| (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:
Cont'd... |
