Part 4.
EMPLOYEES RETIREMENT SYSTEM OF TEXAS
Chapter 67.
HEARINGS ON DISPUTED CLAIMS
34 TAC §67.47
The Employees Retirement System of Texas (ERS) proposes amendments
to §67.47 concerning continuances.
Paula A. Jones, General Counsel, has determined that for the first five-year
period the rule is in effect there will be no fiscal implications for state
or local government as a result of enforcing or administering the rule.
Ms. Jones also determined that for each year of the first five years the
rule is in effect the public benefit anticipated as a result of enforcing
the rule will be updated information. There will be no affect on small businesses.
There are no known anticipated economic costs to persons who are required
to comply with the rule as proposed.
Comments on the proposed rule amendments may be submitted to Paula A. Jones,
General Counsel, Employees Retirement System of Texas, P. O. Box 13207, Austin,
Texas 78711-3207, or email Ms. Jones at pjones@ers.state.tx.us
The amendments are proposed under Tex. Gov't Code §815.102,
which provides authorization for the board to adopt rules for the transaction
of any other business of the board, No other statutes are affected by these
proposed amendments.
Section 67.47 is amended in order to clarify deadlines for filing continuances.
§67.47.Postponements or Continuances.
(a)
(No change.)
(b)
A motion for postponement or continuance shall be in writing,
shall be
served on all parties and
filed with the [
This agency hereby certifies that the proposal has been reviewed
by legal counsel and found to be within the agency's legal authority to adopt.
Filed with the Office of
the Secretary of State, on July 9, 2001.
TRD-200103886
Sheila W. Beckett
Executive Director
Employees Retirement System of Texas
Earliest possible date of adoption: August 19, 2001
For further information, please call: (512) 867-7125
34 TAC §71.17
The Employees Retirement System of Texas (ERS) proposes amendments
to §71.17 concerning credit for unused accumulated leave.
Paula A. Jones, General Counsel, has determined that for the first five-year
period the rules are in effect there will be no fiscal implications for state
or local government as a result of enforcing or administering the rule.
Ms. Jones also determined that for each year of the first five years the
rule is in effect the public benefit anticipated as a result of enforcing
the rule will be updated information and clarification of the rule. There
will be no affect on small businesses. There are no known anticipated economic
costs to persons who are required to comply with the rule as proposed.
Comments on the proposed rule amendments may be submitted to Paula A. Jones,
General Counsel, Employees Retirement System of Texas, P. O. Box 13207, Austin,
Texas 78711-3207, or email Ms. Jones at pjones@ers.state.tx.us
The amendments are proposed under Tex. Gov't Code §815.102,
which provides that the board may adopt rules for the transaction of any business
of the board. No other statutes are affected by these proposed amendments.
This section is amended in order to implement the provisions of §4
and §5 of Senate Bill 292, 77th Texas Legislature, 2001, involving the
conversion of sick and annual leave to service credit in certain situations.
§71.17.Credit for Unused Accumulated Leave.
(a)
Unused accumulated leave is creditable only in the employee
class of membership and only so long as the last day of employment occurs
during the month in which the
member dies or the member's
retirement
becomes effective. [
(b)
(No change.)
(c)
Eligible leave credit will become effective as service
credit only after retirement
or death
. Subject to that limitation
and upon receipt of a certification pursuant to subsection (b) of this section,
the ERS shall grant any service credit to which a retiree is thereby entitled.
An increase in the computation of an annuity because of leave credit shall
be effective from the time of certification.
(d)
(No change.)
This agency hereby certifies that the proposal has been reviewed
by legal counsel and found to be within the agency's legal authority to adopt.
Filed with the Office of
the Secretary of State, on July 9, 2001.
TRD-200103887
Sheila W. Beckett
Executive Director
Employees Retirement System of Texas
Earliest possible date of adoption: August 19, 2001
For further information, please call: (512) 867-7125
34 TAC §73.11, §73.17
The Employees Retirement System of Texas (ERS) proposes amendments
to §73.11 concerning the supplemental retirement program, and to §73.17
concerning disability retirement eligibility.
Paula A. Jones, General Counsel, has determined that for the first five-year
period the rules are in effect there will be no fiscal implications for state
or local government as a result of enforcing or administering the rules.
Ms. Jones also determined that for each year of the first five years the
rules are in effect the public benefit anticipated as a result of enforcing
the rules will be updated information and clarification of the rules. There
will be no affect on small businesses. There are no known anticipated economic
costs to persons who are required to comply with the rules as proposed.
Comments on the proposed rule amendments may be submitted to Paula A. Jones,
General Counsel, Employees Retirement System of Texas, P. O. Box 13207, Austin,
Texas 78711-3207, or email Ms. Jones at pjones@ers.state.tx.us
The amendments are proposed under Tex. Gov't Code §815.102,
which provides that the board may adopt rules for the transaction of any business
of the Board. No other statutes are affected by these proposed amendments.
Section 73.11 is amended to clarify how a member qualifies for the supplemental
benefit and implements §16 of Senate Bill 292, 77th Texas Legislature,
2001, by clarifying when the supplemental benefit goes into effect. Section
73.17 is amended to clarify eligibility requirements for disability retirement.
§73.11.Supplemental Retirement Program.
(a) - (e)
(No change.)
(f)
An occupational disability retirement annuity
is
subject to increase
pursuant to the supplemental program
as a result
of the individual's submission of evidence
satisfactory to the retirement
system that the person's condition makes the person incapable of gainful occupation
and is considered a
[
(g)
An annuity increase under Subsection (f)
is not payable before the first month following the month in which the satisfactory
evidence under Subsection (f) is received by the retirement system.
(h)
[
§73.17. Disability Retirement - Eligibility.
Incapacity from the further performance of duty means that the member
has demonstrably sought and been denied workplace accommodation of the disability
in accordance with applicable law, and that the member
is physically
or mentally unable to continue to hold the position occupied
and
[
This agency hereby certifies that the proposal has been reviewed
by legal counsel and found to be within the agency's legal authority to adopt.
Filed with the Office of
the Secretary of State, on July 9, 2001.
TRD-200103888
Sheila W. Beckett
Executive Director
Employees Retirement System of Texas
Earliest possible date of adoption: August 19, 2001
For further information, please call: (512) 867-7125
34 TAC §73.19
The Employees Retirement System of Texas (ERS) proposes new §73.19
concerning limitation of disability claims. This new section is proposed in
order to reflect the statute of limitation on disability claims in accordance
with Tex. Gov't Code Ann., §814.201(c).
Paula A. Jones, General Counsel, has determined that for the first five-year
period this new rule is in effect there will be no fiscal implications for
state or local government as a result of enforcing or administering the rule.
Ms. Jones also determined that for each year of the first five years the
new rule is in effect the public benefit anticipated as a result of enforcing
the rule will be clarification of the rules concerning the time frame during
which claims for disability retirement benefits must be filed. There will
be no affect on small businesses. There are no known anticipated economic
costs to persons who are required to comply with the new rule as proposed.
Comments on the proposed new rule may be submitted to Paula A. Jones, General
Counsel, Employees Retirement System of Texas, P. O. Box 13207, Austin, Texas
78711-3207, or email Ms. Jones at pjones@ers.state.tx.us
This new rule is proposed under Tex. Gov't Code §815.102,
which provides that the board may adopt rules for the transaction of any business
of the board.
No other statutes are affected by this new rule.
§73.19.Limitation of Disability Claims.
In accordance with § 814.201(c), Government Code, an application
for occupational disability retirement benefits shall be barred if it is filed
more than two years after the date on which the applicant knew or reasonably
should have discovered the alleged disability which forms the basis of the
application, except as allowed in the discretion of the executive director
upon a showing of good cause for the delay.
This agency hereby certifies that the proposal has been reviewed
by legal counsel and found to be within the agency's legal authority to adopt.
Filed with the Office of
the Secretary of State, on July 9, 2001.
TRD-200103889
Sheila W. Beckett
Executive Director
Employees Retirement System of Texas
Earliest possible date of adoption: August 19, 2001
For further information, please call: (512) 867-7125
34 TAC §75.2
The Employees Retirement System of Texas (ERS) proposes new §75.2
concerning benefit claims. This new section is proposed in order to reflect
the additional documentation required in connection with a claim for benefits
under Tex. Gov't Code Chapter 615, Subchapter F. The new section also establishes
a limit for certain benefits under Tex. Gov't Code Chapter 615, Subchapter
F.
Paula A. Jones, General Counsel, has determined that for the first five-year
period this new rule is in effect there will be no fiscal implications for
state or local government as a result of enforcing or administering the rule.
Ms. Jones also determined that for each year of the first five years the
new rule is in effect the public benefit anticipated as a result of enforcing
the rule will be updated information. There will be no affect on small businesses.
There are no known anticipated economic costs to persons who are required
to comply with the new rule as proposed.
Comments on the proposed new rule may be submitted to Paula A. Jones, General
Counsel, Employees Retirement System of Texas, P. O. Box 13207, Austin, Texas
78711-3207, or email Ms. Jones at pjones@ers.state.tx.us
This new rule is proposed under Tex. Gov't Code §615.121,
which provides that the board may adopt rules to administer this section of
the Tex. Gov't Code.
No other statutes are affected by this new rule.
§75.2. Additional Benefit Claims.
(a)
In addition to the documents required under §75.1
of this chapter, the following documents shall be submitted in an application
for benefits under Texas Government Code, Chapter 615, Subchapter F, unless
the executive director waives their submission:
(1)
a sworn statement from the person making the claim that:
(A)
the decedent, on the date of death, was not receiving and
was not eligible to receive an annuity under an employee retirement plan;
(B)
the surviving spouse, if any, of the decedent has not remarried;
(C)
the surviving spouse, if any, of the decedent is not retired
and is not eligible to retire under an employee retirement plan; and
(D)
the surviving spouse, if any, of the decedent is not receiving
and is not eligible to receive social security benefits; and
(2)
an itemized statement of funeral expenses incurred, if
the application includes a claim for payment of funeral expenses.
(b)
The amount reimbursed for funeral expenses under Texas
Government Code, Chapter 615, Subchapter F, shall not exceed the lesser of
$6,000 or the amount of funeral expenses actually incurred.
(c)
The executive director may require additional information
or affidavits as necessary to establish the validity of any claim under this
section.
This agency hereby certifies that the proposal has been reviewed
by legal counsel and found to be within the agency's legal authority to adopt.
Filed with the Office of
the Secretary of State, on July 9, 2001.
TRD-200103890
Sheila W. Beckett
Executive Director
Employees Retirement System of Texas
Earliest possible date of adoption: August 19, 2001
For further information, please call: (512) 867-7125
34 TAC §§81.1, 81.3, 81.7, 81.11
The Employees Retirement System of Texas (ERS) proposes amendments
to §§81.1, 81.3, 81.7, and 81.11 concerning the Texas Employees
Uniform Group Insurance Program. Section 81.1 is amended to revise the definitions
of "dependent" and "retiree"; §81.3 is amended to delete all references
to the Group Benefits Advisory Committee and to revise language pertaining
to the payment of premiums; §81.7 is amended to clarify conditions and
coverage effective dates for employees re-enrolling after a lapse in coverage;
and §81.11 is amended to update language pertaining to termination of
coverage.
Paula A. Jones, General Counsel, has determined that for the first five-year
period the rules are in effect there will be no fiscal implications for state
or local government as a result of enforcing or administering the rules.
Ms. Jones also determined that for each year of the first five years the
rules are in effect the public benefit anticipated as a result of enforcing
the rules will be simplified administration of the Texas Employees Uniform
Group Insurance Program. There will be no affect on small businesses. There
are no known anticipated economic costs to persons who are required to comply
with the rules as proposed.
Comments on the proposed rule amendments may be submitted to Paula A. Jones,
General Counsel, Employees Retirement System of Texas, P. O. Box 13207, Austin,
Texas 78711-3207, or email Ms. Jones at pjones@ers.state.tx.us
The amendments are proposed under Tex. Ins. Code, art. 3.50-2, §4A,
which provides authorization for the board to adopt rules necessary to carry
out its statutory duties and responsibilities.
No other statutes are affected by these proposed amendments.
§81.1.Definitions.
The following words and terms, when used in this chapter, shall have
the following meanings, unless the context clearly indicates otherwise.
(1) - (11)
(No change.)
(12)
Dependent - The spouse of an employee or retiree and unmarried
children under 25 years of age, including:
(A) - (H)
(No change.)
(I)
a child eligible under Section 3(a)(8)B of the Act,
provided that the child's mental retardation or physical incapacity is a medically
determinable condition which prevents the child from engaging in self-sustaining
employment, that the condition commences before the date of the child's 25th
birthday,
[
(13) - (27)
(No change.)
(28)
Retiree -
An employee who retires or is retired and
who:
[
(A)
is authorized by the Act to
participate in the program as a retiree;
(B)
on August 31, 1992, was a participant
in a group insurance program administered by an institution of higher education;
or
(C)
on the date of retirement,
meets the service credit requirements of the Act for participation in the
program as an annuitant and, on August 31, 2001:
(i)
was an eligible employee with a department whose
employees are authorized to participate in the program; or
(ii)
had three years of service as an eligible employee
with a department whose employees are authorized to participate in the program.
(29) - (31)
(No change.)
§81.3.Administration.
[
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(a)
[
(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.
(b)
[
(1)
Premiums for coverage provided under the program are funded
from three sources: state contributions, system contributions, and participant
contributions. The legislature appropriates monies to fund group insurance
benefits for all employees as defined in the Act. Monies for employees compensated
from funds other than the General Appropriations Act are appropriated from
the official operating budget of the respective department. In addition, the
system may contribute an additional amount, as determined by the trustee,
for payment of premiums for participants. A participant who applies for coverage
for which the monthly premium exceeds the state's or employing department's
and the system's contribution must pay the excess amount.
(2)
A participant's share of premiums shall be paid through
deductions from monthly compensation or annuities or by direct payment, as
provided in this paragraph.
(A)
An employee or annuitant who applies for coverage for which
the monthly premium exceeds the state or employing department and the system
contributions must authorize on a form prescribed by the system a deduction
from his or her monthly compensation or annuity to pay the difference. If
the compensation or annuity is insufficient to provide for the appropriate
deduction, the participant must pay premiums directly as provided 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 participant 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, the participant will be enrolled in the basic plan except as
provided for in §81.7(l)(2)(B) of this title.
(B)
A participant shall pay premiums directly, as provided
in this subparagraph, if the participant is not on a payroll or is in a leave
without pay status, is not receiving an annuity from a state retirement system
from which the appropriate premiums may be deducted, or is not receiving a
salary or annuity sufficient to allow for a full required premium deduction.
[
(i)
An employee [
(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 of Texas
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 of Texas
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.
(3)
An employee whose dependent child is eligible for coverage
under Section 14A of the Act is eligible for the supplemental state contribution
as authorized by that section and provided in the paragraph.
(A)
An employee becomes eligible for the supplemental contribution
on the first day of the month following the date on which the system receives
certification of the dependent child's eligibility for coverage under that
section. Eligibility for the supplemental contribution terminates on the last
day of the contract year. An employee may apply for the supplemental contribution
for an additional period of coverage during the annual enrollment period applicable
to that period of coverage.
(B)
A dependent child of an employee who is eligible for the
supplemental contribution is not required to provide evidence of insurability.
§81.7.Enrollment and Participation.
(a)
Full-time employees and their dependents.
(1)
(No change.)
(2)
To enroll eligible dependents, to elect to enroll in an
approved HMO or in HealthSelect Plus, and to elect optional coverages, the
employee shall complete an enrollment form within 30 days after the date on
which the employee begins active duty. Coverages selected on or before the
date on which the employee begins active duty become effective on the date
on which the employee begins active duty. Coverages selected within 30 days
after the date on which the employee begins active duty become effective on
the first day of the month following the date on which the
enrollment
form is completed
[
(3) - (9)
(No change.)
(10)
For purposes of this section,
an enrollment form is completed when all information necessary to effect an
enrollment has been transmitted to the system in the form and manner prescribed
by the system.
(b) - (c)
(No change.)
(d)
Surviving dependents
(1)
(No change.)
(2)
A surviving spouse who is receiving an annuity shall make
premium payments by deductions from the annuity as provided in
§81.3(b)(2)(A)
[
(e)
Former COBRA unmarried children. A former COBRA unmarried
child must provide an application to continue health and dental insurance
coverage within 30 days after the date the notice of eligibility is mailed
by the system. Coverage becomes effective on the first day of the month following
the month in which continuation coverage ends. Premium payments may be made
as provided in
§81.3(b)(2)(B)
[
(f)
(No change.)
(g)
Special rules for additional or alternative coverages.
(1) - (3)
(No change.)
(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)
[
(5) - (6)
(No change.)
(h)
Changes in coverage after the initial period for enrollment.
(1)
Changes for Qualifying Life Event.
(A) - (D)
(No change.)
(E)
Except as otherwise provided in subsections (a)(6) and
(a)(8) of this section, the change in coverage is effective on the first day
of the month following the date
on which the enrollment form is completed
[
(F)
(No change.)
(2) - (3)
(No change.)
(4)
The evidence of insurability provision applies only to:
(A) - (B)
(No change.)
(C)
employees, retirees, or eligible dependents who wish to
enroll in HealthSelect of Texas after the initial period for enrollment, except
as provided in subsections (a), (g)(5)-(6), and (h)(6)-(10) of this section
and
§81.3(b)(3)(B)
[
(D) - (E)
(No change.)
(5) - (11)
(No change.)
(i) - (j)
(No change.)
(k)
Re-enrollment
[
(1)
The provisions of subsection (a) of this section shall
apply to the enrollment of an employee who terminates employment and returns
to active duty within the same contract year, who transfers from one department
to another, or who returns to active duty after a period of leave without
pay during which coverage is canceled.
[
(2)
An employee to whom paragraph (k)(1) applies shall
not be required to submit evidence of insurability acceptable to the carrier.
[
(3)
If an employee is a member of the Texas National Guard
or any of the reserve components of the United States armed forces, and the
employee's coverages are canceled during a period of leave without pay or
upon termination of employment as the result of an assignment to active military
duty, the period of active military duty shall be applied toward satisfaction
of any period of preexisting conditions exclusions remaining upon the employee's
return to active employment.
(l)
Continuing coverage in special circumstances.
(1)
(No change.)
(2)
Continuation of coverages for employees in a leave without
pay status.
(A)
An employee in a leave without pay status may continue
the coverages in effect on the date the employee entered that status for the
period of leave, but not more than 12 months. The employee must pay premiums
directly as provided in
§81.3(b)(2)(B)(i)
[
(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(b)(2)(B)(i)
[
(3) - (10)
(No change.)
(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)
(No change.)
(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) - (iv)
(No change.)
(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(b)(2)(B)(ii)
[
(vi) - (viii)
(No change.)
(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(b)(2)(B)(ii)
[
(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(b)(2)(B)(ii)
[
(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(b)(2)(B)(iii)
[
(D) - (E)
(No change.)
(12)
(No change.)
§81.11.Termination of Coverage.
(a) - (b)
(No change.)
(c)
Sanctions for Insurance Program Violations.
[
(1)
The Employees Retirement System of Texas may rescind
any insurance coverage or impose one or more sanctions described by Insurance
Code, Article 3.50-2, §13A against any person, including, but not limited
to any current or former participant, employee, annuitant, dependent or insurance
claimant who commits any of the violations enumerated in the Insurance Code,
Article 3.50-2, §13A(a).
[
(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.
Any person
who disputes a recission of coverage, a denial of benefits or other sanctions
imposed in connection with a determination made under Insurance Code, Article
3.50-2, §13A(b), may appeal the determination in accordance with §81.9
of this title (relating to Grievance Procedure). A timely appeal of a determination
made pursuant to Insurance Code, Article 3.50-2, §13A shall automatically
stay the imposition of sanctions. However, at the time such a determination
is made pursuant to Insurance Code, Article 3.50-2, §13A, no further
claims will be paid until the agency decision is final. Upon final agency
action, all eligible claims will be processed subject to any offsets for overpayments
made by the carrier.
[
(3)
[
(4)
[
[
[
(5)
[
(6)
[
[
This agency hereby certifies that the proposal has been
reviewed by legal counsel and found to be within the agency's legal authority
to adopt.
Filed with the Office of
the Secretary of State, on July 9, 2001.
TRD-200103891
Sheila W. Beckett
Executive Director
Employees Retirement System of Texas
Earliest possible date of adoption: August 19, 2001
For further information, please call: (512) 867-7125
executive
director or
] examiner no later than
five (5) days prior to
[
5:00 p.m. on the last work day before
] the date of the hearing,
and shall set forth the specific grounds upon which the continuance is sought
. If good cause for the late filing is demonstrated in the motion, the examiner
may consider a motion filed after that time or presented orally at the hearing
[
; provided, however, once a contested case has actually proceeded
to a hearing, a postponement or continuance may be granted by the examiner
upon either oral or written motion
].
Chapter 71.
CREDITABLE SERVICE
Credit for unused accumulated leave may not be used
to establish length of service requirements for purposes of death benefit
plan eligibility.
]
Chapter 73.
BENEFITS
of
] total disability under the federal
social security law [
shall be effective with the first payment following
receipt of the social security statement
].
(g)
] An adjustment under the provisions
of subsection (f) of this section shall include any reduction option factor
applicable to a survivor benefit.
or
] to hold
any other
[
a
] position [
with the state
] offering comparable pay. The education, training, and
experience of the employee are to be considered when making this determination.
Chapter 75.
HAZARDOUS PROFESSION DEATH BENEFITS
Chapter 81.
INSURANCE
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 and at such intervals
thereafter as may be required by the system.
A person authorized by the Act to participate in the program
as a retiree or a retired employee who, as of August 31, 1992, was a participant
in a group insurance program administered by an institution of higher education.
]
(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)
The GBAC shall advise and consult with the
trustee on matters concerning all insurance coverage provided under this Act
and shall present recommendations to the trustee regarding other existing
or proposed state employee benefits, other than retirement benefits. The committee
shall cooperate and work with the trustee in coordinating and correlating
the administration of the Texas Employees Uniform Group Insurance Program
among the various state agencies and institutions of higher education. The
duties of each member of the GBAC shall be to secure input from fellow employees
and shall be considered additional duties required of the member's other state
office or employment, and all expenses incurred by any such member in performing
the member's duties as a member of the committee shall be paid from funds
made available for those purposes to the agency or institution of higher education
of which the member is an employee or officer.]
(3)
During a term of appointment or election, a
vacancy shall be filled by an employee of the same agency or institution of
higher education from which the vacancy occurred, being appointed by its governing
body or designee for the balance of the vacated term. A vacancy on the GBAC
exists when any member of the GBAC:]
(A)
resigns from the GBAC;]
(B)
transfers from a state agency or institution
of higher education from which the member was appointed or elected to serve
on the GBAC; or]
(C)
terminates employment from a state agency or
institution of higher education.]
(4)
A vacancy in a position held by a member appointed
by the trustee or the Texas Higher Education Coordinating Board shall be filled
by such body for the balance of the term.]
(5)
A vacancy in a position held by a member of
the private sector shall be filled by the officer who originally made the
appointment to that position.]
(6)
All GBAC meetings are to be open to the public.]
(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)
Petitions for supplemental
coverage.]
(1)
An agency head or a group of employees or retirees
may submit a written petition to the board or to the GBAC requesting the establishment
of a supplemental insurance benefits plan.]
(2)
The petition must include a clear and concise
statement of the type and extent of coverage desired. The petition must show
the relationship of the requested coverage to the existing coverages provided
by the program. The proposed plan must provide coverage that is not available
in the program or must be an extension of the coverage over and above that
provided by the related benefit in the program. The plan must provide that
employees enrolling in an approved supplemental plan must first be enrolled
for the maximum related benefits provided by the program.]
(3)
The proposed plan must meet the requirements
of the Act, including the following:]
(A)
the plan must be reviewed by the GBAC;]
(B)
the plan must be actuarially sound;]
(C)
carriers for the plan must be selected by competitive
bidding;]
(D)
the plan must satisfy the Act's minimum enrollment
requirements; and]
(E)
the proposal must provide evidence that the
proposed coverage is in the best interests of the people covered by the Act.]
(4)
If a proposed plan is approved for payroll
deduction in any state agency, a percentage of all premiums paid is to be
paid into the employees life, accident and health insurance and benefits fund;
such percentage shall be determined by the board, in its sole discretion,
at the time of approval.]
(c)
] Health maintenance organizations.
(d)
] 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.
]
who is in a leave without pay status
or
] whose salary is insufficient, or who is a non-salaried board member,
shall pay monthly premiums in advance through the employing department. Any
other participant to whom this subparagraph applies shall pay monthly premiums
in advance to the system. 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.
employee begins active duty
]. An enrollment
form completed after the initial period for enrollment as provided in this
paragraph is subject to the provisions of subsection (h) of this section.
§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(b)(2)(B)
[
§81.3(d)(2)(B)
] of this
title.
§81.3(d)(2)(B)
]
(relating to Administration).
(1)(2)(B)
] of this section.
of the qualifying life event
].
§81.3(d)(3)(B)
] of this
title (relating to Administration);
Reinstatement
] in
the program.
Except as provided in subsection
(h)(1) of this section, an employee who terminates employment and returns
to active duty within the same contract year shall reinstate the coverages
in effect on the date employment was terminated. Except as provided in subsection
(h)(1), coverage becomes effective on the date on which the employee returns
to active duty. To reinstate canceled coverages, submission of evidence of
insurability acceptable to the carrier will not apply. Provided that all applicable
preexisting conditions exclusions were satisfied on the date of termination,
no new preexisting conditions exclusions will apply. If not, any remaining
period of preexisting conditions exclusions must be satisfied upon reinstatement.
]
Except as provided in subsection (h)(1) of this section, an employee
whose coverages are canceled during a period of leave without pay shall, upon
return to active duty, reinstate the coverages in effect on the date of cancellation.
Except as provided in subsection (h)(1), coverage becomes effective on the
date on which the employee returns to active duty. To reinstate canceled coverages,
submission of evidence of insurability acceptable to the carrier will not
apply.
] Provided that all applicable preexisting conditions exclusions
were satisfied on the date of
termination, transfer, or
cancellation,
no new preexisting conditions exclusions will apply. If not, any remaining
period of preexisting conditions exclusions must be satisfied upon
re-enrollment
[
reinstatement
].
§81.3(d)(2)(B)(i)
] of this title (relating to Administration).
§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.
§81.3(d)(2)(B)(ii)
] and (iii)
of this title (relating to Administration);
§81.3(d)(2)(B)(ii)
] of this
title (relating to Administration).
§81.3(d)(2)(B)(ii)
]
of this title (relating to Administration).
§81.3(d)(2)(B)(iii)
]
of this title (relating to Administration).
Expulsion from the Uniform Group Insurance Program.
]
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.
]
(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
provided
[
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
on
[
and
] Disputed Claims) or the rules of the State Office of Administrative
Hearings, when applicable.
In the event of any conflict between a provision
of Chapter 67 and the rules of the State Office of Administrative Hearings,
the provisions of Chapter 67 shall control.
[
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
determined by the Employees
Retirement System of Texas
[
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)
] If
a person's insurance
[
the participant's
] coverage is rescinded, it may be rescinded
to the date of the inception of the coverage or
from
[
to
]
the date of the
prohibited conduct as found in the determination made
in accordance with Insurance Code, Article 3.50-2, §13A(b)
[
fraudulent act or material misrepresentation
].
(3)
] The
Employees Retirement
System of Texas
[
Executive Director
] also may deny any claim
filed to obtain benefits from the
insurance
[
fraudulently
induced
] coverage
.
in a manner prohibited under Insurance
Code, art. 3.50-2, §13A.
(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)].
Chapter 85.
FLEXIBLE BENEFITS