| (a) A full-time or part-time employee ("Petitioner")
whose application to enroll themselves and/or their dependents in
TRS-ActiveCare is denied by either TRS, the administering firm, or
a participating entity may appeal the denial to TRS.
(b) An appeal made pursuant to subsection (a) of this
section shall be made in writing and must be received by TRS no later
than 45 days after the date of denial. The appeal shall be directed
to the TRS-ActiveCare Grievance Administrator. TRS may, at its sole
discretion, provide a copy of the appeal to the administering firm
or the participating entity that denied enrollment.
(c) An appeal made pursuant to subsection (a) of this
section shall state the basis for appeal and shall include all relevant
documents and correspondence that were considered by TRS, the administering
firm, or a participating entity when the enrollment was denied. The
administering firm or participating entity is required, upon request
by TRS, to participate in the process.
(d) The TRS Appeal Committee ("Committee") is responsible
for the review and determination of appeals made pursuant to subsection
(a) of this section. The Committee shall be appointed by the TRS Deputy
Director or, if the position of the Deputy Director is vacant, the
TRS Chief Financial Officer and shall serve at the discretion of the
Deputy Director or, if the position of the Deputy Director is vacant,
the Chief Financial Officer.
(e) In determining eligibility for enrollment, the
Committee shall apply the TRS-ActiveCare plan design and rules in
effect for the plan year in which the Petitioner is seeking enrollment.
If TRS finds that extraordinary circumstances constituting "good cause"
prevented the Petitioner from complying fully with a deadline established
by TRS under the TRS-ActiveCare plan design or rules, the appeal may
be granted. For purposes of this subsection, "good cause" means that
a person's failure to act was not because of a lack of due diligence
the exercise of which would have caused a reasonable person to take
prompt and timely action. A failure to act based on ignorance of the
law or facts reasonably discoverable through the exercise of due diligence
does not constitute good cause. If a person was reasonably prevented
from complying with a deadline as a result of an unexpected natural
disaster or sudden catastrophic event, that event may constitute "good
cause" even though the event occurs on or near a deadline and arguably
Petitioner could have met the deadline if Petitioner had acted sooner.
Misinformation concerning a deadline provided to Petitioner by either
TRS, the health plan administrator of TRS-ActiveCare, or a participating
entity, and relied upon by Petitioner, may be grounds for "good cause"
if the act of providing misinformation to Petitioner is documented
or substantiated and a reasonable person would have relied on the
information provided to Petitioner and reasonably would not have known
the information provided to Petitioner was inaccurate.
(f) The Committee shall notify the Petitioner, the
administering firm, and the participating entity of its decision in
writing.
(g) If the Committee determines that the enrollment
should be allowed, it shall inform the Petitioner, the administering
firm, and the participating entity of the manner and effective date
of enrollment by the Petitioner.
(h) The Petitioner may appeal the written decision
of the Committee relating to eligibility to the executive director.
(1) A request for an appeal to the executive director
must be submitted by the Petitioner in writing and must be received
by TRS by the later of:
(A) 30 days after the date the initial written decision
by the Committee is mailed; or
(B) a number of days after the decision of the Committee
is mailed equal to the number of days it took the Committee to issue
its decision.
(2) The number of days it took the Committee to issue
its decision is calculated from the date TRS received the Petitioner's
appeal made pursuant to subsection (a) of this section to the date
TRS mailed the Committee's decision.
(3) The request for an appeal to the executive director
shall be directed to the attention of the TRS-ActiveCare Grievance
Administrator.
(4) Subject to subsection (i) of this section and pursuant
to the delegation of authority through this section, the decision
of the executive director is the final decision of TRS.
(i) The Committee shall review an appeal made pursuant
to subsection (a) or (h) of this section for timeliness and may deny
an appeal that is not timely received by TRS. An appeal made pursuant
to subsection (a) or (h) of this section that is denied because TRS
did not timely receive the appeal is a final decision by TRS.
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| Source Note: The provisions of this §41.51 adopted to be effective December 26, 2002, 27 TexReg 12004; amended to be effective March 8, 2007, 32 TexReg 1092; amended to be effective March 25, 2008, 33 TexReg 2556; amended to be effective April 1, 2011, 36 TexReg 2001; amended to be effective December 22, 2014, 39 TexReg 10029; amended to be effective March 19, 2020, 45 TexReg 1862 |
