(a) Description. The HealthSelectShoppERS program is
designed to provide an incentive for eligible health benefit plan
participants to select certain network facilities for specified elective,
non-emergency medical services and procedures. The incentive will
be limited to an amount that is compliant with applicable federal
laws and regulations and will be publicly posted by ERS. The incentive
is an employer contribution by a GBP member's health benefit plan
to the GBP member's TexFlex health care reimbursement account or limited
purpose health care reimbursement account, as set forth in §85.8.
(b) Administration. The HealthSelectShoppERS program
is administered by the Board. The Board may designate and contract
with a vendor, administrator or firm to perform the day-to-day administrative
responsibilities of the HealthSelectShoppERS program. The designated
vendor, administrator or firm shall perform its duties as assigned
by the program administrator and in accordance with its contract with
the program administrator, the Code, rules and all applicable state
and federal laws and regulations.
(c) Eligibility. A GBP member and the member's dependents
are eligible for the HealthSelectShoppERS program if all of the conditions
of this subsection are met:
(1) the GBP member is an employee on active duty on
the date of a search described in subsection (d)(1) of this section
and on the date of payment of an employer contribution described in
subsection (d)(3) of this section;
(2) the GBP member and any dependents participating
in the HealthSelectShoppERS program are enrolled in Consumer Directed
HealthSelect or the HealthSelect of Texas In-Area Benefits Plan or
Out-of-State Plan on the date of a search described in subsection
(d)(1) of this section, on the date of receipt of a service described
in subsection (d)(2) of this section, and on the date of payment of
an employer contribution described in subsection (d)(3) of this section;
(3) neither the GBP member nor any dependents participating
in the HealthSelectShoppERS program is receiving Medicare benefits
as his or her primary coverage on the date of a search described in
subsection (d)(1) of this section, on the date of receipt of a service
described in subsection (d)(2) of this section, and on the date of
payment of an employer contribution described in subsection (d)(3)
of this section; and
(4) the GBP member is eligible to receive an employer
contribution to a TexFlex health care reimbursement account or limited
purpose health care reimbursement account on the date of payment of
an employer contribution described in subsection (d)(3) of this section.
A previously established health care reimbursement account or limited
purpose health care reimbursement account is not required as a condition
of eligibility.
(d) Program Requirements. Participants must complete
all of the following steps to receive a HealthSelectShoppERS program
incentive.
(1) Conduct a search in which the participant is presented
with a selection of network facilities that provide the medical service
or procedure:
(A) the search must be conducted, facilitated and documented
in accordance with requirements established by ERS and the vendor,
administrator, or firm with administrative responsibilities designated
by the Board;
(B) the medical service or procedure must meet all
health benefit plan requirements to be a covered service when performed,
including, but not limited to, applicable requirements related to
referrals, prior authorizations and medical necessity;
(C) the search must identify the participant who will
receive the medical service or procedure;
(D) on the date of the search, the GBP member must
meet all eligibility requirements set forth in subsection (c)(1) of
this section; and
(E) on the date of the search, the participant and
the GBP member, if the participant is not the GBP member, must meet
all eligibility requirements set forth in subsection (c)(2) and (3)
of this section.
(2) Receive the medical service or procedure for which
the described search was conducted:
(A) the participant must receive the medical service
or procedure at a facility included in a search described in subsection
(d) of this section;
(B) the participant must receive the medical service
or procedure for which the described search was conducted within applicable
program deadlines; and
(C) on the date of the participant's medical service
or procedure, the participant and the GBP member, if the participant
is not the GBP member, must meet all program eligibility requirements
set forth in subsection (c)(2) and (3) of this section.
(3) Meet all HealthSelectShoppERS program requirements
on the date that the employer contribution to the GBP member's TexFlex
account is made by the health benefit plan. Once processed by ERS,
a contribution in the amount specified in the related search applicable
to the facility providing the medical service or procedure shall be
made by the health benefit plan to the GBP member's TexFlex health
care reimbursement account or limited purpose health care reimbursement
account as provided herein. The contribution will be an employer contribution
to the applicable TexFlex account. The employer contribution will
be made only if, on the date of the contribution and as determined
in the sole discretion of ERS:
(A) all program requirements have been met; and
(B) all eligibility requirements set forth in subsection
(c) of this section are met.
(e) Funding.
(1) Funding of the employer contributions by the health
benefit plan shall originate from the Employees Life, Accident, and
Health Insurance and Benefits Fund specified in §1551.401 of
the Act.
(2) No GBP member may receive more employer contributions
per plan year related to program participation by the GBP member and
all of the GBP member's dependents than the designated amount set
by the Employees Retirement System of Texas and publicly posted.
(3) All employer contributions will be made by the
health benefit plan solely at the discretion of ERS.
(f) Standing. A person has no standing to submit a
grievance or appeal regarding HealthSelectShoppERS under §81.9(c)
of this title or any other rule or statutory provision that provides
for the submission of a grievance or appeal to ERS.
(g) Termination. The HealthSelectShoppERS program may
be terminated by the Board if the Board determines that the plan is
no longer advantageous to the GBP or its participants.
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