Part 4.
EMPLOYEES RETIREMENT SYSTEM OF TEXAS
Chapter 81.
INSURANCE
34 TAC §81.7
The Employees Retirement System of Texas (ERS) proposes to
amend Trustee Rule, 34 TAC §81.7, in order to conform to changes in insurance
coverages for eligible group insurance program participants.
Paula A. Jones, General Counsel, has determined that for the first five-year
period the section is in effect there will be no fiscal implications for state
or local government as a result of enforcing or administering the section.
Ms. Jones has also determined that for each year of the first five years
the proposed amendments are in effect, the public benefit anticipated as a
result of enforcing the section will be that the plan will conform to changes
in insurance coverages for group insurance program participants. There will
be no effect on small businesses.
Comments may be submitted to Paula A. Jones, General Counsel, Employees
Retirement System of Texas, P.O. Box 13207, Austin, Texas, 78711-3207.
The amendments are proposed under Article 3.50-2 §4A, Texas
Insurance Code, which provides authorization for the Board of Trustees to
adopt rules necessary for the administration and implementation of insurance
plans for state employees. Effective June 1, 2003, the Board's rulemaking
authority will be codified in §1551.052, Texas Insurance Code.
The Texas Insurance Code Article 3.50-2 and Texas Insurance Code Chapter
1551 are affected by the proposed amendments.
§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 [
(3) - (10)
(No change.)
(b) - (f)
(No change.)
(g)
Special rules for additional [
(1)
Only an employee or retiree or a former officer or employee
specifically authorized to join the program may apply for
additional
[
(A)
dental coverage;
(B)
optional term life;
(C)
dependent term life;
(D)
short and long-term disability;
(E)
voluntary accidental death and dismemberment;
(F)
long-term care; or
(G)
health care and dependent care reimbursement.
(2)
(No change.)
[(3)
An eligible participant in the program
and eligible dependents may participate in HealthSelect Plus if they reside
in an approved service area of HealthSelect Plus.]
(3)
[
(4)
[
(A)
change to another approved HMO for which the participant
is eligible [
(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.
(5)
[
(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
[
(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 [
(h)
Changes in coverage after the initial period for enrollment.
(1) - (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)
(4) - (5)
[
(D) - (E)
(No change.)
(5)
An employee or retiree who wishes to add eligible dependents
to the employee's or retiree's HMO [
(A)
during the annual enrollment period (coverage will become
effective on September 1); or
(B)
upon the occurrence of a qualifying life event as provided
in paragraph (1) of this subsection.
(6)
A participant who is enrolled in
an
[
(A)
enroll in another approved HMO for which the participant
and all covered dependents are eligible;
or
[(B)
enroll in HealthSelect Plus, if the participant
and all covered dependents are eligible; or]
(B)
[
(i)
enroll in HealthSelect of Texas without providing evidence
of insurability; or
(ii)
enroll in an approved HMO [
[(7)
A participant who is enrolled in HealthSelect
Plus and who permanently moves out of the HealthSelect Plus service area,
shall make one of the following elections, to become effective on the first
day of the month following the date on which the participant moves out of
the HealthSelect Plus service area:]
[(A)
enroll in an approved HMO for which the participant and
all covered dependents are eligible; or ]
[(B)
if the participant and all covered dependents are not
eligible to enroll in an approved HMO, either;]
[(i)
enroll in HealthSelect of Texas without providing evidence
of insurability; or ]
[(ii)
enroll in an approved HMO for which the participant is
eligible and drop any ineligible covered dependent, unless not in compliance
with §81.11(a)(2) of this title (relating to Termination of Coverage).]
(7)
[
(A)
drop the ineligible dependent, unless not in compliance
with §81.11(a)(2) (relating to Termination of Coverage);
(B)
enroll in an approved HMO [
(C)
enroll in HealthSelect of Texas without providing evidence
of insurability if the participant and all covered dependents are not eligible
to enroll in an approved HMO [
[(9)
When a covered dependent of a participant
permanently moves out of the HealthSelect Plus service area, the participant
shall make one of the following elections, to become effective on the first
day of the month following the date on which the dependent moves out of the
HealthSelect Plus service area:]
[(A)
drop the ineligible dependent, unless not in compliance
with §81.11(a)(2) (relating to Termination of Coverage);]
[(B)
enroll in an approved HMO if the participant and all covered
dependents are eligible; or]
[(C)
enroll in HealthSelect of Texas without providing evidence
of insurability, if the participant and all covered dependents are not eligible
to enroll in an approved HMO.]
(8)
[
(A)
A participant 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;]
(ii)
[
(iii)
apply for coverage in HealthSelect,
if eligible, subject to approval of evidence of insurability;
[(vi)
change from HealthSelect Plus to HealthSelect
of Texas;]
(iv)
[
(v)
[
(vi)
[
(vii)
[
(viii)
[
(ix)
[
(x)
[
(xi)
[
(B)
Surviving dependents and former COBRA unmarried children
are not eligible for the provisions in subparagraph (A)
(iv),
(vii),
or (viii)
[
(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.
(9)
[
(i) - (l)
(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 April 28, 2003.
TRD-200302672
Paula A. Jones
General Counsel
Employees Retirement System of Texas
Earliest possible date of adoption: June 8, 2003
For further information, please call: (512) 867-7125
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. 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.
or alternative
]
coverages
and plans which include optional and voluntary coverages
.
optional
] coverages
and plans
. An employee/retiree
may apply for or elect additional coverages and plans without concurrent enrollment
[
must be enrolled
] in health coverage provided by the program
[
to apply for any optional coverages, but a
]
. A
member
of the Texas National Guard or any of the reserve components of the United
States armed forces who is assigned to active military duty and who is enrolled
in
additional coverages and plans
[
optional term life insurance
coverage
] may cancel health coverage and retain
all other coverages
and plans
[
life insurance coverage
] during the period of
such assignment.
Additional coverages and plans, as determined by the
board, may include:
(4)
] An eligible participant in
the Program electing [
optional
] additional
coverages and plans
[
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:
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;
(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
terms of its contract with the Employees Retirement System of Texas
[
letter of agreement
] will be eligible to make one of the following elections:
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
or in HealthSelect Plus, if the participant
is eligible
]. The effective date of the change in coverage will be determined
by the board.
(5) - (6)
],
and (h)(6) -
(8)
[
(10)
] of this section and §81.3(b)(3)(B)
of this title (relating to Administration);
or HealthSelect Plus
] coverage
may do so:
a
] approved HMO and who permanently moves out of the HMO service area
shall make one of the following elections, to become effective on the first
day of the month following the date on which the participant moves out of
the HMO service area:
(C)
] if the participant and all
covered dependents are not eligible to enroll in [
either
] an approved
HMO [
or HealthSelect Plus
]; either:
or in HealthSelect Plus,
] if the participant is eligible, and drop any ineligible covered dependent,
unless not in compliance with §81.11(a)(2) of this title (relating to
Termination of Coverage).
(8)
] When a covered dependent of
a participant permanently moves out of the participant's HMO service area,
the participant shall make one of the following elections, to become effective
on the first day of the month following the date on which the dependent moves
out of the HMO service area:
or HealthSelect Plus,
]
if the participant and all covered dependents are eligible; or
or HealthSelect Plus
].
(10)
] An eligible participant will
be allowed an annual opportunity to make changes in coverages.
(v)
] change from HealthSelect of
Texas to an HMO;
(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;
(xiii)
]
add,
decrease
,
or cancel
eligible
coverage, unless prohibited by §81.11(a)(2)
(relating to Termination of Coverage); and
(xiv)
] apply for coverage for which
evidence of insurability is required as provided in paragraph (3) of this
subsection.
(x), or (xi)
] of this paragraph, except that a
surviving dependent or former COBRA unmarried child may enroll an eligible
dependent in dental insurance coverage if the dependent is enrolled in health
insurance coverage.
(11)
] A participant who is a retiree
or a surviving dependent, or who is in a direct pay status, may decrease or
cancel any coverage at any time unless such coverage is health insurance coverage
ordered by a court as provided in §81.5(d) (relating to Eligibility).
Chapter 85.
FLEXIBLE BENEFITS