34 Tex. Admin. Code § 41.7 - Effective Date of Coverage
(a) Except
as allowed by subsection (c) of this section, for TRS members who take a
service or disability retirement and enroll in coverage during their initial
enrollment period as described in §
41.1 of this title (relating to
Initial Enrollment Periods for the Health Benefits Program Under the Texas
Public School Retired Employees Group Benefits Act (TRS-Care)), the effective
date of coverage is:
(1) the first day of the
month following the effective date of retirement if the application for
coverage is received by TRS-Care on or before the effective retirement date;
or
(2) the first day of the month
following the receipt of the application for coverage by TRS-Care if the
application is received after the effective retirement date but within the
initial enrollment period.
(b) A TRS member who takes a service or
disability retirement and enrolls in coverage during his or her initial
enrollment period may, at any time during his or her initial enrollment period,
make changes to his or her coverage elections. The effective date of coverage
for the new elections is the first day of the month following receipt by
TRS-Care of the application requesting the change in coverage.
(c) Regardless of the date a TRS member
submits his application for retirement, if a TRS member enrolls in coverage
during his initial enrollment period as described in §
41.1 of this title, the TRS member
may defer the effective date of coverage described in subsection (a) of this
section for himself and his eligible dependents to the first day of any of the
three (3) months immediately following the month after the effective date of
retirement. This deferment period runs concurrent with, and does not extend,
the enrollment period as described in §
41.1 of this title. In no event
may a TRS member defer the effective date of TRS-Care coverage to a date prior
to the date upon which TRS-Care receives the application for coverage from the
TRS member.
(d) Surviving spouses
and surviving dependent child(ren) who are currently enrolled with the retiree
at the time of the retiree's death will continue to be enrolled in the same
coverage plan, subject to the applicable eligibility requirements of that
coverage plan.
(e) If the surviving
spouse or the surviving dependent child was not enrolled in TRS-Care
immediately preceding his or her becoming eligible for coverage, the effective
date of coverage will be, at the election of the surviving spouse or the
surviving dependent child, either the first day of the month following:
(1) TRS-Care's receipt of an application
during the initial enrollment period as described in §
41.1 of this title; or
(2) the month of the death of the deceased
TRS service or disability retiree or deceased active TRS member, provided
TRS-Care receives an application during the initial enrollment period as
described in §
41.1 of this title.
(f) The effective date of coverage
for an eligible dependent who is enrolled under a retiree's or surviving
spouse's TRS-Care coverage during the initial enrollment period is the same
date as the retiree or surviving spouse's effective date of coverage unless the
dependent is enrolled after the retiree's effective retirement date and after
the retiree has enrolled but within the initial enrollment period, in which
case the dependent's effective date of coverage will be the first day of the
month following TRS-Care's receipt of the application to enroll the
dependent.
(g) The effective date
of coverage for an eligible individual who is enrolled in TRS-Care as a result
of a special enrollment event, as described in §
41.2(b) of this
title (concerning Additional Enrollment Opportunities), is the date specified
under the provisions of the Health Insurance Portability and Accountability Act
of 1996 (Pub. L. No.
104-191 , 110 Stat. 1936 (1996)).
(h) The effective date of coverage for an
eligible individual who is enrolled in TRS-Care as a result of the Age 65
enrollment opportunity, as described in §
41.2(a) of this
title is:
(1) the first day of the month
following the month of the retiree's or surviving spouse's 65th birthday if the
application for coverage is received by TRS-Care before or during the month of
the retiree's or surviving spouse's 65th birthday; or
(2) the first day of the month following the
receipt of the application by TRS-Care if the application for coverage is
received after the month of the retiree's or surviving spouse's 65th birthday
but within the enrollment period.
(i) Except as provided in subsections (k),
(l), and (m) of this section, the effective date of changes in coverage due to
the acquisition of Medicare Part A and/or Medicare Part B is the first of the
month following the date of TRS-Care's receipt of proof, satisfactory to
TRS-Care, of the participant's or dependent's Medicare Part A and/or Medicare
Part B coverage.
(j) A retiree,
surviving spouse, or surviving dependent child may cancel any coverage by
submitting the appropriate notice of cancellation form to TRS-Care.
Cancellations will be effective on the later of:
(1) the first day of the month following
TRS-Care's receipt of the completed notice of cancellation form; or
(2) the date requested by the retiree,
surviving spouse, or surviving dependent child on the completed notice of
cancellation form received by TRS-Care.
(k) Where a participant has Medicare Part A
coverage and TRS-Care has been paying primary to Medicare on Medicare Part A
claims, TRS-Care may seek the recovery of funds and may make the effective date
of the correct coverage retroactive to the first day of the earliest month for
which recovery of such overpaid funds is possible under Medicare
rules.
(l) Where a participant has
Medicare Part A coverage and TRS-Care has been paying primary to Medicare on
Medicare Part A claims, TRS-Care may make the effective date of the correct
coverage retroactive to when the participant was first enrolled in both
Medicare and TRS-Care to a maximum retroactive period of twelve months,
including the month in which proof, satisfactory to TRS-Care, of Medicare Part
A coverage is received by TRS-Care, and based thereon, TRS-Care may refund or
credit the amount due to the participant.
(m) Upon TRS-Care's discovery that a
participant does not have Medicare Part A coverage, in contrast to TRS-Care
records indicating the participant has Medicare Part A coverage, TRS-Care will
contact the participant and advise the participant that the cost of coverage
and the coverage will be adjusted prospectively effective the first day of the
next month unless proof, satisfactory to TRS-Care, of Medicare Part A coverage
is received by TRS-Care prior to that date. Claims will be paid based upon the
coverage in effect at the time the services were provided. Any claims already
paid as if Medicare Part A were in effect will not be adjusted.
(n) Notwithstanding any other provision of
this section to the contrary, the effective date of coverage of individuals who
enroll in a Medicare plan associated with TRS-Care is subject to the federal
laws, regulations, policies and procedures that control the Medicare
program.
Notes
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No prior version found.