employment; employee's dependent
regains Program eligibility; employee acquires a Program eligible dependent;
employee is court ordered to provide medical support for dependent child;
dependent goes on or returns from leave without pay; dependent involuntarily
loses health coverage or dependent child loses dependent eligibility for other
health coverage; dependent gains or loses Medicaid eligibility; Program covered
dependent loses Program eligibility; Program covered dependent becomes eligible
for Program as a retiree; or, a dependent gains or loses eligibility for Medicare.
]
or HealthSelect Plus
] to HealthSelect of Texas
after the initial period for enrollment
[
more than 30 days after
the initial date of eligibility
] must make application for approval
by providing evidence of insurability acceptable to the system. Unless not
in compliance with paragraph (1) of this subsection, coverage will become
effective on the first day of the month following the date approval is received
by the employee's benefits coordinator or by the system, if the applicant
is a retiree or an individual in a direct pay status. If the applicant is
an employee in a leave without pay status, the approved change in coverage
will become effective on the date the employee returns to active duty if the
employee returns to active duty within 30 days of the approval letter. If
the date the employee returns to active duty is more than 30 days after the
date on the approval letter, the approval is null and void; and a new application
shall be required. An employee or retiree may withdraw the application at
any time prior to the effective date of coverage by submitting a written notice
of withdrawal.
more than 30 days after the
initial date of eligibility
];
more than 30 days after the initial date of eligibility
],
except as provided in subsections (a), (g)(5)-(6), and (h)
(6)-(10)
[
(7)-(11)
] of this section; [
or
]
subsection (k)(3), (4), and (6)
] of this section;
and
when a dependent
terminates employment, when a dependent loses health coverage for reasons
other than voluntary cancellation, when a dependent changes employment status,
when an employee or retiree divorces, or when a spouse dies, and as provided
in paragraph (13) of this subsection, unless not in compliance with paragraph
(1) of this subsection. The effective date of coverage will be the first day
of the month following the event date if an enrollment form is completed and
signed on or within 30 days following the date the dependent becomes eligible
under this rule
].
An employee, who is otherwise eligible to participate in the
Program but who did not decline participation in premium conversion prior
to the beginning of a plan year or who elected to participate and who has
a change in family status as defined in paragraph (1) of this subsection after
the beginning of the plan year, may elect not to participate in premium conversion,
if the change is consistent with the change in family status, by completing
and submitting an enrollment form within 30 days from the date the family
status change occurs.
]
An eligible participant, who
is enrolled in an approved HMO and permanently moves his or her place of residence
out of that HMO's service area to a location where the participant is no longer
eligible to be enrolled in any approved HMO, will be allowed to enroll in
HealthSelect of Texas or HealthSelect Plus, if the participant is eligible.
Coverage in the HMO will be canceled on the last day of the month in which
the previously described employee, retiree, or other participant moved from
the service area, and the coverages in HealthSelect of Texas or HealthSelect
Plus will become effective on the day following the day HMO coverage is canceled.
The evidence of insurability provision shall not apply in these cases.
]
An eligible participant, who is enrolled in
HealthSelect Plus and permanently moves his or her place of residence out
of the HealthSelect Plus service area will be enrolled in HealthSelect of
Texas, whether or not an HMO is available. Coverage in HealthSelect Plus will
be canceled on the last day of the month in which the previously described
employee, retiree, or other participant moved from the service area, and coverage
in HealthSelect of Texas will become effective on the day following the day
HealthSelect Plus coverage is canceled. The evidence of insurability provision
shall not apply.
]
When a covered dependent of an
eligible participant permanently moves out of the participant's HMO service
area, the participant must make one of the following elections, to become
effective on the first day of the month following the date the dependent moved
out of the participant's HMO service area:
]
(A)
drop the ineligible dependent, unless
not in compliance with paragraph (1) of this subsection, or §81.11(a)(2)
(relating to Termination of Coverage); or
]
(B)
enroll in HealthSelect of Texas or HealthSelect
Plus, if the participant and all covered dependents are eligible. The evidence
of insurability provision shall not apply.
]
(10)
When a covered dependent of
an eligible participant permanently moves out of the HealthSelect Plus service
area, the participant must make one of the following elections to become effective
on the first day of the month following the date the dependent moved out of
the HealthSelect Plus service area:
]
(A)
drop the ineligible dependent, unless
not in compliance with paragraph (1) of this subsection, and §81.11(a)(2)
(relating to Termination of Coverage; or
]
(B)
change coverage to HealthSelect of Texas.
The evidence of insurability provision shall not apply.
]
(11)
]
to their
] coverages [
and premium conversion election, if applicable
].
Persons
] will be allowed
to:
or
]
enroll
or cancel enrollment in the premium conversion plan
].
(viii),
] (x), or (xi) of this paragraph
, except that a surviving dependent
or former COBRA unmarried child may enroll an eligible dependent in dental
insurance coverage if the dependent is enrolled in health insurance coverage.
The evidence of
insurability provision shall not apply to persons changing from HealthSelect
Plus to HealthSelect of Texas.
]
(D)
Employees on approved leave of absence
or extended sick leave without pay on the first day of a new plan year will
be provided an opportunity to change their enrollment in the premium conversion
plan and apply through evidence of insurability for coverage within the first
30 days after return to active duty.
]
(12)
]
Unless not in compliance with paragraph (1) of
this subsection and §81.11(a)(2) (relating to Termination of Coverage),
an eligible participant who wishes to decrease or cancel coverage may do so
at any time. Coverage will continue through the last day of the month following
the signature date of the enrollment form.
]
(13)
An eligible dependent spouse or
child who has health coverage as an employee under the program becomes eligible
for coverage as a dependent on the day following termination of employment.
Eligible dependent children who have health coverage in the program as dependents
of an employee who terminates employment also become eligible for coverage
on the day following termination of employment. In order to be eligible for
coverage, dependents must meet the definition of dependent contained in §81.11
of this title (relating to Definitions) and be enrolled for coverage by the
employee of whom they are the eligible dependent and who is enrolled for health
coverage under the program. The effective date of coverage will be the first
day of the month following termination of employment if an enrollment form
is completed and signed on or within 30 days following the date the dependent(s)
become eligible under this rule.
]
(14)
Notwithstanding the effective dates
of coverages, as defined in paragraphs (3)-(12) of this subsection, an eligible
participant in the program may complete an enrollment form or enrollment forms
during the annual enrollment period to make coverage changes, as determined
by the trustee, to be effective September 1.
]
Disability
] coverage. The exclusion for benefit payments shall not apply
after the first six consecutive months that the employee has been actively
at work or after the employee's disability coverage has been continuously
in force for 12 months for a preexisting condition, as defined in §81.1
of this title (relating to Definitions). The preexisting conditions exclusion
will not apply to[
:
]
a medical condition resulting from congenital
or birth defects.
(1)
a medical condition resulting from congenital
or birth defects; or
]
(2)
an individual returning to state
employment in accordance with the conditions described in subsection (k)(3)
of this section.
]
Unless specifically prohibited by these
sections, paragraph (2) of this subsection, or contractual provisions, an
employee who terminates employment and returns to active duty within the same
contract year may reinstate health coverage for himself and his dependents
identical to, and optional coverages no greater than, those that were in effect
when the employee terminated by submitting an enrollment form for the coverages.
The enrollment form must be submitted on the first day the employee returns
to active duty, and, unless the employee completes the enrollment form indicating
coverages are to be effective on the first day of the month following the
date the employee returns to active duty, the coverages will be effective
on the day the employee returns to active duty. Dependents acquired during
the break in employment may be added on the enrollment form. A returning employee
who has selected coverages less than those for which the employee is eligible
may reinstate any waived coverages by submitting the appropriate enrollment
form during the 30 days following the date the employee returns to active
duty. The change in coverage will become effective on the first day of the
month following the date of signature on the enrollment form. If the coverage
of an employee returning to active duty within the same plan year is affected
by paragraph (2) of this subsection, the employee must reinstate all coverages
that were in effect on the termination date, and the effective date of reinstated
coverage must be the date the employee returns to active duty.
]
A terminated employee who returns
to state or institution of higher education employment, or an employee who
returns to active duty from an approved leave of absence without pay, or transfers
from one state agency to another or between an agency and an institution of
higher education as defined in these rules, within the same plan year, must
retain for the remainder of the plan year the premium conversion election
in existence on the employee's last active duty date, unless an eligible change
in family status occurred in accordance with subsection (h) of this section.
]
An
] employee who is a member of the Texas National
Guard or any of the reserve components of the United States Armed Forces and
who is in a military leave without pay status or who must terminate employment
as the result of an assignment to active military duty
shall
[
may
], upon return to active employment, reinstate all
canceled
[
program
] coverages that were in effect immediately prior
to the commencement of active military duty, as long as the return to active
employment occurs within 90 days of the release from active military duty.
An employee
shall
[
may
] also reinstate the coverage
of the employee's dependent, who is a member of the Texas National Guard or
any of the reserve components of the United States Armed Forces and whose
coverage is terminated as the result of an assignment to active military duty.
Except as provided in subsection (h)(1) of this section, coverage becomes
effective on the date of return to active employment.
To reinstate canceled
coverages, submission of evidence of insurability acceptable to the carrier
will not apply. Provided all applicable preexisting conditions exclusions
were satisfied at the time coverages were canceled, no additional preexisting
conditions exclusions will apply upon reinstatement of coverages. If not,
any remaining period of preexisting conditions exclusions must be satisfied
upon reinstatement
, except that the period of active military duty shall
be applied toward satisfaction of the remaining period of preexisting conditions
exclusions.
[
The enrollment form to reinstate such coverages must
be completed and signed during the 30 days following the day the employee
returns to active employment. In the case of dependents, the enrollment form
to reinstate coverages must be completed and signed within 30 days following
the release from active duty. Enrollment forms for coverages to be effective
on the day the employee returns to active employment must be completed and
signed on or before the first day of the return to active employment. Coverages
for which the enrollment form is completed and signed after the first day
of the return to active state employment and within 30 days after that day
will be effective on the first day of the month following the date of signature
on the enrollment form. However, if the coverage of an employee returning
to active duty within the same plan year is affected by paragraph (2) of this
subsection, the employee must reinstate all coverages that were in effect
on the day immediately prior to entering the leave without pay status, and
the effective date of reinstated coverage must be the date the employee returns
to active duty.
]
Employees
] whose coverages were canceled
during a period of leave without pay due to a certified work-related disability
shall
[
may
], upon return to active duty status, reinstate
all coverages that were in effect on the day immediately prior to entering
the leave without pay status
. Except as provided in subsection (h)(1)
of this section, coverage becomes effective on the date on which the employee
returns to active duty.
[
, except as provided in §81.11(c)(4)
of this title (relating to Termination of Coverage), and provided an enrollment
form to reinstate such coverages is completed and signed within 30 days of
the return to active duty.
]
To reinstate canceled coverages, submission
of evidence
[
Evidence
] of insurability
acceptable to
the carrier
will not apply. Provided all applicable preexisting conditions
exclusions were satisfied at the time coverages were canceled, no additional
preexisting conditions exclusions will apply upon reinstatement of coverages.
If not, any remaining period of preexisting conditions exclusions must be
satisfied upon reinstatement. [
Coverages applied for on the first day
of return to active duty will be effective on that day unless the employee
completes and signs the enrollment form indicating coverages are to be effective
on the first day of the month following the date the employee returns to active
duty. Coverages applied for after the first day of return to active duty and
within 30 days after that day will be effective on the first day of the month
following the date of signature on the enrollment form. However, if the coverage
of an employee returning to active duty within the same plan year is affected
by paragraph (2) of this subsection, the employee must reinstate all coverages
that were in effect on the day immediately prior to entering the leave without
pay status, and the effective date of reinstated coverage must be the date
the employee returns to active duty.
]
Employees whose
coverages were cancelled
] during a period of leave without pay as a
result of the Family and Medical Leave Act of 1993
shall
[
may
], upon return to active duty, reinstate all coverages that were
in effect on the day immediately prior to entering the leave without pay status.
Except as provided in subsection (h)(1) of this section, coverage becomes
effective on the date on which the employee returns to active duty.
[
, provided an enrollment form to reinstate such coverages is completed
and signed within 30 days of the return to active duty. However, if the coverage
of an employee returning to active duty within the same plan year is affected
by paragraph (2) of this subsection, the employee must reinstate all coverages
that were in effect on the day immediately prior to entering the leave without
pay status, and the effective date of reinstated coverage must be the date
the employee returns to active duty.
] To reinstate
canceled
[
cancelled
] coverages, submission of evidence of insurability acceptable
to the carrier will not apply. Provided all applicable preexisting conditions
exclusions were satisfied at the time coverages were
canceled
[
cancelled
], no additional preexisting conditions exclusions will apply
upon reinstatement of coverages. If not, any remaining period of preexisting
conditions exclusions must be satisfied upon reinstatement.
(6)
Employees whose coverages were canceled
on or after January 31, 1995, during a period of leave without pay, except
as provided in paragraphs (3)-(5) of this section, shall upon return to active
duty be enrolled in the basic plan, provided the employee is eligible for
the full state contribution. Reinstatement of canceled coverages must be in
compliance with subsection (h) of this section.
]
first day
]
the employee returns to active duty if the entire period of unpaid leave was
certified by the department as approved leave without pay.
Except as prohibited by §81.7(h)(1) of this
title (relating to Enrollment and Participation) and paragraph (2) of this
subsection, an employee, retiree, or surviving spouse may cancel any coverage
in effect.
] Coverage will continue through the last day of the month
in which coverage is
canceled
[
cancelled
]. Coverage
canceled by a surviving spouse or dependent of a deceased retiree may never
be reinstated.
Chapter 85.
Flexible Benefits