Part IV.
Employees Retirement System
Chapter 81.
Insurance
34 TAC §§81.1, 81.3, 81.5, 81.7, 81.9, 81.11
The Employees Retirement System of Texas (ERS) adopts amendments
to §§81.1, 81.3, 81.5, 81.7, 81.9, and 81.11, concerning the Uniform
Group Insurance Program, with changes to the proposed text as published in
the November 7, 1997, issue of the
Texas Register
(22 TexReg 10907).
These rules are being amended to bring them into compliance with recent
legislation.
These rules are amended to add and clarify definitions, in addition to
updating and clarifying existing rules to bring them into compliance with
recent legislation.
One organization commented generally on the policy direction contemplated
in the proposed amendments to 34 TAC Chapter 81, to select health maintenance
organizations (HMOs) to participate in certain regions by competitive bidding.
This commentator expressed concern that the selection of HMOs by competitive
bid will place too much emphasis on low cost rather than overall quality.
This commentator also expressed concern that proposed rule 34 TAC §81.3(c)(1)(A)
and (B) would require the submission of duplicative proposals for each Regional
Bidding Area (RBA) and requested that any duplicative information be required
to be submitted only once. The commentator also requested clarification of
the submission deadline for responses to the Request for Proposal. The commentator
questioned proposed rule 34 TAC §81.7(a)(8) which would automatically
place a participant in the HealthSelect plan if he moves out of the service
area for HealthSelect Plus, and requested that such participant be permitted
to select any HMO. Finally, the commentator questioned rule 34 TAC §81.7(g)(2)
and (3) which states that an eligible participant must reside in the service
area, rather than reside or work in the service area.
One state agency submitted comments regarding proposed rules for Accelerated
Life Benefits (ALB). Regarding the proposed rules located at 34 TAC §81.1,
the agency noted that Article 3.50-2, Texas Insurance Code, as amended by
House Bill 163 requires that ALB be made available to annuitants but that
the proposed rules do not refer to ALB being available to annuitants, and
proposed 34 TAC §81.7 expressly prohibits annuitants from eligibility
for ALB. The agency further noted that legislation makes ALB subject to Article
3.50-6, Texas Insurance Code, which was not referred to in the proposed rules
either, nor were costs and conditions of coverages detailed. The agency suggested
that the rules define "terminal illness", a term defined in Art. 3.50-6. The
agency also suggested that the rule proposed at 34 TAC §81.7(j), which
appears to prohibit retirees from electing ALB, conflicts with a provision
in Senate Bill 1102 which makes ALB available to a retiree whose terminal
condition began before retirement. The commentator recommended that the rules
be clarified to state that the amount paid out as an accelerated benefit will
be deducted from the amount otherwise payable as a death benefit. Finally,
the commentator noted that Senate Bill 1102 provides that the trustee may
provide ALB without increasing the cost of providing the benefit and suggested
that the rules clarify whether there are any special premiums, charges or
fees associated with exercising the ALB option.
A state legislator commented that the proposed rules are not consistent
with House Bill 163 in that they do not make ALB available to annuitants as
well as to employees and dependents. The commentator also noted that the proposed
rules do not define "terminal illness", do not describe all of the costs and
conditions associated with the accelerated benefit, and do not refer to Article
3.50-6, Texas Insurance Code, regarding ALB.
The ERS responded in writing to all commentators. To the HMO organization
expressing concern that the selection of participating HMOs by competitive
bidding will place too much emphasis on low cost rather than on overall quality,
the ERS responded that, while cost containment is an important objective of
the bidding process, premium cost will be only one important factor considered
in the selection of HMOs to serve the Texas Employees Uniform Group Insurance
Program (UGIP). Other important factors will include quality of care and availability
and accessibility of providers. In response to the organization's concern
that the rules set out in 34 TAC §81.3 may require multiple response
documents to the Request for Proposals (RFP), the ERS clarified that only
one response document will be necessary. The ERS also clarified the filing
deadline as requested. In response to the commentator's objection to proposed
rule 34 TAC §81.7(a)(8) which would automatically place a participant
in the HealthSelect of Texas plan if the participant moves out of the service
area of the HealthSelect Plus plan, the ERS noted that this option was selected
because both HealthSelect plans are self-insured by the ERS, and that the
employee may change to any participating HMO during the next annual enrollment
period. Finally, in response to the organization's comment that proposed rule
34 TAC §81.7(g)(2) and (3), which requires that a participant reside
in an HMO's service area, is in conflict with the rule of the Texas Department
of Insurance (TDI) and federal law, which permits participation in an HMO
if the participant either lives or works in the HMO's service area, the ERS
noted that it disagreed with TDI's rule and interpretation of federal law,
but would follow the "live or work" rule as of the next annual enrollment
period, effective September 1, 1998. Extensive system reprogramming and communications
to over 250,000 employees and retirees prevent earlier adoption of the "live
or work" rule for the UGIP.
In response to the state agency's comment that Article 3.50-2, Texas Insurance
Code, as amended by House Bill 163, requires ALB to be made available to annuitants
as well as employees and dependents, the ERS responded that because Senate
Bill 1102 prohibits extending ALB to annuitants, the two bills are in direct
conflict. The ERS has determined that, pursuant to the Texas Code Construction
Act, Senate Bill 1102 is the controlling legislation. The state agency also
suggested that House Bill 1865 requires the proposed rules to be subject to
Article 3.50-6, Texas Insurance Code, and that the rules do not refer to Article
3.50-6. The ERS responded that House Bill 1865 does not directly address rules
adopted by the ERS. Rather, House Bill 163 requires the rules to be subject
to Article 3.50-6 and, in response, the ERS has amended the definition of
ALB in the rules to refer to Article 3.50-6. The agency also suggested that
the rules define "terminal illness" and, in response, the ERS has amended
the rules to define "terminal condition". In response to the agency's suggestion
that the rule proposed at 34 TAC §81.7(j) be clarified to make ALB available
to a retiree whose terminal condition began before retirement, the ERS amended
the proposed rule to so clarify. The state agency recommended that the rules
be amended to clarify that the amount paid out as an accelerated benefit will
be deducted from the amount otherwise payable as a death benefit, and the
ERS has amended the proposed rule to so clarify. Finally, in response to the
state agency's comment that Senate Bill 1102 provides that the trustees may
provide ALB without increasing the cost of providing the benefit, and its
recommendation that the rules clarify whether there are any special premiums,
charges or fees associated with exercising the ALB option, the ERS noted that
while an administrative fee will be charged for handling each ALB application,
the ERS will absorb the cost and no fee will be passed along to the insured.
Because no fee or special premium will be charged the insured at this time,
but the ERS reserves the right to adopt a fee or surcharge in the future if
necessary, the ERS responded that it believes it is best not to amend the
proposed rules at this time to address a matter which is moot.
The ERS agreed with the legislator's comment that the rule should define
"terminal illness" and included a definition of "terminal condition" in the
rules under the definition of ALB. In response to the state legislator's comment
that the proposed rules do no permit annuitants to participate in accelerated
life benefits in conflict with House Bill 163, the ERS responded that it was
unable to do so pursuant to the terms of Senate Bill 1102. Senate Bill 1102
prohibits making ALB available to annuitants and is, therefore, in direct
conflict with House Bill 163. The ERS determined that pursuant to the Texas
Code Construction Act, Senate Bill 1102 is the controlling legislation.
Comments were received from the Texas Health Maintenance Organization Association,
from the Texas Department of Insurance, and from the Honorable Representative
Glen Maxey, Texas House of Representatives, but the comments were instructive
or technical in nature and could not be characterized as either "for" or "against"
the proposed rules.
These amendments are adopted under Insurance Code, Article 3.50-2,
§4A, which provides the ERS with the authority to promulgate all rules
and regulations necessary to implement and to administer the Uniform Group
Insurance Program and the Flexible Benefits (Cafeteria Plan) Program.
§81.1.Definitions.
The following words and terms, when used in this chapter, shall have
the following meanings, unless the context clearly indicates otherwise.
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.
Dependent
- The spouse of an employee or retiree and unmarried
children under 25 years of age, including:
(A)-(B)
(No change.)
(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.
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).
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 (COBRA) reinstates UGIP coverage.
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 plan include out-of-pocket premium for group
term life, health (including HMO premiums), accidental death and dismemberment,
dental, and long and short term disability, but does not include out-of-pocket
premium for dependent term life.
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.
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.
§81.3. Administration.
(a)
Group Benefits Advisory Committee (GBAC).
(1)
The GBAC is established by the Act, §18, as amended.
Its membership shall be composed as defined in the Act. The Executive Director
of the Employees Retirement System of Texas shall establish procedures for
the determination of the committee's membership, terms of office, and representation
of the applicable state agencies and institutions of higher education, in
accordance with the Act.
(2)-(6)
(No change.)
(7)
The Executive Director of the Employees Retirement
System of Texas shall file a notice of the GBAC's meetings with the secretary
of state for publication in the Texas Register.
(8)
The Executive Director shall be the custodian of
the minutes of the GBAC's meetings and will have those minutes available for
public inspection at the offices of the Employees Retirement System of Texas
during normal working hours.
(b)
(No change.)
(c)
Health maintenance organizations.
(1)
The board may approve a health maintenance organization
(HMO) to offer a health benefits plan to participants in the Program. The
board may:
(A)
utilize a bidding process to approve one or more HMOs
in areas of the state determined by the board to be regional bidding areas
(RBAs);
(B)
utilize an application process to approve one or more
HMOs in areas of the state determined by the board to be non-bidding areas;
(C)
determine the criteria to be used to approve the HMOs
for the RBAs and non-bidding areas;
(D)
determine the number of HMOs to approve in each RBA and
non-bidding area; and
(E)
determine the length of the contracts with the approved
HMOs.
(2)
In order to seek approval, an HMO must:
(A)
submit an application to provide health benefits in the
areas within the State of Texas determined by the board to be non-bidding
areas;
(B)
submit a proposal, in response to a request for bid, in
the format determined by the system for one or more of the designated RBAs;
or
(C)
submit application(s) and bid(s).
(3)
An HMO seeking board approval in response to
a request for bid in one or more of the RBAs, must satisfy the following conditions:
(A)
The HMO must be licensed by the Texas Department of Insurance
to operate in the State of Texas.
(B)
The HMO must have been providing services in the RBA for
at least 6 months prior to September 1 of the fiscal year in which the bid
response is due to be filed with the system. Also, the HMO must demonstrate
the capacity to provide adequate services, as determined by the system, to
the program participants.
(C)
The HMO must submit the bid, with rates, to the board
at the time and in the format prescribed by the system. Once adopted by the
board, the rates may not be modified without the approval of the board. A
request for expansion of a non-contiguous service area, as described in this
section, shall require a separate application.
(D)
The HMO agrees to the provisions contained in the contract
between the system and the HMO as adopted for the entire time specified in
the contract.
(E)
The HMO must provide standardized benefits as described
in the contract between the system and the HMO. This document, which is to
be considered a part of this section for all purposes, may be obtained from
the Executive Director of the system.
(F)
If an HMO, approved by the board, fails to maintain compliance
with the contract, the board has the right to cancel the existing contract
with that HMO upon proper notice as specified in the contract.
(G)
An HMO that loses its state license will automatically
become ineligible to offer its health benefits plan to participants in the
Program.
(4)
An HMO, seeking board approval in response to
an application in one or more of the non-bidding areas, must satisfy the following
conditions:
(A)
The HMO must be licensed by the Texas Department of Insurance
to operate in the State of Texas.
(B)
The HMO must have been providing managed care services
in the area for which the application is made for at least 6 months prior
to September 1 of the fiscal year in which the application is due to be filed
with the system. Also, the HMO must demonstrate the capacity to provide adequate
services, as determined by the system, to the program participants.
(C)
The HMO must submit the application, with rates, to the
board at the time and in the format prescribed by the system. Once adopted
by the board, the rates may not be modified without the approval of the board.
(D)
The HMO agrees to the provisions contained in the contract
between the system and the HMO as adopted for the entire time specified in
the contract.
(E)
The HMO must provide standardized benefits as described
in the contract between the system and the HMO. This document, which is to
be considered a part of this section for all purposes, may be obtained from
the Executive Director of the system.
(F)
If an HMO, approved by the board, fails to maintain compliance
with the contract, the board has the right to cancel the existing contract
with that HMO upon proper notice as specified in the contract.
(G)
An HMO that loses its state license will automatically
become ineligible to offer its health benefits plan to participants in the
insurance program.
(d)
Funding.
(1)
(No change.)
(2)
Payment of premiums. Deductions from monthly compensation
or annuities and direct payment of premiums are two methods of payments used
for the employee's, retiree's, or other participant's share of premiums.
(A)
Employee deductions. An employee or retiree who applies
for coverage for which the monthly premium exceeds the state or employing
department and the system contributions must authorize in writing on a form
prescribed by the system a deduction from his or her monthly compensation
or annuity to pay the difference. If an employee's monthly compensation or
retiree's annuity is insufficient to provide for the appropriate deduction,
the employee or retiree must pay premiums directly as explained in subparagraph
(B)(i) of this paragraph. Failure to make the required payment of premiums
by the due date will result in the cancellation of all coverages not fully
funded by the state contribution. A person entitled to the state contribution
will retain member only health and basic life coverage provided the state
contribution is sufficient to cover the premium for such coverage. If the
state contribution is not sufficient for member only coverage in the health
plan selected by the employee or retiree, the employee or retiree will be
enrolled in the basic plan except as provided for in §81.7(l)(2)(B) of
this title.
(B)
Direct payment of premiums. Persons who are eligible participants
in the program and who are not on a payroll or who are not receiving an annuity
from a state retirement system from which the appropriate premiums may be
deducted or whose salary or annuity are insufficient to allow for a full required
deduction must pay premiums directly as indicated in the following.
(i)
A person who is eligible to receive but is not actually
receiving a TRS annuity, a retiree who is eligible to receive an annuity whose
benefit is assigned to an alternate payee, a person whose retirement annuity
is temporarily suspended, a person whose annuity is insufficient, a person
who is receiving or eligible to receive an annuity under the ORP, a former
elected official, a former employee of the legislature, a surviving spouse
and/or dependent child/children of a deceased employee or retiree, and a former
COBRA unmarried child must pay monthly premiums in advance directly to the
system. A person in a leave without pay status, a person whose salary is insufficient,
and a non-salaried board member must pay monthly premiums in advance through
the employee's employing department. Premium payments are due on the first
day of the month covered and must be postmarked or received by the system
or the employing department, whichever is appropriate, within 30 days of the
due date to avoid cancellation of coverage. Failure to make the required premium
payment by the due date will result in cancellation of all coverages not fully
funded by the state contribution, if applicable. A person entitled to the
state contribution will retain member only health and basic life coverage
provided the state contribution is sufficient to cover the premium for such
coverage. If the state contribution is not sufficient for member only coverage
in the health plan selected by the employee or retiree, the employee or retiree
will be enrolled in the basic plan except as provided for in §81.7(l)(2)(B)
of this title.
(ii)
A person who continues group health and dental benefits
as provided in §81.5(k) of this title (relating to Eligibility) must
pay premiums in advance on a monthly basis. Premiums for such a person will
be 102% of the rates charged for other participants in the same coverage category
and with the same plan. All premiums due for the election/enrollment period
must be postmarked or received by the Employees Retirement System on or before
the date indicated on the continuation of coverage enrollment form. Subsequent
premiums are due on the first day of the month covered and must be postmarked
or received by the Employees Retirement System within 30 days of the due date
to avoid cancellation of coverage.
(iii)
A person who continues group health and dental benefits
as provided in §81.5(k)(3) of this title (relating to Eligibility) must
pay premiums in advance on a monthly basis. Premiums for such a person for
each month of coverage after the 18th month of coverage will be 150% of the
rates charged for other participants in the same coverage category and with
the same plan. All premiums are due on the first day of the coverage month
and must be postmarked or received by the Employees Retirement System of Texas
within 30 days of the due date to avoid cancellation of coverage.
§81.5. Eligibility.
(a)
Full-time employees. A full-time employee, elected officer,
or appointed officer of the State of Texas is eligible for coverage 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.
(b)-(c)
(No change)
(d)
Dependents of employees and retirees. 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 natural child
is covered automatically on 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.
(e)
Former COBRA unmarried children. 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 Budget Reconciliation Act (COBRA), Public law 99-272.
(f)
Surviving dependents.
(1)
The surviving spouse of a retiree or the surviving spouse
of an active employee is eligible to continue coverage in the health and dental
benefits plans in which the surviving spouse was enrolled on the day of death
of the employee/retiree provided, however, the deceased active employee must
have had at least 10 years of service credit, including 3 years of service
as an eligible employee with a Program participating department, at the time
of death. A surviving spouse who is also a state retiree or state employee
shall not be eligible for surviving spouse benefits as long as he or she is
eligible for coverage as an employee or retiree. Participants continuing coverage
as surviving spouses are not eligible for life insurance coverages.
(2)
Dependent children of a deceased employee or retiree
are eligible to continue coverage in the health and dental benefits plans
in which the dependent children were enrolled on the day of death of the employee/retiree
provided, however, the deceased active employee must have had, at the time
of death, at least 10 years of service credit, including 3 years of service
as an eligible employee with a Program participating department, as long as
the surviving spouse is eligible and continues to participate in the program.
Dependent children of deceased employees or retirees will be considered as
dependents of the deceased employee's or retiree's surviving spouse for purposes
of the program. Participants continuing coverage as surviving dependents are
not eligible for life insurance coverage.
(3)
Dependent children of a deceased employee/retiree
are eligible to continue coverage in the health and dental benefits plans
in which the dependent children were enrolled on the day of death of the employee/retiree
provided, however, the deceased active employee must have had at least 10
years of service credit, including 3 years of service as an eligible employee
with a Program participating department, at the time of death. A surviving
dependent child may continue such coverage until the dependent child becomes
ineligible as defined in §81.1 of this title (relating to Definitions).
Participants continuing coverage as surviving dependents are not eligible
for life insurance coverage.
(4)
A surviving spouse 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.
(g)
Retiree under ORP. A retiring member of the ORP is eligible
to remain in the insurance program if he or she becomes an annuitant of the
ORP and the member's age and amount of service on which the annuity is based
is such that the retiree meets the age and length-of-service requirements
used by the Teacher Retirement System for regular service retirements. A retiring
member will remain eligible for coverage in the program as long as he or she
would have been eligible to receive an annuity had his or her membership been
in the Teacher Retirement System rather than the ORP.
(h)
Disability retirement. An applicant who is approved for
disability retirement is entitled to retiree insurance coverages as provided
in §81.7(c) of this title (relating to Enrollment and Participation).
An ORP participant granted ORP disabled retiree status in the program, as
established by the disability test used by the system, is eligible to remain
in the program for the amount of time the person would be eligible for benefits
had retirement coverages been under the Teacher Retirement System of Texas.
Initial or continued eligibility for insurance coverage for an ORP disabled
retiree will be determined by the system under the following provisions.
(1)
An ORP participant is eligible for ORP disabled retiree
status in the program if the ORP participant is not otherwise eligible to
participate in the program as an employee or retiree and is certified by a
licensed physician designated by the system as disabled as provided in paragraph
(2) of this subsection. An ORP participant may apply for disabled retiree
status in the program by filing a written application for ORP disabled retiree
status in the program or having an application filed with the system by the
ORP participant's spouse, employer, or legal representative. In addition to
an application for ORP disabled retiree status in the program, an ORP participant
must file with the system the results of a medical examination of the ORP
participant. After an ORP participant applies for ORP disabled retiree status
in the program, the system may require the ORP participant to submit additional
information about the disability. The system will prescribe forms for the
information required by this section.
(2)
If a licensed physician designated by the system
finds that the ORP participant is mentally or physically disabled from the
further performance of duty and that the disability is probably permanent,
the physician will certify disability. The Executive Director is authorized
to approve ORP disabled retiree status in the program after a certification
of disability is made. Once each year during the first five years after an
ORP participant enrolls in the program as an ORP disabled retiree, and once
in each three-year period after that, the system may require an ORP disabled
retiree to undergo a medical examination by a physician the system designates.
If an ORP disabled retiree refuses to submit to a medical examination as provided
by this section, the system will suspend the ORP disabled retiree's enrollment
in the program until the ORP disabled retiree submits to an examination. The
system will terminate the ORP disabled retiree's coverage in the program and
notify the ORP participant in writing if:
(A)
the system concurs with a certification issued by the
designated physician which finds that an ORP disabled retiree is no longer
mentally or physically disabled from the further performance of duty; or
(B)
an ORP disabled retiree refuses for more than one year
to submit to a required medical examination.
(3)
The effective date of coverage for an ORP disabled
retiree in the program is the first of the month following the date the application
for ORP disabled retiree status in the program is received by the system,
or the first of the month following the date employment is terminated, whichever
is later.
(i)
Former members of the legislature. On application to the
trustee and on arrangement for the payment of contributions, a person who
has at least eight years of creditable legislative service, as defined in
the Government Code, §812.002, on ending his or her service in the legislature,
continues to be eligible for participation in the program under the Act. Except
as provided in this section, former members of the legislature will be subject
to the same eligibility rules and effective dates that apply to active members
of the legislature.
(j)
Former employees of the legislature. On application to
the trustee and on arrangement for the payment of contributions, a person
who has at least 10 years of creditable service in the system, as defined
in the Government Code, §812.003, as an employee of the legislature,
on ending his or her service for the legislature, continues to be eligible
for participation in the program under the Act. Except as provided in this
section, a former legislative employee will be subject to the same eligibility
rules and effective dates that apply to an active employee of the State of
Texas.
(k)
Continuation of health and dental coverages only for certain
spouses and dependent children of employees/retirees, and for certain terminating
employees, their spouses, and dependent children (as provided by the Consolidated
Omnibus Budget Reconciliation Act, Public Law 99-272).
(1)
The surviving spouse and/or dependent child/children of
a deceased employee or retiree who are not eligible to continue coverage under
the provisions of the Act or subsection (f) of this section, who are not entitled
to benefits under the Social Security Act, Title XVIII, and who are not covered
under any other group health plan, or who were covered by a plan that subjects
them to a preexisting conditions limitation or exclusion that was not satisfied
by the service credit provisions of Public Law 104-91 Health Insurance Portability
and Accountability Act (HIPAA), may continue for up to 36 months the health
and dental coverages only that were in effect immediately prior to the date
of death of the employee/retiree. A formal election must be made to continue
coverage by the surviving spouse and/or the dependent child/children. The
formal election must be postmarked or received by the system within 60 days
of the date of notice contained in the notice of right to continue coverage
form or by the date coverage terminated, whichever is later.
(2)
An employee whose employment has been terminated
voluntarily or involuntarily (other than for gross misconduct), whose work
hours have been reduced such that the employee is no longer eligible for the
program as an employee, or whose coverage has ended following the maximum
period of leave without pay as provided for in §81.7(l)(2)(A) of this
title, except for those persons not eligible pursuant to §81.11(c) of
this title (relating to Termination of Coverage), and/or his or her spouse
and/or dependent child/children who are not eligible to continue coverage
under the provisions of the Act or subsection (h) or (i) of this section,
who are not entitled to benefits under the Social Security Act, Title XVIII,
who are not covered under any other group health plan, or who were covered
by a plan that subjects them to a preexisting conditions limitation or exclusion
that was not satisfied by the service credit provisions of Public Law 104-91
(HIPAA), may continue for up to 18 months the health and dental coverages
only without the basic term life that were in effect immediately prior to
the date of the loss of coverage. A formal election must be made to continue
coverage by the employee and/or his or her spouse and/or dependent child/children.
The formal election must be postmarked or received by the system within 60
days of the date of notice contained in the notice of right to continue coverage
form or by the date coverage terminated, whichever is later.
(3)
If an employee, spouse, or dependent child is determined
by the Social Security Administration to have been disabled before or during
the first 60 days of continuation coverage, all covered individuals may continue
health and dental coverages extended up to an additional 11 months, for a
total of 29 months. Notification of the Social Security Administration's determination
must be received by the system before the end of the original 18 months of
continuation coverage. Continuation coverage will be canceled the month that
begins more than 30 days after the date the Social Security Administration
determines that the participant is no longer disabled.
(4)
A spouse who is divorced from an employee/retiree
and/or the spouse's dependent child/children who are not otherwise eligible
to continue coverage under the provisions of the Act or subsection (d) of
this section, who are not entitled to benefits under the Social Security Act,
Title XVIII, who are not covered under any other group health plan, or who
are covered by a plan that subjects them to a preexisting conditions limitation
or exclusion that was not satisfied by the service credit provisions of Public
Law 104-912 (HIPAA), may continue for up to 36 months the health and dental
coverages only that were in effect immediately prior to the date the divorce
decree is signed. The employee/retiree or the divorced spouse or the divorced
spouse's dependent child/children must notify the system through the employing
department or retiree benefits coordinator of the divorce within 60 days from
the date the divorce decree is signed. A formal election must be made to continue
coverage by the divorced spouse and/or the dependent child/children. The formal
election must be postmarked or received by the system within 60 days of the
date of notice contained in the notice of right to continue coverage form
or by the date coverage is terminated, whichever is later.
(5)
A dependent child under 25 years of age who marries,
who is not entitled to benefits under the Social Security Act, Title XVIII,
who is not covered under any other group health plan, or who are covered by
a plan that subjects the child to a preexisting conditions limitation or exclusion
that was not satisfied by the service credit provisions of Public Law 104-91
(HIPAA), may continue for up to 36 months the health and dental coverages
only that were in effect immediately prior to the date of the marriage. The
married child or the employee/retiree must notify the system through the employing
department or retiree benefits coordinator of the marriage within 60 days
from the date of the marriage. A formal election must be made by the married
child to continue coverage. The formal election must be postmarked or received
by the system within 60 days of the date of notice contained in the notice
of right to continue coverage form or by the date coverage is terminated,
whichever is later.
(6)
A dependent child who has attained 25 years of age,
who is not otherwise eligible to continue coverage indefinitely under the
provisions of the Act or subsection (d) of this section, who is not entitled
to benefits under the Social Security Act, Title XVIII, who is not covered
under any other group health plan, or who is covered by a plan that subjects
the child to a preexisting conditions limitation or exclusion that was not
satisfied by the service credit provisions of Public Law 104-91 (HIPAA), may
continue for up to 36 months the health and dental coverages only that were
in effect immediately prior to the date of the child's 25th birthday. The
child or employee/retiree must notify the system through the employing department
or retiree benefits coordinator within 60 days of the child's 25th birthday.
A formal election must be made by the 25-year-old child to continue coverage.
The formal election must be postmarked or received by the system within 60
days of the date of notice contained in the notice of right to continue coverage
form or by the date coverage is terminated, whichever is later.
(7)
Extension of continuation of coverage for certain
spouses and/or dependent child/children of former employees who are continuing
coverage under the provisions of paragraph (2) of this subsection is governed
by the following provisions.
(A)
The surviving spouse and/or dependent child/children of
a deceased former employee whose death occurred during the period of continuation
coverage, who satisfy the provisions of paragraph (1) of this subsection and
who notify the Employees Retirement System within 60 days of the date of death
of the former employee are entitled to a total of 36 months of continuation
coverage.
(B)
A spouse who is divorced from a former employee during
the period of continuation coverage and/or the divorced spouse's dependent
child/children who satisfy the provisions of paragraph (4) of this subsection
are entitled to a total of 36 months of continuation coverage.
(C)
A dependent child under 25 years of age who marries during
the period of continuation coverage and who satisfies the provisions of paragraph
(5) of this subsection is entitled to a total of 36 months of continuation
coverage.
(D)
A dependent child who attains the age of 25 years during
the period of continuation coverage and who satisfies the provisions of paragraph
(6) of this subsection is entitled to a total of 36 months of continuation
coverage.
(E)
An employee, spouse, or dependent child determined by
the Social Security Administration to be disabled at the time of termination
of the employee's employment and who satisfies the provisions of paragraph
(3) of this subsection is entitled to a total of 29 months of continuation
coverage.
(F)
No person shall be allowed to continue health and dental
coverages under the provisions of this subsection for more than 36 months.
(8)
A person who continues benefits under the provisions
of paragraphs (1)-(7) of this subsection may change coverage levels or plans
during the continuation period on the same basis as an employee/retiree participant,
provided, however, that health and dental coverages which are canceled during
the continuation period may not be reestablished.
(9)
In all situations deemed applicable by the Employees
Retirement System where state or federal laws or regulations mandate specific
terms or provisions which are omitted or conflict with specific terms or provisions
of the group contracts or trustees' rules, the appropriate contracts and rules
shall be interpreted and administered to comply with such laws or regulations.
§81.7. Enrollment and Participation.
(a)
Full-time employees and their dependents.
(1)
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.
(2)
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.
(3)
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.
(4)
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 change in 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 (7) and (9) of this subsection, will be effective on the
date the person becomes a dependent if an enrollment form is completed and
signed on or within 30 days after the date the dependent first becomes eligible.
If the enrollment form is completed and signed 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 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)
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)
The effective date of a newborn natural child's
life and AD&D insurance will be the 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 become effective as stated in paragraph (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 to provide medical support becomes eligible for health
coverage upon receipt by the department of a valid court order.
(10)
The effective date of HealthSelect of Texas coverage
for an employee's or retiree's dependent, other than a newborn natural child,
will be as stated in paragraph (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.
(b)
Part-time employees. A part-time employee is not automatically
covered but must complete an application form provided by the Employees Retirement
System, 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 through his
or her employing agency on 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 rules for enrollment stated in subsection (a) of this section, other than
the rule as to automatic coverage, apply to a part-time employee.
(c)
Retirees and their dependents.
(1)
Provided the required premiums are paid or are deducted,
an employee's health, dental and term life insurance coverages (including
eligible dependent coverages) may be continued upon retirement 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.
(2)
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 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.
(d)
Surviving dependents. 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.
(e)
Former COBRA unmarried children. A former COBRA unmarried
child must provide an application for coverage within 30 days from the date
the notice of eligibility was mailed by the system. Coverage 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).
(f)
Premium conversion plans.
(1)
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.
(2)
Maximum benefit available. Subject to the limitations
set forth in these rules and in the plan, to avoid discrimination, the maximum
amount of flexible benefit dollars which a participant may receive in any
plan year for insurance premium expenses under this section shall be the amount
required to pay the participant's portion of the premiums for coverage under
each type of insurance included in the plan.
(g)
Special rules for additional or alternative coverages.
(1)
An employee/retiree must be enrolled in health coverage
provided by the program to apply for any optional coverages. Only an employee
or retiree or a former officer or employee specifically authorized to join
the program may apply for optional coverages.
(2)
An eligible participant in the 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
letter of agreement with the HMO.
(3)
An eligible participant in the Program and eligible
dependents may participate in HealthSelect Plus if they reside in the approved
service area of HealthSelect Plus.
(4)
An eligible participant in the Program electing optional
additional coverage and/or HMO or HealthSelect Plus coverage in lieu of the
basic plan of insurance is obligated for the full payment of premiums. If
the premiums are not paid, all coverages not fully funded by the state contribution
will be canceled. A person entitled to the state contribution will retain
member only health coverage provided the state contribution is sufficient
to cover the premium for such coverage. If the state contribution is not sufficient
for member only coverage in the health plan selected by the employee or retiree,
the employee or retiree will be enrolled in the basic plan except as provided
for in subsection (l)(2)(B) of this section.
(5)
An eligible participant in the Program enrolled in
an HMO whose contract is not renewed for the next fiscal year will be eligible
to make one of the following elections:
(A)
change to another approved HMO for which the participant
is eligible or to HealthSelect Plus (if the participant is eligible) by completing
an enrollment form during the annual enrollment period. The effective date
of the change in coverage will be September 1;
(B)
enroll in HealthSelect of Texas without evidence of insurability
by completing an enrollment form during the annual enrollment period, if the
participant is eligible to enroll in another approved HMO. The effective date
of the change in coverage for the eligible participant shall be September
1. Eligible dependents shall be subject to evidence of insurability requirements.
The effective date of coverage for dependents may be either September 1 or
the first day of the month following the date approval is received by the
department;
(C)
enroll in HealthSelect of Texas without evidence of insurability
by completing an enrollment form during the annual enrollment period, if the
participant is not eligible to enroll in another approved HMO (an approved
HMO is not available to the participant). Eligible dependents shall not be
subject to evidence of insurability requirements. The effective date of the
change in coverage will be September 1; or
(D)
if the participant does not make one of the elections,
as defined in subparagraphs (A)-(C) of this paragraph, the participant will
automatically be enrolled in the basic plan. Evidence of insurability for
the participant and the participant's dependents will apply as referenced
in subparagraph (B) of this paragraph.
(6)
An employee, retiree, or other eligible program
participant enrolled in an HMO whose contract is terminated during the fiscal
year or which fails to maintain compliance with the letter of agreement will
be eligible to make one of the following elections:
(A)
change to another approved HMO for which the participant
is eligible. The effective date of the change in coverage will be determined
by the board;
(B)
enroll in HealthSelect of Texas without evidence of insurability
or in HealthSelect Plus if the participant is eligible, provided the participant
is not eligible to enroll in another approved HMO. The effective date of the
change in coverage will be determined by the board; or
(C)
if a participant is eligible to enroll in another HMO,
the board may allow the participant to enroll in HealthSelect of Texas without
evidence of insurability or in HealthSelect Plus, if the participant is eligible.
The effective date of the change in coverage will be determined by the board.
(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.
(h)
Changes in coverages beyond the first 31 days of eligibility.
(1)
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.
(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 or HealthSelect Plus to HealthSelect of Texas 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.
(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 more than 30
days after the initial date of eligibility;
(C)
employees, retirees, or eligible dependents who wish to
enroll in HealthSelect of Texas more than 30 days after the initial date of
eligibility, except as provided in subsections (a), (g)(5)-(6), and (h)(7)(11)
of this section; or
(D)
employees enrolled in the program whose coverage was dropped
or canceled, except as provided in subsection (k)(3), (4), and (6) 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)
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.
(6)
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.
(7)
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.
(8)
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.
(9)
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)
An eligible participant will be allowed an
annual opportunity to make changes to their coverages and premium conversion
election, if applicable.
(A)
Persons will be allowed to:
(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; or
(xiii)
enroll or cancel enrollment in the premium conversion
plan.
(B)
Surviving dependents and former COBRA unmarried children
are not eligible for the provisions in subparagraph (A)(vii), (viii), (x),
or (xi) of this paragraph.
(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. 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 §81.1 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.
(i)
Preexisting conditions exclusion. The preexisting conditions
exclusion shall apply to employees who enroll in 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:
(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.
(j)
Special provisions relating to term life benefits
(1)
An employee who is enrolled in the Group Term Life Plan
may file a claim for an accelerated life benefit for himself or his covered
dependent in accordance with the terms of the group term life insurance plan
in effect at that time. A retiree who is enrolled in the plan is eligible
to file a claim for an accelerated life benefit for himself or his covered
dependent only if the retiree or dependent was determined, in a written statement
by his attending physician, prior to the effective date of the retirement,
to have had a terminal condition as defined in these rules. An accelerated
life benefit paid will be deducted from the amount that would otherwise be
payable under the Group Term Life Plan.
(2)
An employee or retiree who is enrolled in the Group
Term Life Plan may make an irrevocable beneficiary designation and enter into
a viatical settlement in accordance with the terms of the group term life
insurance plan in effect at that time.
(k)
Reinstatement in the program.
(1)
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.
(2)
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 paragraph (h) of this section.
(3)
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 may, upon return to
active employment, reinstate all 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 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. 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.
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 the dependents, the enrollment form to reinstate such 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.
(4)
Employees whose coverages were canceled during a
period of leave without pay due to a certified work-related disability 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 §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. Evidence
of insurability 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.
(5)
Employees whose coverages were cancelled during a
period of leave without pay as a result of the Family and Medical Leave Act
of 1993 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,
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 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 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.
(l)
Continuing coverage in special circumstances.
(1)
Continuation of health, dental, and optional coverages
for terminating employees. A terminating employee is eligible to continue
all coverages through the last day of the month in which employment is terminated.
(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 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.
(B)
An employee whose leave without pay is a result of the
Family and Medical Leave Act of 1993 will continue to receive the state contribution
during such period of leave without pay. The employee must pay premiums directly
as defined in §81.3(d)(2)(B)(i) of this title. Failure to make the required
payment of premiums by the due date will result in the cancellation of all
coverages except for member only health and basic life coverage. The employee
will continue in the health plan in which he or she was enrolled immediately
prior to the cancellation of all other coverages. If a premium beyond the
state contribution for member only health and basic life coverage is owed,
the employee must make the required payment of premiums directly to the employing
department upon return to active duty.
(3)
Continuation of health, dental, and life coverages
for a former member or employee of the legislature. A former member or employee
of the legislature, who is eligible to continue to participate in the program,
must notify the system within 30 days after leaving office or employment of
the employee's intent to continue the coverage in effect. Coverage will be
canceled if a premium is not received within 30 days of the due date. A former
member or employee of the legislature is not eligible to continue disability
insurance coverage.
(4)
Continuation of health, dental, and life coverages
for a former judge. A former State of Texas judge, who is eligible for judicial
assignments and who does not serve on judicial assignments during a period
of one calendar month or longer, may continue the types and amounts of coverages,
other than disability income, that were in effect during the calendar month
immediately prior to the month in which the former judge did not serve on
judicial assignments. These coverages may continue for no more than 12 continuous
months during which the former judge does not serve on judicial assignments
as long as, during the period, the former judge continues to be eligible for
assignment. Disability income coverage during the period will be canceled
on the first day of the month during which the former judge does not serve
on a judicial assignment. To reinstate canceled disability income coverage
once service on judicial assignments is resumed, a former judge must submit
evidence of insurability acceptable to the system. If approved, disability
income coverage will become effective on the first day of the month following
the date approval is received by the employing department.
(5)
Continuation of health and dental coverage for a
surviving spouse and/or dependent child/children of a deceased employee or
retiree. The surviving spouse and/or dependent child/children of a deceased
employee/retiree, who, in accordance with §81.5(k)(1) of this title,
elects to continue coverage may do so by submitting the required election
notification and enrollment forms to the system. The enrollment form, including
all premiums due for the election/enrollment period, must be postmarked or
received by the system on or before the date indicated on the continuation
of coverage enrollment form. Continuing coverage will begin on the first day
of the month following the month in which the employee/retiree dies, provided
all group insurance premiums due for the month in which the employee/retiree
died and for the election/enrollment period have been paid in full.
(6)
Continuation of health and dental coverage for a
covered employee whose employment has been terminated, voluntarily or involuntarily
(other than for gross misconduct), whose work hours have been reduced such
that the employee is no longer eligible for the program as an employee, or
whose coverage has ended following the maximum period of leave without pay
as provided in paragraph (2)(A) of this section. An employee, his or her spouse
and/or dependent child/children, who, in accordance with §81.5(k)(2)
of this title, elects to continue health and dental coverages may do so by
submitting the required election notification and enrollment forms to the
system. The enrollment form, including all premiums due for the election/enrollment
period, must be postmarked or received by the system on or before the date
indicated on the continuation of coverage enrollment form. Continuing coverage
will begin on the first day of the month following the month in which the
employee's coverage ends, provided all group insurance premiums due for the
month in which the coverage ends and for the election/enrollment period have
been paid in full.
(7)
Continuation of health and dental coverage for a
spouse who is divorced from an employee/retiree and/or the spouse's dependent
child/children. The divorced spouse and/or the spouse's dependent child/children
(not provided for by §81.5(a) of this title of an employee/retiree who,
in accordance with §81.5(k)(4) of this title, elects to continue coverage
may do so by submitting the required election notification and enrollment
forms to the system. The enrollment form, including all premiums due for the
election/enrollment period, must be postmarked or received by the system on
or before the date indicated on the continuation of coverage enrollment form.
Continuing coverage will begin on the first day of the month following the
month in which the divorce decree is signed, provided all group insurance
premiums due for the month in which the divorce decree is signed and for the
election/enrollment period have been paid in full.
(8)
Continuation of health and dental coverage for a
dependent child under 25 years of age who marries. A dependent child under
25 years of age who marries and who, in accordance with §81.5(k)(5) of
this title, elects to continue coverage may do so by submitting the required
election notification and enrollment forms to the system. The enrollment form,
including all premiums due for the election/enrollment period, must be postmarked
or received by the system on or before the date indicated on the continuation
of coverage enrollment form. Continuing coverage will begin on the first day
of the month following the month in which the dependent child's marriage occurred,
provided all group insurance premiums due for the month in which the dependent
child's marriage occurred and for the election/enrollment period have been
paid in full.
(9)
Continuation of health and dental coverage for a
dependent child who has attained 25 years of age. A 25-year-old dependent
child (not provided for by §81.5(d) of this title of an employee/retiree
who, in accordance with §81.5(k)(6) of this title, elects to continue
coverage may do so by submitting the required election notification and enrollment
forms to the system. The enrollment form, including all premiums due for the
election/enrollment period, must be postmarked or received by the system on
or before the date indicated on the continuation of coverage enrollment form.
Continuing coverage will begin on the first day of the month following the
month in which the dependent child of the employee/retiree attains 25 years
of age, provided all group insurance premiums due for the month in which the
dependent child attained age 25 and for the election/enrollment period have
been paid in full.
(10)
Extension of continuation of health and dental coverages
for certain spouses and/or dependent child/children of former employees who
are continuing coverage under the provisions of paragraph (6) of this subsection.
(A)
The surviving spouse and/or dependent child/children of
a deceased former employee, who, in accordance with §81.5(k)(7)(A) of
this title (relating to Eligibility), elects to extend continuation coverage
may do so by submitting the required election notification and enrollment
forms to the Employees Retirement System. The enrollment form, including all
premiums due for the election/enrollment period, must be postmarked or received
by the Employees Retirement System on or before the date indicated on the
continuation enrollment form. The election/enrollment period begins on the
first day of the month following the month in which the former employee died.
(B)
A spouse who is divorced from a former employee and/or
the divorced spouse's dependent child/children, who, in accordance with §81.5(k)(7)(B)
of this title (relating to Eligibility), elects to extend continuation coverage
may do so by submitting the required election notification and enrollment
forms to the Employees Retirement System. The enrollment form, including all
premiums due for the election/enrollment period, must be postmarked or received
by the Employees Retirement System on or before the date indicated on the
continuation enrollment form. The election/enrollment period begins on the
first day of the month following the month in which the divorce decree was
signed.
(C)
A dependent child under 25 years of age who marries, who,
in accordance with §81.5(k)(7)(C) of this title (relating to Eligibility),
elects to extend continuation coverage may do so by submitting the required
election notification and enrollment forms to the Employees Retirement System.
The enrollment form, including all premiums due for the election/enrollment
period, must be postmarked or received by the Employees Retirement System
on or before the date indicated on the continuation enrollment form. The election/enrollment
period begins on the first day of the month following the month in which the
dependent child marries.
(D)
A dependent child who has attained 25 years of age, who,
in accordance with §81.5(k)(7)(D) of this title (relating to Eligibility),
elects to extend continuation coverage may do so by submitting the required
election notification and enrollment forms to the Employees Retirement System.
The enrollment form, including all premiums due for the election/enrollment
period, must be postmarked or received by the Employees Retirement System
on or before the date indicated on the continuation enrollment form. The election/enrollment
period begins on the first day of the month following the month in which the
dependent child attained age 25.
(11)
Continuation coverage defined. Continuation
coverage as provided for in paragraphs (5)-(10) of this subsection means the
continuation of only health and dental coverage benefits which meet the following
requirements.
(A)
Type of benefit coverage. The coverage shall consist of
only the health and dental coverages, which, as of the time the coverage is
being provided, are identical to the health and dental coverages provided
for a similarly situated person for whom a cessation of coverage event has
not occurred.
(B)
Period of coverage. The coverage shall extend for at least
the period beginning on the first day of the month following the date of the
cessation of coverage event and ending not earlier than the earliest of the
following:
(i)
in the case of loss of coverage due to termination of
an employee's employment, reduction in work hours, or end of maximum period
of leave without pay, the last day of the 18th calendar month of the continuation
period;
(ii)
in the case of loss of coverage due to termination of
an employee's employment, reduction in work hours, or end of maximum period
of leave without pay, if the employee, spouse, or dependent child has been
certified by the Social Security Administration as being disabled as provided
in §81.5(k)(3) of this title, the last day of the 29th calendar month
of the continuation period;
(iii)
in any case other than loss of coverage due to termination
of an employee's employment, reduction in work hours, or end of maximum period
of leave without pay, the last day of the 36th calendar month of the continuation
period;
(iv)
the date on which the employer ceases to provide any
group health plan to any employee/retiree;
(v)
the date on which coverage ceases under the plan due to
failure to make timely payment of any premium required as provided in §81.3(d)(2)(B)(ii)
and (iii) of this title (relating to Administration);
(vi)
the date on which the participant, after the date of
election, becomes covered under any other group health plan under which the
participant is not subject to a preexisting conditions limitation or exclusion;
(vii)
the date on which the participant, covered under any
other group health plan that subjects him or her to a preexisting conditions
limitation or exclusion that was not satisfied by the service credit provisions
of Public Law 104-91 (HIPAA), is no longer subject to the preexisting conditions
limitation or exclusion in the other plan;
(viii)
the date on which the participant, after the date of
election, becomes entitled to benefits under the Social Security Act, Title
XVIII.
(C)
Premium requirements. The premium for a participant during
the continuation coverage period will be 102% of the employee's/retiree's
health and dental coverages only rate and is payable as provided in §81.3(d)(2)(B)(ii)
of this title (relating to Administration).
(i)
The premium for a participant eligible for 36 months of
coverage will be 102% of the employee's/retiree's health and dental coverages
only rate for the 19th through 36th months of coverage and is payable as provided
in §81.3(d)(2)(B)(ii) of this title (relating to Administration).
(ii)
The premium for a participant eligible for 29 months
of coverage will be 150% of the employee's/retiree's health and dental coverages
only rate for the 19th through 29th months of coverage and is payable as provided
in §81.3(d)(2)(B)(iii) of this title (relating to Administration).
(D)
No requirement of insurability. No evidence of insurability
is required for a participant who elects to continue coverage under the provisions
of §81.5(k)(1)-(6) of this title (relating to Eligibility).
(E)
Conversion option. An option to enroll under the conversion
plan available to employees/retirees is also available to a participant who
continues health and dental coverages for the maximum period as provided in
subparagraph (B)(i)-(iii) of this section. The conversion notice will be provided
to a participant during the 180-day period immediately preceding the end of
the continuation period.
§81.9. Grievance Procedure.
(a)
Except for persons enrolled in an HMO, any person participating
in the insurance program, who is denied payment of insurance benefits, may
request the health carrier to reconsider the claim. Any additional documentation
in support of the claim may be submitted with the request for reconsideration.
If the claim is again denied, the claim, accompanied by all related documents
and copies of correspondence with the insurance company, may be submitted
by the person to the Executive Director of the Employees Retirement System
of Texas for review. A request for review must be filed by the person in writing
within 90 days from the date the insurance company formally denies the claim
and mails notice of this denial and right of appeal to the person.
(b)
Any person with a grievance regarding eligibility or other
matters involving the program, including eligibility for participation in
the premium conversion plan, may submit a written request to the Executive
Director to make a determination on the matter in dispute.
(c)
When the Executive Director reviews any matter arising
under this section, all of the available information will be considered. When
the Executive Director completes the review and makes a decision, all parties
involved will be notified in writing of the decision.
(d)
Any person or insurance company that does not accept the
Executive Director's decision may appeal the decision to the board. A notice
of appeal to the board must be filed in writing 30 days from the date the
Executive Director's decision is mailed by certified mail.
(e)
Appeals to the board will be processed under the provisions
of Chapter 67 of this title (relating to Hearings and Disputed Claims), or
the rules of the State Office of Administrative Hearings, when applicable,
and Chapter 2001, Government Code.
(f)
(No change.)
(g)
In computing time under this section, the day after any
mailing by the carrier or the Executive Director shall be counted as the first
day of the time period. A document is considered to be filed with the Executive
Director when it is received by the executive director or when it is postmarked,
whichever is earlier.
§81.11.Termination of Coverage.
(a)
Cancellation of coverage.
(1)
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 the coverage
is cancelled. Coverage canceled by a surviving spouse or dependent of a deceased
retiree may never be reinstated.
(2)
Court ordered health coverage for a dependent cannot
be canceled unless the dependent is no longer eligible as a dependent as defined
in §81.1 of this title, the court order is no longer valid, or comparable
coverage has been obtained.
(3)
Coverage for a dependent, who marries or attains
age 25, shall be canceled as of the last day of the month following the date
of marriage or attainment of age 25, as the case may be.
(4)
Surviving spouse coverage for a person who becomes
a state employee shall be canceled as of the effective date of coverage as
an active employee. Surviving spouse coverage may be reinstated when the spouse
terminates employment with the state.
(5)
Coverage shall be canceled for non-payment of premium
if a premium is not paid within 30 days of the date payment is due. Coverage
will be canceled effective the last day of the month for which timely payment
was made.
(b)
(No change.)
(c)
Expulsion from the Uniform Group Insurance Program.
(1)
The board of trustees may expel any person participating
in the Uniform Group Insurance Program who submits a fraudulent claim or otherwise
defrauds or attempts to defraud any plan of benefits offered under the program,
within the terms of the Insurance Code, Article 3.50-2, §13A.
(2)
Any person with a grievance regarding eligibility
or other matters involving the program may submit a written request to the
Executive Director to make a determination on the matter in dispute.
(3)
The Executive Director is authorized to call a hearing
on behalf of the Board when he has reason to believe that a person may be
subject to expulsion under this section and the Insurance Code, Article 3.50-2,
§13A.
(4)
Any hearing called pursuant to this section shall
be a contested case under Government Code, Chapter 2001, and conducted in
the manner prescribed by law and by Chapter 67 of this title (relating to
Hearings and Disputed Claims) or the rules of the State Office of Administrative
Hearings, when applicable. During such hearing, the standard of proof requiring
a finding against the participant shall be the preponderance of evidence.
At the time a case is assigned to a hearings examiner, no further claims will
be paid until a finding has been made. When a finding has been made, all eligible
claims will be processed subject to any offsets for overpayments made by the
carrier.
(5)
Any person expelled from the Uniform Group Insurance
Program may not be insured under any health benefits plan offered by the program
for a period of five years from the effective date of the expulsion.
(d)
Coverage rescinded.
(1)
The Executive Director may rescind any insurance coverage
of a participant in the program, if the Executive Director determines that
the coverage was obtained by a fraudulent act or by making a material misrepresentation
or by supplying false information on any enrollment form or application for
coverage or related documentation or in any communication.
(2)
(No change.)
(3)
The Executive Director also may deny any claim filed
to obtain benefits from the fraudulently induced coverage.
(4)
The Executive Director's decision to rescind insurance
coverage or to deny a claim may be appealed to the board in accordance with
§81.9 of this title (relating to Grievance Procedure).
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
26, 1998.
TRD-9801147
Sheila W. Beckett
Executive Director
Employees Retirement System
Effective date: February 16, 1998
Proposal publication date: November 7, 1997
For further information, please call: (512) 867-3336
Chapter 87.
Deferred Compensation