Part 3.
TEACHER RETIREMENT SYSTEM OF TEXAS
Chapter 41.
HEALTH CARE AND INSURANCE PROGRAMS
Subchapter C. TEXAS SCHOOL EMPLOYEES GROUP HEALTH (TRS-ACTIVECARE)
34 TAC §§41.34, 41.41, 41.50
The Teacher Retirement System of Texas (TRS) proposes amendments
to §§41.34, 41.41, and 41.50, relating to the Texas School Employees
Uniform Group Health Coverage Program known as TRS-ActiveCare. Section 41.34
relates to eligibility for coverage in TRS-ActiveCare; §41.41 relates
to premium payments for TRS-ActiveCare; and §41.50 concerns the adjudication
of claims in TRS-ActiveCare. The proposed amendment to §41.34 clarifies
the length of TRS-ActiveCare eligibility for an individual who is eligible
for or participating in COBRA continuation coverage through the individual's
employer when the employer first becomes a participating entity in TRS-ActiveCare.
The proposed amendment also provides that the individual's eligibility for
TRS-ActiveCare coverage continues only so long as the individual's eligibility
for COBRA continuation coverage exists. The proposed amendments to §41.41
clarify the TRS-ActiveCare premium billing process and reduce the time frame
for participating entities to request changes to their premium bills. The
proposed amendments also clarify that the premium bill includes all employees
enrolled in TRS-ActiveCare who are employed by a participating entity on the
date that the bill is generated rather those employed on the first day of
the month. Additionally, the proposed amendments reduce the time period for
a participating entity to request an adjustment to the premium bill from 90
days to 45 days. The proposed amendments to §41.50 permit the TRS-ActiveCare
Appeal Committee, after a request for an appeal conference, to resolve the
appeal in favor of the claimant without the necessity of an appeal conference.
The proposed amendment would prevent the Appeal Committee from resolving the
appeal against the claimant without holding the appeal conference.
Tony Galaviz, Chief Financial Officer, has determined that for each year
of the first five-year period the amendments are in effect, there will be
no fiscal implications to state or local governments as a result of enforcing
or administering the sections. There is no foreseeable effect on local employment
or local economies as a result of the proposed amendments.
Mr. Galaviz has also determined that for each year of the first five years
the proposed amendments are in effect the public benefit anticipated as a
result of the proposed amendments to §41.34 will be that the employers
and employees will have notice of the length of TRS-ActiveCare eligibility
in certain circumstances. In addition, the proposed amendments to §41.41
provide employers notice of which employees are included in the TRS-ActiveCare
premium bills. Additionally, corrections to premium bills will be made more
quickly so that providers may not suffer recoupment for payments made on behalf
of individuals who were not eligible for TRS-ActiveCare coverage when they
received services. The public benefit anticipated as a result of the proposed
amendments to §41.50 will be administrative efficiency for TRS and for
claimants who may be relieved of traveling to TRS to hold an appeal conference
if the appeal can be resolved in the claimant's favor without the necessity
of the conference. There is no anticipated adverse economic effect on small
businesses or micro-businesses as a result of compliance with the proposed
sections. Mr. Galaviz has determined that there are no anticipated economic
costs to persons required to comply with the proposed sections for each year
of the first five years the proposal will be in effect.
Comments on the proposal may be submitted to Charles L. Dunlap, Executive
Director, 1000 Red River, Austin, Texas 78701. To be considered, written comments
must be received by TRS no later than 30 days after publication of the amendments
for proposal.
These amendments are proposed under the Insurance Code article
3.50-7, §3, which gives TRS authority to adopt rules as necessary to
implement and administer the TRS-ActiveCare program. The amendments are also
proposed under Government Code, Chapter 825, §825.102, which authorizes
the Board of Trustees of the Teacher Retirement System to adopt rules for
the transaction of business of the Board.
There are no other codes affected.
§41.34.Eligibility for Coverage under the Texas School Employees Uniform Group Health Coverage Program.
The following persons are eligible to be enrolled in the TRS-ActiveCare
program under terms, conditions and limitations established by the trustee
unless expelled from the program under provisions of Insurance Code article
3.50-7.
(1)
A full-time employee as defined in §41.33 of this
title (relating to Definitions Applicable to the Texas School Employees Uniform
Group Health Coverage Program).
(2)
A part-time employee as defined in §41.33 of this
title (relating to Definitions Applicable to the Texas School Employees Uniform
Group Health Coverage Program).
(3)
Dependents, as defined under Insurance Code article 3.50-7,
section 2(3)(A), (B) or (C), of either a full-time employee or a part-time
employee. A child defined in Insurance Code article 3.50-7, §2(3)(C)
is eligible for coverage only if, and only for so long as, such child's mental
retardation or physical incapacity is a medically determinable condition that
prevents the child from engaging in self-sustaining employment as determined
by TRS.
(4)
Individuals employed or formerly employed by a participating
entity, and their dependents, who are eligible for, or participating in, continuation
coverage under the Consolidated Omnibus Budget Reconciliation Act of 1985
(Pub. L. 99-272), through a group health benefit plan sponsored by the individual's
employer on the first day that employer becomes a participating entity if
such individuals or their dependents would have met the requirements for eligibility
in paragraphs (1), (2), or (3) of this section on the individual's last day
of employment with the participating entity.
Notwithstanding the foregoing,
the individual is eligible to participate in TRS-ActiveCare only for the duration
of the individual's eligibility for COBRA continuation coverage.
(5)
Full-time or part-time employees as defined in §41.33
of this title and their eligible dependents may participate in an approved
HMO if they reside, live, or work in the approved service area of the HMO
and are otherwise eligible to participate in the HMO under the terms of the
TRS contract with the HMO.
(6)
Individuals who become eligible as determined by TRS for
continuation coverage under the Consolidated Omnibus Budget Reconciliation
Act of 1985 (Pub. L. No. 99-272), through their participation in the TRS-ActiveCare
program.
(7)
Individuals who become eligible for coverage under provisions
of the Health Insurance Portability and Accountability Act of 1996 (Pub. L.
No. 104-191, 110 Stat. 1936 (1996)) (HIPAA), except for any provisions of
HIPAA from which TRS has elected to be exempt in accordance with its status
as a self-insured non-Federal governmental plan.
(8)
Any other individuals who are required to be covered under
applicable law.
§41.41.Premium Payments.
(a)
Each participating entity shall remit to TRS the amount
on each bill directed to the participating entity by TRS or the administering
firm. The participating entity shall remit payment on or before the sixth
day after the last day of each month in which TRS or the administering firm
issued a bill. Payment shall be delivered in the same manner (e.g., currently,
TEXNET) in which the participating entity delivers retirement contributions.
Any waiver granted to a participating entity under Government Code §825.408(a)
does not apply to amounts billed under this section or to amounts otherwise
owed to TRS for the TRS-ActiveCare program.
(b)
A participating entity will be billed for all full-time
and part-time employees enrolled in the TRS-ActiveCare program who were employed
by the participating entity on the
date that TRS or its designee generates
the bill for that billing month
[
(c)
Participating entities shall not modify the amount of any
bill or remit any amount different from the amount billed. A participating
entity shall report proposed adjustments, including those seeking credit for
terminated employees, to the administering firm no later than the
45th
[
(d)
TRS may take corrective action against a participating
entity that fails to remit payment in accordance with the timelines and other
requirements of this section, including but not limited to placement of a
warrant hold with the Comptroller of Public Accounts.
§41.50.Adjudication of Claims.
(a)
A person enrolled in the TRS-ActiveCare program who is
denied payment of a claim or other benefit may submit a written request to
the administering firm for reconsideration of the claim. A person shall submit
a request for reconsideration according to procedures established by the administering
firm. All relevant medical information should be submitted to the administering
firm prior to a final decision.
(b)
A person may appeal the final denial of a claim or other
benefit by the administering firm to the Teacher Retirement System of Texas
(TRS), acting in its capacity as trustee of the TRS-ActiveCare program.
(c)
An appeal of a final denial of a claim or other benefit
by the administering firm must be submitted in writing and received by TRS
no later than 60 days after the date of the letter from the administering
firm finally denying the claim. The appeal shall be directed to the attention
of the TRS-ActiveCare Grievance Administrator.
(d)
An appeal of denial of a claim shall state the nature of
the claim and shall include copies of all relevant documents that were considered
by the administering firm, including copies of the correspondence to and from
the administering firm.
(e)
The TRS Appeal Committee ("Committee") is responsible for
review and determination of appeals. The Committee shall be appointed by the
TRS Deputy Director and shall serve at the discretion of the Deputy Director.
(f)
The Committee shall review an appeal for timeliness and
sufficiency and may deny an appeal that is not timely filed. Denial of an
appeal for failure to file in a timely manner is a final decision by TRS.
(g)
If the Committee determines that the claim should be paid,
it shall so inform the administering firm and the person who filed the appeal.
(h)
If the Committee determines that the information submitted
with the appeal supports the denial by the administering firm, the Committee
shall provide a written explanation of the reasons to the claimant and to
the administering firm. The explanation shall include information on how the
claimant may request an appeal conference.
(i)
To obtain an appeal conference, a claimant must submit
a request in writing to the TRS-ActiveCare Grievance Administrator no later
than 45 days after the date of the written explanation of the Committee.
(j)
Upon receipt of a timely request for an appeal conference,
the TRS-ActiveCare Grievance Administrator shall schedule an appeal conference
with the Committee. The Grievance Administrator shall notify the person who
filed the appeal and the administering firm of the time, date, and manner
of the conference, as well as the procedures applicable to the conference.
(k)
At any time prior to the appeal
conference, the Committee may decide to grant the appeal and will notify the
claimant of this determination without the necessity of an appeal conference.
The Committee can not deny a claim after an appeal conference has been requested
without holding the conference.
(l)
[
(m)
[
(n)
[
This agency hereby certifies that the proposal has been reviewed
by legal counsel and found to be within the agency's legal authority to adopt.
Filed with the Office of
the Secretary of State on July 11, 2003.
TRD-200304181
Charles Dunlap
Executive Director
Teacher Retirement System of Texas
Proposed date of adoption: September 25, 2003
For further information, please call: (512) 542-6115
Chapter 190.
ALLOCATION OF STATE'S LIMIT ON CERTAIN PRIVATE ACTIVITY BONDS
Subchapter A. PROGRAM RULES
first day of the billing month
] as reported by the participating entity. In addition, a participating
entity will be billed retroactively for all full-time and part-time employees
who enroll after the
date on which the bill is generated for that month
[
first day of a month
] and choose coverage for that month.
A participating entity will also be billed for any individual covered in accordance
with §41.40 of this title (relating to Coverage Continuation While on
Leave Without Pay.) Participating entities are responsible for collecting
all applicable premiums and other costs that are required to be paid by its
full-time employees, part-time employees, and any individuals covered in accordance
with §41.40 of this title. A participating entity shall remit the full
amount billed each month.
90th
] day after the billing date. TRS may reject any [
inappropriate
] proposed adjustments
that are inappropriate or untimely
, including those
adjustments seeking credit for terminated employees
reported later than
45
[
90
] days after the billing
date
on which the employee was first incorrectly reported as eligible
for coverage
. Approved adjustments will be reflected on a subsequent
bill.
(k)
] At the conference, the Committee
shall consider the medical information previously submitted to the administering
firm in support of the payment of the claim or benefit, as well as the administering
firm's determination regarding medical issues. The Committee may request additional
review by the administering firm on medical issues before the Committee issues
a decision.
(l)
] The Committee shall decide
the appeal and shall notify the claimant and the administering firm of the
decision in writing. The decision will include an explanation of the basis
for the decision.
(m)
] The decision of the Committee
may be appealed by the claimant to the TRS Executive Director. An appeal to
the Executive Director shall be submitted to TRS in writing no later than
30 days after the date of the written decision by the Committee. The appeal
shall specifically describe why the claimant alleges that the Committee's
decision is erroneous. The Executive Director shall make a decision based
on the written appeal and based on the written decision of the Committee,
as well as any written documents reviewed by the Committee. Pursuant to the
delegation of authority through this section, the decision of the Executive
Director is the final decision of TRS.
Part 9.
TEXAS BOND REVIEW BOARD