34 Tex. Admin. Code § 81.1 - Definitions
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.
(28) LWOP (Leave without
pay)--The leave status of an employee who is certified by his/her employer to
be absent from active duty for an entire calendar month, who does not receive
any compensation for time absent from active duty, and who has not received a
refund of retirement contributions based upon the most recent term of
employment.
(29) Medicare Advantage
Plan--A plan, approved by the Board of Trustees, that provides health coverage
for participants who are eligible for Medicare-primary coverage. The plan is
administered as a Medicare Advantage Plan as permitted by CMS through:
(A) a health maintenance organization;
or
(B) any other plan,
organization, carrier or administering firm approved by the Board of Trustees
to provide the coverage.
(30) Medicare-eligible--The status of a
participant who is eligible for primary coverage under Medicare Part A and/or
Part B. Eligibility may extend to a dependent that is qualified to receive
Medicare benefits as his/her primary coverage as permitted by CMS.
(31) Member--For purposes of this chapter
only regarding insurance plan participation in the GBP, a member is a
participant who is an employee, retiree, or other person eligible to
participate in the GBP as provided under the Act and who is not a
dependent.
(32) Minimum retiree
optional life--A standard $10,000 term life insurance policy whose insurance
required contribution is set solely on the basis of the benefit rather than on
the retiree's age. It is available for retirees at any time during their
retirement. If a retiree does not have life insurance, the retiree may apply
for this coverage with evidence of insurability. If the retiree has Election 1
or Election 2 optional life, the retiree may elect to reduce the life coverage
to this coverage by requesting the change without an application or evidence of
insurability.
(33) Optional
Coverage--Coverage established by the Board of Trustees in the GBP and as set
forth in §81.7(c)(1)(A) - (K).
(34) ORP--The Optional Retirement Program as
provided in the Government Code, Chapter 830.
(35) Participant--An employee, annuitant, or
dependent, as defined in the Act, a surviving spouse or child of a deceased
member, or any other person eligible for coverage under the Act and enrolled in
any coverage offered under the GBP.
(36) Placement for adoption--The legal status
of a child under which a person assumes and retains the legal obligation for
total or partial support of the child in anticipation of the person's adoption
of such child.
(37) Preexisting
condition--Any injury or medical condition for which a participant received
medical treatment or services, or was prescribed drugs or medicines during the
three-month period immediately prior to the effective date of such coverage.
However, if the evidence of insurability requirements set forth in §
81.7(d) of this
chapter must first be satisfied, the three-month period for purposes of
determining the preexisting conditions exclusion will be the three-month period
immediately preceding the date of the employee's completed application for
coverage.
(38) Premium conversion
plan--A separate plan, under the Internal Revenue Code, §79 and §106,
adopted by the Board of Trustees and designed to provide premium conversion as
described in §
81.7(b) of this
chapter.
(39) Retiree--An employee
who retires or is retired and who:
(A) is
authorized by the Act to participate in the GBP as an annuitant;
(B) on August 31, 1992, was a participant in
a group insurance program administered by an institution of higher education;
or
(C) on the date of retirement,
meets the service credit requirements of the Act for participation in the GBP
as an annuitant; and
(i) on August 31, 2001,
was an eligible employee with an employer whose employees are authorized to
participate in the GBP and, on the date of retirement has three years of
service with such an employer;
(ii)
on August 31, 2001, had three years of service as an eligible employee with an
employer whose employees are authorized to participate in the GBP; or
(iii) is determined by ERS to be eligible as
described by §1551.102 and §1551.114 of the Act.
(40) Salary--The amount of
compensation, which includes the employee's regular salary, longevity, shift
differential, hazardous duty pay, and benefit replacement pay, received by an
employee as of the employee's first day of active duty and as of September 1,
for an existing or rehired employee. This amount is used for determining
optional term life and disability income limitations. Non-salaried appointed
officials, state-wide elected officials and members of the Legislature may use
the salary of a state district judge or their actual salary as of September 1
of each year for determining their optional term life. For members of the
Legislature, disability income limitations will be based on their actual
monthly salary.
(41) Tobacco
product--All types of tobacco, including, but not limited to, cigarettes,
cigars, pipe tobacco, chewing tobacco, snuff, and dip; and all electronic
cigarettes and vaping products.
(42) Tobacco user--A participant who has used
a tobacco product or tobacco products five or more times during the preceding
three months.
(43) TRS--The Teacher
Retirement System of Texas.
Notes
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