34 TAC §41.7, §41.11
The Teacher Retirement System of Texas (TRS) proposes amendments
to §41.7, relating to effective date of coverage and a new §41.11,
relating to years of service credit used to determine premiums, each relative
to the Texas Public School Retired Employees Group Insurance Program (TRS-Care).
These proposed amendments and the new section implement Senate Bill 1369 and
House Bill 3459, 78th Legislature, Regular Session, 2003, and House Bill 7,
78th Legislature, 3rd Called Session, 2003. The proposed amendments to §41.7
implement changes to the effective date of coverage based on the new TRS-Care
eligibility criteria set out in House Bill 7 for those TRS members taking
a service retirement after September 1, 2004. They also address when TRS-Care
coverage begins for those retirees taking advantage of the additional enrollment
opportunity provided by the referenced legislation. The proposed new §41.11
addresses which years of service credit will be used in determining premiums
for TRS retirees, surviving spouses, and divorced spouses who elect COBRA
coverage pursuant to Senate Bill 1369 and House Bill 3459.
Ronnie Jung, Executive Director, has determined that for each year of the
first five-year period that the proposed amendments and the new section are
in effect, there will be no fiscal implications to state or local governments
as a result of enforcing or administering the amendments or the new section.
There is no foreseeable effect on local employment or local economies as a
result of the proposed amendments or new section.
Mr. Jung has also determined that for each year of the first five years
that the proposed amendments to §41.7 are in effect, the public benefit
anticipated as a result of the amendments will be that TRS rules will comply
with the statutory changes and that those TRS members taking a retirement
after September 1, 2004 will have notice of when their coverage will be effective.
Mr. Jung has determined that for each year of the first five years that the
proposed new §41.11 is in effect, the public benefit anticipated as a
result of the new section will be notice to retirees, surviving spouses, and
divorced spouses electing COBRA of the years of service credit that will be
used to determine their TRS-Care premiums. There is no anticipated adverse
economic effect on small businesses or micro-businesses as a result of compliance
with the proposed amendments or new section. Mr. Jung has determined that
there is no potential economic costs to persons required to comply with the
proposed amendments. Mr. Jung has determined that the potential economic costs
to persons required to comply with the proposed new section for each year
of the first five years the proposal will be in effect may be the difference
in the amount of premium paid based on their years of service credit as provided
by the new section.
Written comments on the proposal may be submitted to Ronnie Jung, Executive
Director, 1000 Red River, Austin, Texas 78701.
These sections are proposed under Insurance Code §1575.052,
which gives TRS the authority to adopt rules as necessary to administer and
operate the TRS-Care program. The sections are also proposed under Government
Code, Chapter 825, §825.102, which authorizes the Board of Trustees of
the Teacher Retirement System to adopt rules for the transaction of business
of the Board.
There are no other codes affected.
§41.7.Effective Date of Coverage.
(a)
The following words and phrases, when used in this section,
[
shall
] have the following meanings, unless the context clearly
indicates otherwise.
(1)
Noncontributory coverage
means TRS-Care
[
--The
] coverage provided at no cost to eligible
TRS
retirees
and surviving spouses
.
(2)
Contributory coverage
means TRS-Care coverage
[
--Coverage
] for which
eligible TRS retirees, surviving spouses,
and surviving dependent children must pay at least some part of the cost
[
a contribution is required
].
(b)
For those TRS members who take a service or disability
retirement before September 1, 2004, and who enroll or are enrolled in noncontributory
coverage during their initial enrollment period as described in §41.1
of this chapter relating to Enrollment Periods for the Texas Public School
Retired Employees Group Insurance Program (TRS-Care), the
[
The
] effective date of
such
[
noncontributory
] coverage
is
[
for a retiree shall be
] the first day of the month following
the effective date of retirement unless the retiree has waived coverage in
writing.
(c)
This subsection applies to the following TRS members:
those who take a service or disability retirement after September 1, 2004,
and enroll in noncontributory coverage during their initial enrollment period
as described in §41.1 of this chapter and those who, regardless of their
retirement date, enroll in contributory coverage during their initial enrollment
period as described in §41.1. For such members, the
[
The
]
effective date of [
contributory
] coverage
is
[
for the retiree shall be
]:
(1)
the first day of the month following the effective date
of retirement if the application for coverage is received by TRS-Care on or
before the effective retirement date; or
(2)
the first day of the month following the receipt of the
application by TRS-Care if the application is received after the effective
retirement date but within the
initial
[
31-day
] enrollment
period.
(d)
Retirees who
,
due to their effective retirement
date
,
have a choice of beginning [
contributory
] coverage
in two different months may defer the effective date of coverage to the first
day of the latter month if that election is made in writing and is received
by TRS-Care
before
[
in advance of
] the beginning of
the first month in which the effective date of coverage could have taken place.
(e)
The effective date of coverage for a surviving spouse or
for a surviving dependent child
is
[
shall be
] the first
day of
his or her
[
their
] eligibility if TRS-Care receives
an application within the
initial
enrollment period
as described
in §41.1 of this chapter
and the deceased participant had the surviving
spouse or the surviving dependent child
enrolled in TRS-Care
[
covered under the program
] before
the participant
[
he or she
] died.
(f)
If
[
Where
] the surviving spouse or
the surviving dependent child was not
enrolled in TRS-Care
[
covered under the program
] immediately preceding his or her becoming
eligible for coverage
,
the effective date of coverage will be the
first day of the month following
TRS-Care's
receipt of an application
during the
initial
enrollment period
as described in §41.1
of this chapter
[
by TRS-Care
].
(g)
The effective date of coverage for
an eligible dependent
[
dependents who are eligible to be enrolled and
] who
is
[
are
] enrolled under a retiree's or surviving spouse's
TRS-Care
coverage
during the initial enrollment period is the same
date as the retiree or surviving spouse's effective date of coverage unless
the dependent is enrolled after the retiree's effective retirement date and
after the retiree has enrolled but within the initial enrollment period, in
which case the dependent's effective date of coverage will be the first day
of the month following TRS-Care's receipt of the application to enroll the
dependent.
[
will be:
]
[
(1)
the same date as the retiree or surviving
spouse if the enrollment is during the initial enrollment period;
]
[
(2)
the first day of the month following receipt
of the application by TRS-Care if the enrollment of the dependents is after
the initial enrollment period; or
]
[
(3)
the day on which a child is born, if the
participant has coverage for children already in effect under TRS-Care.
]
(h)
The effective date of coverage
for an eligible dependent who is enrolled under a retiree's or surviving spouse's
TRS-Care coverage as a result of a special enrollment event under the Health
Insurance Portability and Accountability Act of 1996 (HIPAA) is the date specified
by HIPAA.
(i)
The effective date of coverage
for a retiree, a surviving spouse, and an eligible dependent who have a second
initial enrollment period as described in §41.1 of this chapter relating
to Enrollment Periods for the Texas Public School Retired Employees Group
Insurance Program (TRS-Care) and who enroll during the time period prescribed
by §41.1 is:
(1)
the first day of the month following the date
that the retiree or surviving spouse becomes eligible for TRS-Care under subsections
(c)(1), (c)(2), or (c)(3) of §41.10 of this chapter relating to Eligibility
to Enroll in the Texas Public School Retired Employees Group Insurance Program
if the application for coverage is received by TRS-Care on or before the date
of eligibility for TRS-Care under subsections (c)(1), (c)(2), or (c)(3) of §41.10;
or
(2)
the first day of the month following the receipt
of the application by TRS-Care if the application is received after the date
on which the retiree or surviving spouse becomes eligible for TRS-Care under
subsections (c)(1), (c)(2), or (c)(3) of §41.10 of this chapter but within
the enrollment period.
(j)
The effective date of coverage
for a retiree, a surviving spouse, and an eligible dependent who have an additional
enrollment opportunity as described in §41.2(b) of this chapter relating
to Additional Enrollment Opportunity and who submit an application within
the time period described by §41.2 is:
(1)
September 1, 2004, if the application for coverage
is received by TRS-Care by August 31, 2004; or
(2)
October 1, 2004, if the application is received
on or after September 1, 2004 but within the enrollment period.
(k)
The effective date of coverage
for a retiree, a surviving spouse, and an eligible dependent who have an additional
enrollment opportunity as described in §41.2(c) or §41.2(d) of this
chapter relating to Additional Enrollment Opportunity and who submit an application
within the time period described by §41.2 is:
(1)
the first day of the month following the retiree's
or surviving spouse's 65th birthday if the application for coverage is received
by TRS-Care on or before the retiree's or surviving spouse's 65th birthday;
or
(2)
the first day of the month following the receipt
of the application by TRS-Care if the application is received after the retiree's
or surviving spouse's 65th birthday but within the enrollment period.
(l)
[
(h)
] Except as provided in subsections
(o), (p), and (q)
[
(l), (m), and (n)
] of this section, the
effective date of changes in coverage due to the acquisition of Medicare
is
[
shall be on
] the first of the month following the date
of
TRS-Care's
receipt of a copy of the participant's or dependent's
Medicare card [
by TRS-Care
].
(m)
[
(i)
] Except as provided in subsections
(o), (p), and (q)
[
(l), (m), and (n)
] of this section, the
effective date of reduction in coverage shall be the first day of the month
following
TRS-Care's
receipt of a signed request [
by TRS-Care
] for reduced coverage.
(n)
[
(j)
] A retiree, surviving spouse,
or surviving dependent child may cancel any coverage by submitting the appropriate
cancellation notice to TRS-Care.
(1)
Cancellations will be effective
on:
[
at midnight on the last day of the month in which the signed notice is received
by the program.
]
(A)
the first day of the month
following the date printed on the notice of cancellation form ("notice date")
sent to the retiree at the retiree's last known address, as shown in the TRS-Care
records, if TRS-Care receives the completed notice of cancellation within
fourteen days of the notice date; or
(B)
the first day of the month
following TRS-Care's receipt of the retiree's completed notice of cancellation
form if the form is received more than fourteen calendar days after the notice
date; or
(C)
the first day of the month following TRS-Care's
receipt of a written request to cancel coverage from a surviving spouse or
from or on behalf of a surviving dependent child.
(2)
This
subsection
[
section
]
shall also apply to waivers of noncontributory coverage by retirees
who
take a TRS retirement before September 1, 2004
.
[(k)
All participants and dependents shall
be entitled to all applicable rights under the Federal Public Health Service
Act (COBRA), Title XXII.]
(o)
[
(l)
] Where a participant who has
Medicare Part A coverage incorrectly enrolls in an insurance coverage option
that provides for coverage without corresponding Medicare Part A coverage
and [
as a result
] payment is made by Medicare and TRS-Care in a
manner that violates the provisions of
Chapter 1575,
Insurance
Code, [
Article 3.50-4,
] which requires TRS-Care to be secondary
to Medicare,
TRS may
[
the Teacher Retirement System of Texas
(TRS) is authorized to
] seek the recovery of funds paid in violation
of
Chapter 1575
[
Article 3.50-4
] and
may
[
to
] make the effective date of the correct coverage retroactive to the
first day of the earliest month for which recovery of such overpaid funds
is possible under Medicare rules.
(p)
[
(m)
] Where a participant who has
Medicare Part A coverage incorrectly enrolls in a TRS-Care coverage option
that provides for coverage without corresponding Medicare Part A and there
is no claim made upon TRS-Care or the legitimate claim is less than the amount
of overpaid contributions, TRS-Care
may
[
is authorized to
] refund or credit the amount due to the participant and
may
[
to
] make the effective date of the correct coverage retroactive to when
the participant was first enrolled in both Medicare and TRS-Care to a maximum
retroactive period of twelve months, including the month in which proof of
Medicare Part A is received by TRS-Care.
(q)
[
(n)
] Upon
TRS-Care's
discovery
that
[
by TRS-Care of
] a participant [
who
] does
not have Medicare Part A coverage and [
who
] is incorrectly enrolled
in a TRS-Care coverage option that
requires
[
provides for
corresponding
] Medicare Part A
coverage
, TRS-Care will contact
the participant and advise
the participant
[
them
] that
the cost of coverage and the coverage will be adjusted prospectively effective
the first day of the next month unless a copy of a Medicare card showing Part
A coverage is received prior to that date. Claims
will
[
shall
] be paid based upon the coverage in effect at the time the services
were provided. Any claims already paid as if Part A
were
[
was
] in effect
will
[
shall
] not be adjusted.
§41.11.Years of Service Credit Used to Determine Premiums.
(a)
In addition to other criteria that TRS may use to determine
premiums, pursuant to section 1575.212, Insurance Code, TRS may use years
of service credit to determine applicable premium rates.
(b)
To determine the applicable premium for those retirees
who take a TRS retirement before September 1, 2004, TRS will use the retiree's
years of service credit to which the retiree is entitled under the Chapter
823, Government Code, at the time of the TRS retirement.
(c)
To determine the applicable premium for those retirees
who take a TRS retirement after September 1, 2004, TRS will use the retiree's
years of service credit that can be considered in determining eligibility
for TRS-Care benefits at the time of the TRS retirement.
(d)
To determine the applicable premium for surviving spouses
and divorced spouses who elect COBRA coverage, TRS will use the retiree's
years of service credit as determined by either subsection (b) or subsection
(c) of this section, as applicable.
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 June 7, 2004.
TRD-200403715
Ronnie G. Jung
Executive Director
Teacher Retirement System of Texas
Proposed date of adoption: July 23, 2004
For further information, please call: (512) 542-6115
Subchapter C. TEXAS SCHOOL EMPLOYEES GROUP HEALTH (TRS-ACTIVECARE)
34 TAC §41.38, §41.50
The Teacher Retirement System of Texas (TRS) proposes amendments
to §41.38, relating to termination date of coverage and to §41.50,
relating to adjudication of claims, both concerning the Texas School Employees
Uniform Group Health Coverage Program known as TRS-ActiveCare. The proposed
amendments to §41.38 clarify that coverage for an individual enrolled
in a TRS-ActiveCare health maintenance organization (HMO) terminates for the
reasons and on the date specified in the individual's evidence of coverage
from the HMO. The proposed amendments to §41.38 also add a termination
provision for participants whose participating entity fails to make all premium
payments for at least 90 days. The proposed amendments to §41.50 clarify
that appeals from enrollees participating in a TRS-ActiveCare health maintenance
organization (HMO) are not included within this appeal process but follow
the HMO's appeal process.
Ronnie Jung, Executive Director, has determined that for each year of the
first five-year period the amendments are in effect, there will be no determinable
fiscal implications to state or local governments as a result of enforcing
or administering the amended sections. There is no foreseeable effect on local
employment or local economies as a result of the proposed amendments.
Mr. Jung has also determined that for each year of the first five years
that the proposed amendments are in effect the public benefit anticipated
as a result of the amendments to §41.38 will be that the rules are consistent
with current HMO practice and that TRS-ActiveCare can limit its financial
exposure when participating entities fail to make any premium payments for
an extended period of time. Mr. Jung has determined that for each year of
the first five years that the proposed amendments are in effect the public
benefit anticipated as a result of the amendments to §41.50 will be that
those enrolled in a TRS-ActiveCare HMO have clearer notice of what appeal
process applies to them. There is no anticipated adverse economic effect on
small businesses or micro-businesses as a result of compliance with the proposed
amendments.
Mr. Jung has also determined that the anticipated economic costs to persons
required to comply with the proposed amendments that address termination for
a participating entity's failure to pay all premiums for at least 90 days
for each year of the first five years the proposal will be in effect could
include an individual whose coverage has been terminated and who does not
elect COBRA coverage being required to pay for health care services the individual
received after coverage was terminated. Mr. Jung has determined that there
are no anticipated economic costs to persons required to comply with the other
proposed amendments for each year of the first five years the proposal will
be in effect.
Written comments on the proposal may be submitted to Ronnie Jung, Executive
Director, 1000 Red River, Austin, Texas 78701.
These amendments are proposed under §1579.052, Insurance
Code, which gives TRS authority to adopt rules relating to the TRS-ActiveCare
program as necessary. The amendments are also proposed under Government Code,
Chapter 825, §825.102, which authorizes the Board of Trustees of the
Teacher Retirement System to adopt rules for the administration of the funds
of the retirement system and for the transaction of business of the Board.
There are no other codes affected by the proposal.
§41.38.Termination Date of Coverage.
(a)
Unless otherwise required by law or this section, coverage
shall terminate at the earliest of:
(1) - (2)
(No change.)
(3)
11:59 p.m. Central Time on the last calendar day of the
month in which a covered individual, or the individual under whom a dependent
qualified for coverage, is no longer eligible for coverage under the TRS-ActiveCare
program under §41.34 of this title (relating to Eligibility for Coverage
under the Texas School Employees Uniform Group Health Coverage Program); [
or
]
(4)
11:59 p.m. Central Time on the date specified by the trustee
if the covered individual, or the individual under whom a dependent qualified
for coverage, is expelled from the program
;
[
.
]
(5)
11:59 p.m. Central Time on the last calendar day of the
month immediately preceding the month in which TRS receives a notification
from a participating entity, in the form prescribed by TRS, that a covered
individual failed to make a required monthly premium payment to the participating
entity
;
[
.
]
(6)
11:59 p.m. Central Time on the last calendar day of the
month in which a covered individual enters into active, full-time military,
naval, or air service, except as provided under the Uniformed Services Employment
and Reemployment Rights Act of 1994 (USERRA) or other applicable law
; or
[
.
]
(7)
11:59 p.m. Central Time on the last day
of the month for which TRS-ActiveCare received payment if the participating
entity employing the covered individual, or the individual under whom a dependent
qualified for coverage, has failed to make all premium payments due for a
period of 90 days or longer; or
(8)
the termination date that a health maintenance
organization participating in the TRS-ActiveCare program provides for in its
Evidence of Coverage for the reasons listed in that Evidence of Coverage.
(b)
(No change.)
§41.50.Adjudication of Claims.
(a)
A person enrolled in the TRS-ActiveCare program
, other
than a person enrolled in a health maintenance organization (HMO) participating
in TRS-ActiveCare,
who is denied payment of a claim or other benefit
("Claimant") may submit a written request to the administering firm for reconsideration
of the claim. The claimant shall submit a request for reconsideration according
to procedures established by the administering firm. All relevant medical
information should be submitted to the administering firm prior to a final
decision.
Persons enrolled in a TRS-ActiveCare HMO follow the appeal
procedures set out by the HMO.
(b) - (n)
(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 June 7, 2004.
TRD-200403716
Ronnie G. Jung
Executive Director
Teacher Retirement System of Texas
Proposed date of adoption: July 23, 2004
For further information, please call: (512) 542-6115