34 Tex. Admin. Code § 41.51 - Appeals Relating to Eligibility
(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.
Notes
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