The following words and terms, when used in this chapter, shall
have the following meanings, unless the context clearly indicates
otherwise.
(1) Accelerated life benefit--A term life insurance
benefit to be paid in advance of the death of an insured member or
dependent, as requested by the insured member and approved by the
carrier or administering firm, in accordance with the terms of the
group term life insurance plan as permitted by §1551.254 of the
Act. An accelerated life benefit payment may be requested only if
the insured person is diagnosed with a terminal condition and only
once during the lifetime of the insured person. For purposes of this
definition, a terminal condition is an incurable health condition
that the administering firm or carrier determines with reasonable
medical certainty will result in the death of the insured within 12
months.
(2) Act--The Texas Employees Group Benefits Act, Insurance
Code, Chapter 1551, as amended.
(3) Active duty--An employee's expenditure of time
and energy in the service of his/her employer, including elected officials
of the state of Texas who are eligible for coverage under the Act.
An employee is on active duty on each day of a regular paid vacation
or regular paid sick leave or on a non-working day, if the employee
was on active duty on the last preceding workday.
(4) AD&D--Voluntary accidental death and dismemberment
coverage.
(5) Age of employee--The age to be used for determining
optional term life and AD&D insurance required contributions.
For these purposes, the age of the employee is the employee's attained
age on September 1.
(6) Annuitant--A retired person who is eligible under §1551.102
of the Act to participate in the GBP and meets all requirements for
retirement from a state retirement program or the Optional Retirement
Program.
(7) Basic plan--The plan of group insurance, including
prescription drug coverage, determined by the Board of Trustees, currently
HealthSelect or HealthSelect Medicare Advantage participant-only,
as applicable, and basic term life insurance coverage, in which every
eligible full-time employee and annuitant, is automatically enrolled
after meeting any applicable waiting period or unless participation
is expressly waived.
(8) Benefits Coordinator--A person employed by an employer
to provide assistance to its employees and their dependents with all
aspects of GBP participation. The benefits coordinator for all other
GBP participants is ERS.
(9) Board of Trustees or Board--The Board of Trustees
of the Employees Retirement System of Texas.
(10) CHIP--Children's Health Insurance Program.
(11) CMS--Centers for Medicare and Medicaid Services
or its successor agency.
(12) COBRA--Consolidated Omnibus Budget Reconciliation
Act of 1985, Public Law 99-272, and any subsequent amendments.
(13) Consumer Directed HealthSelectSM
--The self-funded high deductible health benefit plan offered
through the GBP and administered by the Employees Retirement System
of Texas and qualified carriers or administering firms.
(14) Dependent--With respect to an eligible member,
means the member's:
(A) spouse, as recognized by applicable law, which
includes only a married spouse as evidenced by a properly issued and
completed marriage license or an informally married spouse whose marriage
is memorialized by a Declaration of Informal Marriage and filed of
record with an appropriate governmental authority. Absent clear and
compelling evidence of an informal marriage existing at the time of
enrollment and deemed sufficient by ERS, it is a plan design requirement
that the licensed marriage or Declaration of Informal Marriage must
occur, or be filed, as applicable, prior to the effective date of
the dependent spouse's enrollment in the GBP;
(B) child under 26 years of age;
(C) child age 26 and older whom the Board of Trustees
or its designee determines is certified by an approved practitioner
to be mentally or physically incapacitated from gainful employment,
and earns less than the monthly wage standard for enrolling in CHIP
in Texas for a family of one at the time of application or reevaluation.
If the child earns more than this wage standard for a period of six
months or longer in any calendar year, then the child must demonstrate
to ERS his/her continued eligibility for dependent coverage by proving
he/she is dependent on the member for care or support and either lives
with the member or has care provided by the member on a regular basis;
and
(D) child under age 26 who is the member's ward, as
that term is defined by §1002.030, Texas Estates Code.
(E) In this section, "child" includes:
(i) a natural child, adopted child, stepchild, foster
child; or a child in the possession of a participant who is designated
as managing conservator of the child under an irrevocable or unrevoked
affidavit of relinquishment under Texas Family Code, Chapter 161;
or
(ii) a child who is related to the member by blood
or marriage and was claimed as the member's dependent on his/her federal
income tax return for the tax year preceding the plan year in which
the child is first enrolled as the member's dependent in the GBP,
and for each subsequent year in which the child is enrolled as the
member's dependent. The federal income tax return must have been filed
when first due or before any timely extensions expired.
(F) The requirement in subparagraph (E)(ii) of this
paragraph that a child must be claimed as the member's dependent on
his/her federal income tax return preceding the child's enrollment
does not apply if:
(i) the child is born in the year in which the child
is first enrolled; or
(ii) the member can demonstrate good cause for not
claiming the child as a dependent in the preceding tax year.
(15) Employee--A person eligible to participate in
the GBP under §1551.101 of the Act, which includes an appointed
or elected state officer, judicial officer, or employee in the service
of the state of Texas. The term also includes an eligible employee
of an institution of higher education and any persons required or
permitted by the Act to enroll as members.
(16) Employer--State of Texas and its agencies, institutions
of higher education, and other governmental or quasi-governmental
employers within the state whose employees or annuitants are authorized
by the Act to participate in the GBP.
(17) ERS--Employees Retirement System of Texas.
(18) Evidence of insurability--Evidence required by
ERS, an administering firm, or a qualified carrier for approval of
coverage or changes in coverage other than GBP health coverage pursuant
to the enrollment and participation provisions in this chapter.
(19) Executive director--The executive director of
the Employees Retirement System of Texas. All references to the executive
director also include the person or position designated by the executive
director or Board of Trustees to perform the relevant function of
the executive director.
(20) Former COBRA unmarried child--A member's unmarried
child who is at least 26 years of age, who had GBP coverage as a dependent
until the child became ineligible, who had continuation coverage under
COBRA until that coverage expired, and who reinstates GBP coverage
pursuant to §1551.158 of the Act.
(21) GBP (Group Benefits Program)--The Texas Employees
Group Benefits Program as established and administered by the Board
of Trustees pursuant to the Act.
(22) GBP health coverage--Includes HealthSelectSM of Texas, Consumer Directed HealthSelectSM , HMOs and Medicare Advantage plans, as applicable.
(23) Health insurance waiting period--The applicable
waiting period defined in §1551.1055 of the Act.
(24) HealthSelectSM of
Texas--The self-funded health benefit plan offered in the GBP and
administered by the Employees Retirement System of Texas and a qualified
carrier or administering firm. HealthSelect of Texas also includes
a Prescription Drug Plan administered by a Pharmacy Benefit Manager
approved by the Board.
(25) HealthSelectSM Medicare
Rx--A plan, approved by the Board of Trustees, that provides prescription
drug coverage designed for participants who are eligible for Medicare-primary
coverage in the GBP as permitted by CMS.
(26) HMO--A health maintenance organization, as defined
by §1551.007 of the Act, and approved by the Board of Trustees
to provide health care coverage to eligible participants in the GBP.
(27) Insurance required contribution--Any out-of-pocket
charge incurred by a member or by a member's dependent as payment
for coverage provided under the GBP that exceeds the state's or employer's
contributions made on behalf of the member.
Cont'd... |
