34 TAC §§41.31, 41.33, 41.34, 41.36
The Teacher Retirement System of Texas (TRS) adopts amendments
to §41.31 concerning eligible bidders; §41.33 concerning definitions; §41.34
concerning eligibility for coverage; and §41.36 concerning enrollment
periods, all of which are related to the Texas School Employees Uniform Group
Health Coverage Program ("Program"). Sections 41.31 and 41.33 are being adopted
with non-substantive changes to the text as published in the November 8, 2002,
issue of the
Texas Register
(27 TexReg 10572).
The amendments to §41.34 and §41.36 are adopted without changes
to the text as published in the November 8, 2002 issue of the
Texas Register
(27 TexReg 10573) and will not be republished. These
amendments were previously adopted on an emergency basis and published in
the November 8, 2002 issue of the
Texas Register
(27 TexReg 10511) and will be withdrawn effective 20 days after the
filing this permanent adoption.
TRS has made one non-substantive change to §41.31(c)(1) deleting the
word "be" to correct a grammatical error. Similarly, TRS has made one non-substantive
change to § 41.33(3) to add the word "of" between "certificate" and "authority."
The amendments to §41.31 set forth, among other things, the criteria
that HMOs must meet in order to participate in the competitive bid process
to select contractors to offer benefits under the TRS-ActiveCare program.
The amendments also clarify that TRS may establish additional criteria and
the length and terms of any contracts. The amendments to §41.33 add the
definition of HMOs for purposes of this chapter. The amendments to §41.34
set forth the participant eligibility provisions for approved HMOs. In addition,
the amendments to §41.36 establish procedures for participants in an
HMO who become ineligible during the plan year or who participate in an HMO
with a TRS contract that is not renewed for the next plan year or that terminates
before the end of the plan year.
These amendments provide notice to potential bidders as well as participating
entities and their employees of requirements for eligibility in the Program
and notice of enrollment provisions, including certain enrollment deadlines.
No comments on the proposals were received.
The amendments are adopted under the Government Code, Chapter
825, §825.102, which authorizes the Board of Trustees of the Teacher
Retirement System to adopt rules for, among other things, the transaction
of business of the board. The amendments are also adopted under House Bill
3343, which was passed by the 77th Legislature, 2001, including Insurance
Code article 3.50-7, which authorizes TRS to adopt rules to administer the
Program. Insurance Code article 3.50-7, §3(c) further authorizes TRS,
as trustee, to "adopt rules relating to the program as considered necessary
by the trustee."
§41.31.Eligible Bidders.
(a)
The Texas School Employees Uniform Group Health Coverage
Program may include separate contracts for:
(1)
health benefit plan;
(2)
prescription drug provider;
(3)
administrative services;
(4)
utilization review; and
(5)
services to provide other ancillary benefits.
(b)
Except for health maintenance organizations, which must
meet other requirements in this section, to be eligible to bid on health benefit
services or products, prescription drugs or administrative services, a bidder
must have:
(1)
annual health benefit premiums or services or product income
of at least $1 billion; and
(2)
currently be servicing at least twice as many persons as
will be covered under this program as determined by TRS.
(c)
TRS may approve a health maintenance organization (HMO)
to offer a health benefit plan to participants in the TRS-ActiveCare program.
In order to be eligible to bid or make a proposal, an HMO must satisfy all
of the following conditions:
(1)
The HMO must hold a valid certificate of authority issued
by the Texas Department of Insurance to operate in the State of Texas.
(2)
The HMO must have been providing services in the applicable
service area for at least 12 months prior to the date the bid response is
due to be filed with TRS. Also, the HMO must demonstrate the capacity to provide
adequate services, as determined by TRS, to the program participants.
(3)
The HMO must submit a responsive bid or proposal, with
rates, to TRS within the timeframe and in the manner and format prescribed
by TRS. Once adopted by TRS, the rates and benefit may not be modified during
a plan year without the prior written approval of TRS. A request for expansion
to a non-contiguous service area shall require a separate responsive bid or
proposal and approval by TRS.
(4)
Any other criteria established by TRS.
(d)
TRS shall use a competitive bidding process to approve
one or more HMOs to offer a health benefit plan to TRS-ActiveCare program
participants in areas of the state determined by TRS. TRS may establish, for
different areas of the state, different criteria for HMOs to qualify to bid
or make a proposal. TRS may at any time establish or change the number, if
any, of HMOs to approve in each area. If TRS elects to request bids or proposals
for such plans, TRS will establish:
(1)
the criteria to be used to approve HMOs;
(2)
the length and terms of the contracts with approved HMOs;
and
(3)
other matters at the discretion of TRS.
§41.33.Definitions Applicable to the Texas School Employees Uniform Group Health Coverage Program.
The following words and terms when used in subchapter C or in connection
with the administration of Insurance Code §3.50-7 shall have the following
meanings unless the context clearly indicates otherwise.
(1)
Dependent--All individuals described by Insurance Code
3.50-7, §2(3), including an unmarried child under 25 years of age ("child")
who is described by any one of the following subparagraphs at all times during
which the child is receiving coverage under the TRS-ActiveCare Program.
(A)
A child under the legal guardianship of a full-time or
part-time employee;
(B)
A full-time or part-time employee's grandchild whose primary
residence is the household of that full-time or part-time employee if the
child is a dependent of the full-time or part-time employee for federal income
tax purposes; or
(C)
A child in a regular parent-child relationship with a full-time
or part-time employee, meaning that the child's primary residence is the household
of that full-time or part-time employee, the full-time or part-time employee
provides at least 50% of the child's support, neither of the child's natural
parents reside in that household, and the full-time or part-time employee
has the legal right to make decisions regarding the child's medical care.
(2)
Full-time employee--A participating member who:
(A)
is currently employed by a participating entity;
(B)
is eligible for membership in the Teacher Retirement System
of Texas based on current full-time service as described by §25.1 of
this title (relating to Full-Time Service), or based on current employment
as a bus driver as described by §25.2 of this title (relating to Bus
Drivers); and
(C)
is not receiving coverage as an employee or retiree from
a uniform group insurance program under the Texas Employees Uniform Group
Insurance Benefits Act (Insurance Code article 3.50-2) or the Texas State
College and University Employees Uniform Group Insurance Benefits Act (Insurance
Code article 3.50-3) or the Texas Public School Employees Group Insurance
Program established under Insurance Code article 3.50-4 (TRS-Care).
(3)
HMO--A health maintenance organization holding a valid
certificate of authority issued by the Texas Department of Insurance and approved
by TRS to provide health care benefits to eligible full-time and part-time
employees and their eligible dependents.
(4)
Participating entity--An entity participating in the TRS-ActiveCare
program including a school district; another educational district whose employees
are members of the retirement system; a regional education service center;
and a charter school that meets the requirements of Insurance Code article
3.50-7. An entity is considered to be participating in the TRS-ActiveCare
program on and after the first date coverage becomes effective for its employees.
(5)
Participating member--A person defined by Government Code §§822.001
and 822.002 whose membership in the retirement system has not been terminated
as described by Government Code §§822.003 - 822.006 and who is currently
contributing to the Teacher Retirement System of Texas pension trust fund
in accordance with Government Code §825.403.
(6)
Part-time employee--An individual who is currently employed
by a participating entity for 10 hours or more each week; and:
(A)
is not a full-time employee;
(B)
is not a retiree who waived coverage under the Texas Public
School Employees Group Insurance Program established under Insurance Code
article 3.50-4 (TRS-Care); and
(C)
is not receiving coverage as an employee or retiree from
a uniform group insurance program under the Texas Employees Uniform Group
Insurance Benefits Act (Insurance Code article 3.50-2) or the Texas State
College and University Employees Uniform Group Insurance Benefits Act (Insurance
Code article 3.50-3) or the Texas Public School Employees Group Insurance
Program established under Insurance Code article 3.50-4 (TRS-Care).
(7)
Plan year--A plan year begins on the first day of September
and ends on the last day of the following August.
(8)
TRS-ActiveCare program--The Texas School Employees Uniform
Group Health Coverage Program established by Insurance Code article 3.50-7.
(9)
Trustee or TRS--The Teacher Retirement System of Texas
acting in its capacity as trustee under Insurance Code article 3.50-7.
This agency hereby certifies that the adoption has been
reviewed by legal counsel and found to be a valid exercise of the agency's
legal authority.
Filed with the Office of
the Secretary of State on January 8, 2003.
TRD-200300062
Charles L. Dunlap
Executive Director
Teacher Retirement System of Texas
Effective date: January 28, 2003
Proposal publication date: November 8, 2002
For further information, please call: (512) 542-6115