34 Tex. Admin. Code § 81.7 - Enrollment and Participation
(a)
Enrollment Categories.
(1) Full-time
employees and their dependents.
(A) A new
employee:
(i) who is not subject to the
health insurance waiting period and is eligible under the Act and as provided
for in §
81.5(a)(1) of
this chapter (relating to Eligibility) for automatic insurance coverage, shall
be enrolled in the basic plan unless the employee completes an enrollment form
to elect other coverage or to waive GBP health coverage as provided in §
81.8 of this chapter (relating to
Waiver of Health Coverage). Coverage of an employee under the basic plan, and
other coverage selected as provided in this paragraph, becomes effective on the
date on which the employee begins active duty.
(ii) who is subject to the health insurance
waiting period and is eligible under the Act and as provided for in §
81.5(a)(1) of
this chapter for automatic insurance coverage, shall be enrolled in the basic
plan beginning on the first day of the calendar month following 60 days of
employment unless, before this date, the employee completes an enrollment form
to elect other coverage or to waive GBP health coverage as provided in §
81.8 of this chapter.
(iii) who has existing, current, and
continuous GBP health coverage as of the date the employee begins active duty
is not subject to the health insurance waiting period and is eligible to enroll
as a new employee in health insurance and additional coverage and plans which
include optional coverage by completing an enrollment form before the first day
of the calendar month after the date the employee begins active duty. Health
and additional coverage selected before the first day of the calendar month
after the date the employee begins active duty are effective the first day of
the following month.
(B)
Dependent enrollment and optional coverage:
(i) To enroll eligible dependents, to elect
to enroll in an approved HMO, and to elect additional coverage and plans which
include optional coverage, an employee not subject to the health insurance
waiting period shall complete an enrollment form within 30 days after the date
on which the employee begins active duty. Coverage selected within 30 days
after the date on which the employee begins active duty becomes 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 (d) of
this section.
(ii) To enroll
eligible dependents or to elect to enroll in an approved HMO, an employee
subject to the health insurance waiting period shall complete an enrollment
form before the first day of the month following 60 days of employment.
Coverage selected before the first day of the month following 60 days of
employment becomes effective on the first day of the month following 60 days of
employment. An employee completing an enrollment form after the initial period
for enrollment as provided in this paragraph is subject to the provisions of
subsection (d) of this section. The provisions of subparagraph (A)(ii) of this
paragraph apply to the election of additional coverage and plans, which include
optional coverage, for an employee subject to the health insurance waiting
period.
(C) Except as
otherwise provided in this section, an employee may not change
coverage.
(D) An eligible employee
who enrolls in the GBP is eligible to participate in premium conversion and
shall be automatically enrolled in the premium conversion plan. The employee
shall be automatically enrolled in the plan for subsequent plan years as long
as the employee remains on active duty.
(E) Coverage for a newly eligible dependent,
other than a dependent referred to in subparagraph (F) or (H) of this
paragraph, will be effective on the first day of the month following the date
the person becomes a dependent if an enrollment form is completed on or within
30 days after the date the person first becomes a dependent. If the enrollment
form is completed and signed after the initial period for enrollment as
provided in this paragraph, the enrollment form will be governed by the rules
in subsection (d) of this section.
(F) A member's newborn natural child will be
covered immediately and automatically for 30 days from the date of birth in the
health plan in effect for the employee/retiree. A member's newly adopted child
will be covered immediately and automatically from the date of placement for
adoption for 30 days in the health plan in effect for the employee/retiree. To
continue coverage for more than 30 days after the date of birth or placement
for adoption, an enrollment form for GBP health coverage must be submitted by
the member within 30 days after the date of birth or placement for
adoption.
(G) The effective date of
a newborn natural child's life and AD&D coverage will be the date of birth,
if the child is born alive, as certified by an attending physician or a
certified nurse-midwife. The effective date of a newly adopted child's life and
AD&D coverage will be the date of placement for adoption. The effective
date of all other eligible dependents' life and AD&D coverage will be as
stated in subparagraph (E) of this paragraph.
(H) GBP health coverage of a member's
eligible child for whom a covered employee/retiree is court-ordered to provide
medical support becomes effective on the date on which the member's benefits
coordinator receives a valid copy of the qualified medical child support
order.
(I) The effective date of
GBP health coverage for an employee's/retiree's dependent, other than a newborn
natural child or newly adopted child, will be as stated in subparagraph (E) of
this paragraph.
(J) For purposes of
this section, an enrollment form is completed when all information necessary to
effect an enrollment has been transmitted to ERS in the form and manner
prescribed by ERS.
(2)
Part-time employees. A part-time employee or other employee who is not
automatically covered must complete an application/enrollment form provided by
ERS authorizing necessary deductions for insurance required contributions for
elected coverage. All other rules for enrollment stated in paragraph (1) of
this subsection, other than the rule as to automatic coverage, apply to such
employee:
(A) If the employee is not subject
to a health insurance waiting period, this form must be submitted to ERS either
through ERS Online or through his/her benefits coordinator on, or within 30
days after, the date on which the employee begins active duty.
(B) If the employee is subject to a health
insurance waiting period, this form must be submitted to ERS either through ERS
Online or through his/her benefits coordinator before the first day of the
month following 60 days of employment.
(C) If the employee has existing, current,
and continuous GBP health coverage as of the date the employee begins active
duty, the employee is not subject to the health insurance waiting period and is
eligible to enroll as a new employee in health insurance and additional
coverage and plans which include optional coverage by completing an enrollment
form before the first day of the calendar month after the date the employee
begins active duty. Health and additional coverage selected before the first
day of the calendar month after the date the employee begins active duty are
effective the first day of the following month.
(3) Retirees and their dependents.
(A) Provided the insurance required
contributions are paid or deducted, an employee's GBP health, dental, vision
and term life insurance coverage (including eligible dependent coverage) may be
continued upon retirement as provided in §
81.5(b) of this
chapter. The life insurance will be reduced to the maximum amount which the
retiree is permitted to retain under the insurance plan as a retiree. All other
coverage in force for an active employee, but not available to a retiree, will
automatically be discontinued concurrently with the commencement of retirement
status. Except as provided in subparagraph (E) of this paragraph, if a retiree
retires directly from active duty and is not covered as an active employee on
the day before becoming an annuitant, the retiree may enroll in the basic
plan.
(B) A retiree may enroll in
GBP health, dental, vision and life insurance coverage for which the retiree is
eligible as provided in §
81.5(b) of this
chapter, including dependent coverage, by completing an enrollment form as
specified in clauses (i) - (iii) of this subparagraph. For the purposes of this
subparagraph, the effective date of retirement of a retiree who is eligible to
receive, but who has not yet received, an annuity is the date on which ERS
receives written notice of the retirement. An application/enrollment form
received after the initial period for enrollment as provided in this
subparagraph, is subject to the provisions of subsection (d) of this section.
(i) A retiree who is not subject to the
health insurance waiting period on the effective date of retirement as provided
in §
81.5(b) of this
chapter, may enroll in GBP health, dental, vision and life insurance coverage
or waive GBP health coverage as provided in §
81.8 of this chapter for which the
retiree is eligible, including dependent coverage, by completing an enrollment
form or waiver of coverage as applicable before, on, or within 30 days after,
the retiree's effective date of retirement.
(ii) A retiree who is subject to the health
insurance waiting period on the effective date of retirement as provided in
§
81.5(b) of this
chapter, may enroll in GBP health coverage or waive GBP health coverage as
provided in §
81.8 of this chapter for which the
retiree is eligible, including dependent coverage, by completing an enrollment
form or waiver of coverage as applicable, before the first day of the calendar
month following 60 days after the date of retirement or before the first day of
the calendar month after the retiree's 65th birthday, whichever is later as
appropriate. The effective date for such coverage shall be the first day of the
calendar month following 60 days after the date of retirement or the first day
of the calendar month following the retiree's 65th birthday, whichever is later
as appropriate.
(iii) A retiree who
is ineligible for health insurance on the effective date of retirement as
provided in §
81.5(b) of this
chapter, may enroll in GBP health coverage or waive GBP health coverage as
provided in §
81.8 of this chapter for which the
retiree is eligible, including dependent coverage, by completing an enrollment
form or waiver of coverage as applicable, before the first day of the calendar
month after the retiree's 65th birthday. The effective date for such coverage
shall be the first day of the calendar month following 60 days after the date
of retirement or the first day of the calendar month following the retiree's
65th birthday, whichever is later.
(C) A retiree who becomes eligible for
minimum retiree optional life insurance coverage or dependent life insurance
coverage as provided in §
81.5(b)(6) of
this chapter, may apply for approval of such coverage by providing evidence of
insurability acceptable to ERS.
(D)
Enrollments in and applications to change coverage become effective as provided
in subparagraph (B) of this paragraph unless other coverage is in effect at
that time. If other coverage is in effect at that time, coverage or waiver of
coverage becomes effective on the first day of the month following the date of
approval of retirement by ERS; or, if cancellation of the other coverage
preceded the date of approval of retirement, the first day of the month
following the date the other coverage was canceled.
(E) A retiree who seeks enrollment in GBP
health coverage after turning age 65 will be automatically enrolled in
HealthSelect of Texas until Medicare enrollment is confirmed by CMS. A retiree
who is enrolled in a health plan and turns age 65 will remain enrolled in that
health plan until the retiree's Medicare enrollment can be confirmed by CMS.
Once Medicare enrollment is confirmed, the retiree will be automatically
enrolled in the Medicare Advantage Plan unless the retiree opts out of the
Medicare Advantage Plan and enrolls in other coverage by completing an
enrollment form as specified in subparagraph (B)(i) - (iii) of this paragraph.
If the retiree is determined to be ineligible for Medicare coverage, then
he/she will be returned to the coverage in place immediately before turning
65.
(F) A Medicare-eligible retiree
who seeks enrollment in GBP health coverage, or is retired and enrolled in a
health plan and becomes eligible for Medicare, will be automatically enrolled
in the HealthSelect of Texas Prescription Drug Program until Medicare
enrollment is confirmed by CMS. Upon confirmation of Medicare enrollment, the
retiree will be enrolled in HealthSelect Medicare Rx. A retiree who declines
HealthSelect Medicare Rx loses all GBP prescription drug coverage. If the
retiree is determined to be ineligible for Medicare coverage, then he/she will
be returned to the coverage in place immediately before turning 65.
(4) Medicare-eligible Dependents.
(A) A dependent as defined in §
81.1 of this chapter (relating to
Definitions) who becomes eligible for Medicare-primary coverage as specified in
§
81.1 of this chapter, either
through disability, age, or other requirements as set forth by CMS, will be
automatically enrolled in the Medicare Advantage Plan, once Medicare enrollment
is confirmed by CMS, unless the retiree and his/her dependents opt out of the
Medicare Advantage Plan and enroll in other coverage by completing an
enrollment form as specified in paragraph (3)(B)(i) - (iii) of this subsection.
If the dependent is determined to be ineligible for Medicare coverage, then
he/she will be returned to the coverage in place immediately before turning
65.
(B) A Medicare-eligible
dependent eligible for GBP health coverage will be automatically enrolled in
HealthSelect Medicare Rx, once Medicare enrollment is confirmed by CMS. A
Medicare-eligible dependent who declines HealthSelect Medicare Rx loses all GBP
prescription drug coverage. If the dependent is determined to be ineligible for
Medicare coverage, then he/she will be returned to the coverage in place
immediately before turning 65.
(5) Surviving dependents.
(A) Provided that the insurance required
contributions are paid or deducted, the health, dental, and vision insurance
coverage of a surviving dependent may be continued on the death of the deceased
employee/retiree if the dependent is eligible for such coverage as provided by
§
81.5(e) of this
chapter.
(B) A surviving spouse who
is receiving an annuity shall make insurance required contribution payments by
deductions from the annuity as provided in subsection (h)(7) of this section. A
surviving spouse who is not receiving an annuity may make payments as provided
in subsection (h)(7) of this section.
(C) A Medicare-eligible surviving dependent
eligible for GBP health coverage will be automatically enrolled in the Medicare
Advantage Plan, once Medicare enrollment is confirmed by CMS, unless the
surviving dependent opts out of the Medicare Advantage Plan and enrolls in
other coverage.
(D) A
Medicare-eligible surviving dependent eligible for GBP health coverage will be
automatically enrolled in HealthSelect Medicare Rx, once Medicare enrollment is
confirmed by CMS. A Medicare-eligible surviving dependent who declines
HealthSelect Medicare Rx loses all GBP prescription drug coverage.
(6) Former COBRA unmarried
children. A former COBRA unmarried child must provide an application to
continue GBP health, dental and vision insurance coverage within 30 days after
the date the notice of eligibility is mailed by ERS. Coverage becomes effective
on the first day of the month following the month in which continuation
coverage ends. Insurance required contribution payments must be made as
provided in subsection (h)(1)(A) of this section.
(b) Premium conversion plans.
(1) An eligible employee participating in the
GBP is deemed to have elected to participate in the premium conversion plan and
to pay insurance required contributions with pre-tax dollars as long as the
employee remains on active duty. 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 required contributions under this section shall
be the amount required to pay the participant's portion of the insurance
required contributions for coverage under each type of insurance included in
the plan.
(c) Special
rules for additional coverage and plans which include optional coverage.
(1) Only an employee/retiree or a former
officer or employee specifically authorized to join the GBP may apply for
additional coverage and plans. An employee/retiree may apply for or elect
additional coverage and plans for which he/she is eligible without concurrent
enrollment in GBP health coverage provided by the GBP. Additional coverage and
plans, as determined by the Board of Trustees, may include:
(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;
(G) health care and dependent care
reimbursement;
(H) commuter
spending account;
(I)
vision;
(J) limited purpose
flexible spending account; or
(K)
health savings account.
(2) An eligible member in the GBP 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 contract with the HMO.
(3) An
eligible member in the GBP electing additional coverage and plans and/or
Consumer Directed HealthSelect, HMO or Medicare Advantage coverage in lieu of
the basic plan is obligated for the full payment of insurance required
contributions. If the insurance required contributions are not paid, all
coverage not fully funded by the state contribution will be canceled. A person
eligible for the state contribution will retain member-only GBP health coverage
as a member provided the state contribution is sufficient to cover the
insurance required contribution for such coverage. If the state contribution is
not sufficient for member-only coverage in the health plan selected by the
member employee/retiree, the member employee/retiree will be enrolled in the
basic plan or the Medicare Advantage Plan, as applicable, except as provided
for in subsection (g)(2)(B) of this section.
(4) An eligible member in the GBP enrolled in
an HMO and the HMO's 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 member 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, Consumer Directed HealthSelect, or a Medicare Advantage
Plan (if eligible) by completing an enrollment form during the annual
enrollment period. The effective date of the change in coverage will be
September 1; or
(C) if the member
does not make one of the elections, as defined in subparagraphs (A) or (B) of
this paragraph, the member and covered eligible dependents will automatically
be enrolled in the basic plan or the Medicare Advantage Plan, as
applicable.
(5) A member
enrolled in an HMO whose contract with ERS is terminated during the fiscal year
or that fails to maintain compliance with the terms of its contract, as
determined by ERS, will be eligible to make one of the following elections:
(A) change to another approved HMO for which
the member is eligible. The effective date of the change in coverage will be
determined by ERS; or
(B) enroll in
HealthSelect of Texas, Consumer Directed HealthSelect, or a Medicare Advantage
Plan (if eligible). The effective date of the change in coverage will be
determined by ERS.
(d) Changes in coverage after the initial
period for enrollment.
(1) Changes for a
qualifying life event.
(A) Subject to the
provisions of paragraphs (3) and (4) of this subsection, a member shall be
allowed to change coverage during a plan year within thirty (30) days of a
qualifying life event that occurs as provided in this paragraph if the change
in coverage is consistent with the qualifying life event.
(B) A qualifying life event occurs when a
participant experiences one of the following changes:
(i) change in marital status;
(ii) change in dependent status;
(iii) change in employment status;
(iv) change of address that results in loss
of benefits eligibility;
(v) change
in Medicare or Medicaid status, or CHIP status;
(vi) significant cost of benefit or coverage
change imposed by a third party provider; or
(vii) change in coverage ordered by a
court.
(C) A member who
loses benefits eligibility as a result of a change of address shall change
coverage as provided in paragraphs (6) - (9) of this subsection.
(D) A member may apply to change coverage on,
or within 30 days after, the date of the qualifying life event, provided,
however, a change in election due to CHIP or Medicaid status under subparagraph
(B) of this paragraph may be submitted on, or within 60 days after, the change
in CHIP or Medicaid status.
(E)
Except as otherwise provided in subsection (a)(1)(F) and (H) 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) Documentation may be required in support
of the qualifying life event.
(G)
Following a qualifying life event, a member may change applicable coverage,
drop or add an eligible dependent if the change is consistent with the
qualifying life event.
(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 member
who wishes to add or increase optional coverage after the initial period for
enrollment must make application for approval by providing evidence of
insurability acceptable to ERS, if required. 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 ERS, if the
applicant is a retiree or an individual in a direct pay status. If the
applicant is an employee whose coverage was canceled while the employee was on
LWOP, 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/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, except as otherwise
provided in subsection (f) of this section;
(B) employees who wish to enroll in or
increase optional term life insurance, dependent life insurance, or disability
income insurance after the initial period for enrollment;
(C) employees enrolled in the GBP whose
coverage was waived, dropped or canceled, except as otherwise provided in
subsection (f) of this section; and
(D) retirees who wish to enroll in minimum
optional life insurance or dependent life insurance as provided in subsection
(a)(3)(C) of this section.
(5) An employee/retiree who wishes to add
eligible dependents to the employee's/retiree's HMO coverage may do so:
(A) during the annual enrollment period;
or
(B) upon the occurrence of a
qualifying life event as provided in paragraph (1) of this
subsection.
(6) A member
who is enrolled in an 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 member moves out of
the HMO service area:
(A) enroll in another
approved HMO for which the member and all covered dependents are eligible;
or
(B) if the member and all
covered dependents are not eligible to enroll in an approved HMO; either:
(i) enroll in HealthSelect of Texas or
Consumer Directed HealthSelect; or
(ii) enroll in an approved HMO if the member
is eligible, and drop any ineligible covered dependent, unless not in
compliance with §
81.11(c)(3) of
this chapter (relating to Cancellation of Coverage and Sanctions).
(7) When a covered
dependent of a member permanently moves out of the member's HMO service area,
the member 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:
(A) drop the
ineligible dependent, unless not in compliance with §
81.11(c)(3) of
this chapter;
(B) enroll in an
approved HMO if the member and all covered dependents are eligible;
or
(C) enroll in HealthSelect of
Texas or Consumer Directed HealthSelect, provided the eligible member and all
dependents enroll in the same health plan at that time.
(8) An eligible member will be allowed an
annual opportunity to make changes in coverage.
(A) Subject to other requirements of this
section, a member will be allowed to:
(i)
change or enroll themselves and any eligible dependents in an eligible health,
dental or vision plan;
(ii) enroll
themselves and their eligible dependents in an eligible health, dental or
vision plan from a waived or canceled status;
(iii) add, decrease or cancel eligible
coverage, unless prohibited by §
81.11(c)(3) of
this chapter;
(iv) apply for
coverage as provided in paragraph (3) of this subsection; and
(v) waive any or all GBP coverage including
health as provided in §
81.8 of this chapter.
(B) Surviving dependents and
former COBRA unmarried children are not eligible to add dependents to coverage
through annual enrollment. A surviving dependent or former COBRA unmarried
child may enroll an eligible dependent in dental or vision insurance coverage
if the dependent is enrolled in health insurance coverage.
(C) Annual enrollment opportunities will be
scheduled each year at times announced by ERS.
(9) 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(c) of this
chapter.
(10) A member and his/her
dependents who are enrolled in the Medicare Advantage Plan may collectively
enroll in HealthSelect of Texas, Consumer Directed HealthSelect or an HMO.
(A) Such opportunity will be scheduled on at
least an annual basis each year, at times announced by ERS.
(B) Additional opportunities will occur each
month prior to an annual enrollment period. Coverage selected during these
opportunities will be effective on the first of the month following processing
by CMS.
(11) If a member
drops coverage for his/her dependent because the dependent gained other
coverage effective the first day of a month, then the effective date of the
qualifying life event can be either the last day of the month preceding the
gained coverage or on the first day of the month in which the gained coverage
is effective.
(e)
Special provisions relating to term life benefits
(1) An employee or annuitant who is enrolled
in the group term life insurance plan may file a claim for an accelerated life
benefit for himself or his covered dependent in accordance with the terms of
the plan in effect at that time. An accelerated life benefit paid will be
deducted from the amount that would otherwise be payable under the
plan.
(2) An employee or annuitant
who is enrolled in the group term life insurance plan may make, in conjunction
with receipt of a viatical settlement, an irrevocable beneficiary designation
in accordance with the terms of the plan in effect at that time.
(f) Re-enrollment in the GBP.
(1) The provisions of subsection (a)(1) of
this section shall apply to the enrollment of an employee who terminates
employment and returns to active duty within the same fiscal year, who
transfers from one employer to another, or who returns to active duty after a
period of LWOP during which coverage is canceled.
(2) An employee to whom paragraph (1) of this
subsection applies shall be subject to the same requirements as a newly hired
employee to re-enroll in the coverage in which the employee was previously
enrolled. 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.
(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 coverage is canceled during a
period of LWOP 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.
(g) Continuing coverage in special
circumstances.
(1) Continuation of coverage
for terminating employees. A terminating employee is eligible to continue all
coverage through the last day of the month in which employment is
terminated.
(2) Continuation of
coverage for employees on LWOP status.
(A) An
employee in LWOP status may continue the coverage 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 insurance required contributions directly as
provided in subsection (h)(1)(A) of this section.
(B) An employee whose LWOP is a result of the
Family and Medical Leave Act of 1993 will continue to receive the state
contribution during such period of LWOP. The employee must pay insurance
required contributions directly as defined in subsection (h)(1)(A) of this
section. Failure to make the payment of insurance required contributions by the
due date will result in the cancellation of all coverage except for member-only
health and basic life coverage. The employee will continue in the health plan
in which he/she was enrolled immediately prior to the cancellation of all other
coverage.
(3)
Continuation of coverage for a former member or employee of the Legislature.
Provided that the insurance required contributions are paid, the GBP health,
dental, vision and life insurance coverage of a former member or employee of
the Legislature may be continued on conclusion of the term of office or
employment.
(4) Continuation
coverage for a former board member. Provided that the insurance required
contributions are paid, the GBP health, dental, vision and life insurance
coverage of a former member of a board or commission, or of the governing body
of an institution of higher education, as both are described in §1551.109
of the Act, may be continued on conclusion of service if no lapse in coverage
occurs after the term of office. Life insurance will be reduced to the maximum
amount for which the former board member is eligible.
(5) Continuation of coverage 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 coverage that was in effect during the
calendar month immediately prior to the month in which the former judge did not
serve on judicial assignments. This coverage 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.
(6)
Continuation of coverage for a surviving spouse and/or dependent child/children
of a deceased employee/retiree. The surviving spouse and/or dependent
child/children of a deceased employee/retiree, who, in accordance with §
81.5(j)(1) of
this chapter, elects to continue coverage may do so by submitting the required
election notification and enrollment forms to ERS. The enrollment form,
including all insurance required contributions due for the election/enrollment
period, must be postmarked or received by ERS 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 insurance required contributions due for the month in which
the employee/retiree died and for the election/enrollment period have been paid
in full.
(7) Continuation of
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
GBP as an employee, or whose coverage has ended following the maximum period of
LWOP as provided in paragraph (2)(A) of this subsection. An employee, his/her
spouse and/or dependent child/children, who, in accordance with §
81.5(j)(2) of
this chapter, elect to continue GBP health, dental and vision coverage may do
so by submitting the required election notification and enrollment forms to
ERS. The enrollment form, including all insurance required contributions due
for the election/enrollment period, must be postmarked or received by ERS 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 insurance required
contributions due for the month in which the coverage ends and for the
election/enrollment period have been paid in full.
(8) Continuation of coverage for a spouse who
is divorced from a member and/or the spouse's dependent child/children. The
divorced spouse and/or the spouse's dependent child/children of an
employee/retiree who, in accordance with §
81.5(j)(4) of
this chapter, elect to continue coverage may do so by submitting the required
election notification and enrollment forms to ERS. The enrollment form,
including all insurance required contributions due for the election/enrollment
period, must be postmarked or received by ERS 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 insurance required contributions due for the month in
which the divorce decree is signed and for the election/enrollment period have
been paid in full.
(9) Continuation
of coverage for a dependent child who has attained 26 years of age. A
26-year-old dependent child (not provided for by §
81.5(c) of this
chapter) of a member who, in accordance with §
81.5(j)(5) of
this chapter, elects to continue coverage may do so by submitting the required
election notification and enrollment forms to ERS. The enrollment form,
including all insurance required contributions due for the election/enrollment
period, must be postmarked or received by ERS 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 member attains 26 years of age, provided all insurance required
contributions due for the month in which the dependent child attained age 26
and for the election/enrollment period have been paid in full.
(10) Extension of continuation of coverage
for certain dependents of former employees who are continuing coverage under
the provisions of paragraph (6) of this subsection.
(A) The surviving dependent of a deceased
former employee, who, in accordance with §
81.5(j)(6)(A) of
this chapter, elects to extend continuation coverage may do so by submitting
the required election notification and enrollment forms to ERS. The enrollment
form, including all insurance required contributions due for the
election/enrollment period, must be postmarked or received by ERS 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(j)(6)(B) of
this chapter, elects to extend continuation coverage may do so by submitting
the required election notification and enrollment forms to ERS. The enrollment
form, including all insurance required contributions due for the
election/enrollment period, must be postmarked or received by ERS 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 who has attained 26 years of age, who, in accordance with
§
81.5(j)(6)(C) of
this chapter, elects to extend continuation coverage may do so by submitting
the required election notification and enrollment forms to ERS. The enrollment
form, including all insurance required contributions due for the
election/enrollment period, must be postmarked or received by ERS 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 26.
(11) Continuation coverage defined.
Continuation coverage as provided for in paragraphs (6) - (10) of this
subsection means the continuation of only GBP health, dental and vision
coverage which meets the following requirements.
(A) Type of benefit coverage. The coverage
shall consist of only the GBP health, dental and vision coverage, which, as of
the time the coverage is being provided, are identical to the GBP health,
dental and vision coverage 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 for
other than gross misconduct, reduction in work hours, or end of maximum period
of LWOP, 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 for other than gross
misconduct, reduction in work hours, or end of maximum period of LWOP, if the
employee, spouse, or dependent child has been certified by the Social Security
Administration as being disabled as provided in §
81.5(j)(3) of
this chapter, up to 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 for other
than gross misconduct, reduction in work hours, or end of maximum period of
LWOP, 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 insurance required contribution as provided in subsection (h) of this
section;
(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; or
(vii) the date on which the participant,
after the date of election, becomes entitled to benefits under the Social
Security Act, Title XVIII.
(C) Insurance required contribution costs.
The insurance required contribution for a participant during the continuation
coverage period will be 102% of the employee's/retiree's GBP health, dental and
vision coverage rate and is payable as provided in subsection (h) of this
section.
(i) The insurance required
contribution for a participant eligible for 36 months of coverage will be 102%
of the employee's/retiree's GBP health, dental and vision coverage rate and is
payable as provided in subsection (h)(1)(A) of this section.
(ii) The insurance required contribution for
a participant eligible for 29 months of coverage will increase to 150% of the
employee's/retiree's GBP health, dental and vision coverage rate for the 19th
through 29th months of coverage and is payable as provided in subsection
(h)(1)(A) of this section.
(D) No requirement of insurability. No
evidence of insurability is required for a participant who elects to continue
GBP health coverage under the provisions of §
81.5(j)(1) - (6)
of this chapter.
(E) Conversion
option. An option to enroll under the conversion plan available to
employees/retirees is also available to a participant who continues GBP
coverage for the maximum period as provided in subparagraph (B)(i) - (iii) of
this paragraph. The conversion notice will be provided to a participant during
the 180-day period immediately preceding the end of the continuation
period.
(h)
Payment of Insurance Required Contributions.
(1) A member whose monthly cost of coverage
is greater than the combined amount contributed by the state or employer for
the member's coverage must pay a monthly contribution in an amount that exceeds
the combined monthly contributions of the state or the employer. A member shall
pay his/her monthly insurance required contributions through deductions from
monthly compensation or annuity payments or by direct payment, as provided in
this paragraph.
(A) A member who is not
receiving a monthly compensation or an annuity payment, or is receiving a
monthly compensation or annuity payment that is less than the member's monthly
insurance required contribution, shall pay his/her monthly insurance required
contribution under this subparagraph.
(i) An
employee whose monthly compensation is less than the employee's monthly
insurance required contribution shall pay his/her monthly insurance required
contribution through his/her employer. A non-salaried board member of an
employer shall pay his/her monthly insurance required contributions through the
employer for which he/she sits as a board member.
(ii) A retiree whose monthly annuity payment
is less than the retiree's monthly insurance required contribution shall pay
his/her monthly insurance required contributions directly to ERS.
(B) If the member does not comply
with subparagraph (A) of this subsection by the due date required, ERS will
cancel all coverage not fully funded by the state contribution. If the state
contribution is sufficient to cover the required insurance contribution for
such coverage, the member will retain member-only health and basic life
coverage. If the state contribution is not sufficient to cover the member-only
coverage in the health plan selected, the member will be enrolled in the basic
plan except as provided for in paragraph (2)(B) of this subsection.
(2) An institution of higher
education may contribute a portion or all of the insurance required
contribution for its part-time employees described by §1551.101(e)(2) of
the Act, if:
(A) the institution of higher
education pays the contribution with funds that are not appropriated from the
general revenue fund;
(B) the
institution of higher education electing to pay the contribution for its
part-time employees does so for all similarly situated eligible part-time
employees; and
(C) the contribution
paid as provided in this paragraph is paid beginning on the first day of the
month following the part-time employee's completion of any applicable waiting
period.
(3) A
participant who continues GBP health, dental and vision coverage under COBRA as
provided in §
81.5(j) of this
chapter must pay his/her monthly insurance contributions on the first day of
each month covered.
(A) A participant's
monthly insurance required contribution is 102% of the monthly amount charged
for other participants in the same coverage category and in the same plan. All
insurance required contributions due for the election/enrollment period must be
postmarked or received by ERS on or before the date indicated on the
continuation of coverage enrollment form. Subsequent insurance required
contributions are due on the first day of each month of the participant's
coverage and must be postmarked or received by ERS within 30 days of the due
date to avoid cancellation of coverage.
(B) A participant's monthly insurance
required contribution for continuing coverage as provided in §
81.5(j)(3) of
this chapter is increased after the 18th month of coverage to 150% of the
monthly amount charged for other participants in the same coverage category and
in the same plan. The participant's monthly insurance required contribution is
due on the first day of each month covered, and must be postmarked or received
by ERS within 30 days of the due date.
(4) The full cost for GBP health, dental and
vision coverage is required to be paid for a member's unmarried child who is
over 26 years of age, whose coverage under COBRA expired, and who has
reinstated coverage in the GBP pursuant to §1551.158 of the Act. No state
contribution is paid for this coverage.
(5) Survivors 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 death in the
line of duty as provided by Chapter 615, Government Code, are eligible for GBP
coverage as provided in subparagraphs (A) - (C) of this paragraph.
(A) The insurance required contribution due
under this paragraph for a surviving spouse's GBP coverage is the same amount
as a member-only contribution. The state contribution applicable to member-only
coverage is applied to the surviving spouse's contribution for the
coverage.
(B) The insurance
required contribution due under this paragraph for GBP coverage for a surviving
spouse with dependent children is the same amount as the member-with-children
contribution. The state contribution applicable to member-with-children
coverage is applied to the contribution of the surviving spouse with dependent
children for the coverage.
(C) The
insurance required contribution due under this paragraph for a surviving
dependent child's GBP coverage, when there is no surviving spouse, is the same
amount as member-only contribution. The state contribution applicable to
member-only coverage is applied to the surviving dependent child's contribution
for the coverage.
(D) The surviving
spouse or surviving dependent child must timely pay his/her insurance required
contributions for the GBP coverage. The survivor's contribution must be either
deducted by ERS from the survivor's annuity payment, if any, or submitted to
ERS via direct payment. Any applicable state contribution will be paid directly
to ERS by the employer that employed the deceased law enforcement officer or
custodial employee.
(6)
If a retiree whose eligibility for health insurance is based on
§§1551.102(i), 1551.111(e) or 1551.112(c) of the Act, obtains interim
health insurance as provided in §1551.323 of the Act, the retiree must pay
the total contribution for such coverage for as long as the retiree wants the
coverage or until the first day of the month following the retiree's 65th
birthday. The amount of contribution shall be determined by the Board of
Trustees based on an actuarial determination, as recommended by ERS' consulting
actuary for insurance, of the estimated total claims costs for individuals
eligible for such coverage. If a retiree who is eligible for coverage under
this paragraph is also eligible for COBRA coverage, then COBRA coverage should
be exhausted, if possible, before applying for the coverage under this
paragraph.
(7) A member's surviving
spouse or surviving dependent who is receiving an annuity shall authorize
deductions for insurance required contributions from the annuity as provided in
paragraph (1) of this subsection. A member's surviving spouse or surviving
dependent who is not receiving an annuity may make payments as provided in
paragraph (1)(A) of this subsection.
(i) The amount of state contribution for
certain retirees is determined in accordance with §1551.3196 of the Act.
(1) An individual is grandfathered at the
time of retirement and not subject to §1551.3196 of the Act, if on or
before September 1, 2014, the individual has served in one or more positions
for at least five years for which the individual was eligible to participate in
the GBP as an employee.
(2) Records
of ERS shall be used to determine whether or not an individual meets the
grandfathering requirements specified in paragraph (1) of this subsection. ERS
may, in its sole discretion, require an individual to provide additional
documentation satisfactory to ERS that the individual meets the grandfathering
requirements specified in paragraph (1) of this subsection.
(j) Tobacco User Premium
Differential.
(1) Assessment. Pursuant to
§1551.3075 of the Act, ERS shall assess a monthly tobacco user premium
differential, in an amount determined by the Board of Trustees or as set in the
General Appropriations Act, for participants enrolled in GBP health coverage
who are certified as tobacco users or are age eighteen or older at the start of
the current plan year and whose tobacco-use status has not been certified. ERS
shall assess a single premium differential for each GBP member who is a tobacco
user, a single premium differential for the member's dependent spouse who is a
tobacco user, and a single premium differential for one or more of the member's
dependent children who are tobacco users. A participant will not be subject to
a premium differential assessment if the participant has been certified not to
be a tobacco user or ERS has approved the participant for a one-year waiver
under the Choose to Quit program.
(2) Payment. The GBP member responsible for
paying a tobacco user's insurance required contribution shall pay any assessed
premium differential for the member and the member's dependents.
(3) Certification of Tobacco-Use Status. Each
GBP member with GBP health coverage must certify the tobacco-use status of the
member and the member's enrolled dependents.
(A) If participants certify that they are not
a tobacco user, ERS shall not assess the premium differential.
(B) ERS shall assess the premium differential
monthly for any participant age eighteen or older at the start of the current
plan year whose tobacco-use status has not been certified.
(4) Choose to Quit Wellness
Program. ERS may approve a one-year waiver for a participant who completes the
Choose to Quit program for that plan year.
(A) The participant must complete all of the
following steps to have the premium differential waived:
(i) participate in an office visit with a
licensed physician to receive tobacco counseling and establish a tobacco
cessation course of treatment under that physician's recommendation and
supervision;
(ii) complete the
course of treatment, which may or may not result in cessation of tobacco use;
(iii) participate in an office
visit with the licensed physician following completion of treatment and obtain
the physician's signature and the date of signature on the Choose to Quit
certification form; and
(iv) sign
and submit the Choose to Quit certification form to ERS.
(B) The Choose to Quit certification form
must be signed by the physician during the plan year for which the waiver is
requested and postmarked within thirty calendar days of the physician's
signature date to be effective for that plan year.
(C) Once processed and approved by ERS, the
participant's premium differential will be waived for the remainder of the plan
year and any premium differential previously paid for that plan year will be
refunded.
(D) A member with more
than one dependent child certified as a tobacco user will not receive a refund
of the premium differential paid for dependent children unless all dependent
children certified as tobacco users complete the steps set forth in paragraph
(4)(A) of this section.
(E) At the
beginning of each plan year, ERS shall reinstate the monthly assessment of the
premium differential for the participant unless the participant has been
separately certified not to be a tobacco user.
(5) Sanctions. If any participant fails to
accurately certify any participant's use of a tobacco product or submits false
information to ERS regarding a participant's use of a tobacco product, ERS may
impose one or more of the sanctions described in §1551.351(b) of the
Act.
Notes
State regulations are updated quarterly; we currently have two versions available. Below is a comparison between our most recent version and the prior quarterly release. More comparison features will be added as we have more versions to compare.
No prior version found.