Section 81.5 - Eligibility(a) Employees. (1) Full-time Employees. Eligibility for GBP health coverage for full-time employees begins on the first day of the calendar month following the employee's completion of the health insurance waiting period. If the employee described in paragraphs (A) or (B) does not enroll in GBP health coverage on or before becoming eligible, he/she will automatically be enrolled in HealthSelect of Texas upon becoming eligible. (A) A full-time employee of an employer other than an institution of higher education with existing, current, and continuous GBP health coverage as of the date the employee begins active duty or the elected or appointed officer is qualified for and begins to hold office, is eligible for GBP health coverage under this subsection without a waiting period provided there has been no break in coverage in the GBP.(B) A full-time employee of an institution of higher education is eligible for GBP health coverage on the first day that an employee performs services as an employee of an institution of higher education only if: (i) the full amount of insurance required contributions are paid for the employee's coverage from the first date of employment through the completion of the health insurance waiting period ;(ii) any insurance required contributions paid as provided in clause (i) of this subparagraph shall not be paid using money appropriated from the general revenue fund; and(iii) any institution of higher education electing to pay the insurance required contribution for any employee as described in this subparagraph must do so for all eligible similarly situated full-time employees.(2) Part-time employees. (A) A part-time employee or other employee of an employer other than an institution of higher education who is not eligible for automatic coverage becomes eligible for GBP health coverage upon completion of the health insurance waiting period and upon application to participate in the GBP, subject to the provisions of § 81.7(a)(2) of this chapter (relating to Enrollment and Participation). A rehired part-time employee of the state of Texas, including a new part-time employee, each with existing, current, and continuous GBP health coverage as of the date the employee begins active duty or is qualified for and begins to hold office, who is not eligible for automatic coverage is eligible for coverage without a waiting period provided there has been no break in coverage.(B) A part-time employee of an institution of higher education is eligible for GBP health coverage on the first day that a part-time employee performs services as a part-time employee of an institution of higher education only if: (i) the full amount of insurance required contributions are paid for the part-time employee's coverage from the first date of employment through the completion of the health insurance waiting period;(ii) any insurance required contributions paid as provided in clause (i) of this subparagraph shall not be paid using money appropriated from the general revenue fund; and(iii) any institution of higher education electing to pay any portion of the insurance required contribution for any part-time employee as described in this subparagraph or in §1551.101(e)(2) of the Act, must do so for all eligible similarly situated part-time employees.(C) An institution of higher education is also not prohibited from contributing a portion or all of the insurance required contribution for certain part-time employees described by §1551.101(e)(2) of the Act, only if: (i) the insurance required contributions paid by the institution of higher education shall not be paid with funds that are appropriated from the general revenue fund;(ii) any institution of higher education electing to pay the insurance required contributions for any part-time employee as described in §1551.101(e)(2) of the Act, must do so for all eligible part-time employees described therein; and(iii) any insurance required contributions paid as provided in clause (i) of this subparagraph must be paid from the first date of the part-time employee's initial enrollment.(b) Retirees. (1) A retiree who is at least 65 years of age with a minimum of 10 years eligible service credit or a retiree whose age and eligible service credit equals or exceeds 80 with a minimum of 10 years eligible service credit, is eligible for GBP health coverage on the day he/she becomes an annuitant provided the individual retires directly from state service. If the individual does not retire directly from state service as described in §1551.1055(b) of the Act, eligibility for GBP health coverage begins on the first day of the calendar month following 60 days after the date of retirement.(2) A retiree who is less than 65 years of age with a minimum of 10 years eligible service credit is eligible for GBP health coverage with the applicable state contribution on the first day of the calendar month following the date on which the individual reaches 65 years of age, subject to meeting the required health insurance waiting period, if applicable.(3) ORP Retirees. (A) A participant in the ORP is eligible for GBP health coverage on the day he/she receives or is eligible to receive an annuity under the ORP program or would have been eligible to receive an annuity had his/her membership been in TRS rather than the ORP, and meets the age, length-of-service, any applicable health insurance waiting period, and other requirements as provided in this subsection. (B) A participant in the ORP is eligible for additional coverage and plans, which include optional coverage in the GBP, as long as he/she receives or is eligible to receive an annuity under the ORP program or would have been eligible to receive an annuity had his/her membership been in TRS rather than the ORP.(4) Retirees eligible for interim insurance. A retiree with at least 10 years of eligible service credit who is not eligible for a state contribution for GBP health coverage at the time of retirement is eligible for dental and vision coverage and, except as provided in paragraph (5) of this subsection, optional life insurance and dependent life insurance at the time of retirement. A retiree described by this paragraph and by paragraph (2) of this subsection, is eligible for GBP health coverage under the provisions described in §1551.323 of the Act, upon payment of the total cost, as determined by the Board of Trustees. For purposes of §1551.323, the total cost shall be determined by the Board of Trustees based on an actuarial determination, as recommended by ERS' consulting actuary for insurance, of the estimated total claims costs for individuals eligible for interim insurance pursuant to §1551.323 of the Act. If an individual who is eligible for this interim insurance is also eligible for COBRA coverage, then COBRA coverage should be exhausted, if possible, before the interim insurance begins as described by this subsection.(5) A retiree is eligible for optional life insurance and dependent life insurance coverage if the retiree was enrolled in such coverage on the day before becoming an annuitant. Except as provided in paragraph (6) of this subsection, a retiree may not increase the amount of life insurance for which the retiree was enrolled on the day before becoming an annuitant, but may cancel life insurance coverage at any time. Canceled life insurance coverage may never be reinstated. A retiree is not eligible for disability or AD&D coverage.(6) A retiree who is not enrolled in retiree optional life insurance or dependent life insurance coverage is eligible to apply for minimum retiree optional life insurance or dependent life insurance coverage. Submission of evidence of insurability acceptable to ERS shall be required for enrollment in such coverage.(7) A retiree who was not enrolled in dependent life insurance coverage on the day before becoming an annuitant becomes eligible for dependent life insurance coverage of a newly acquired dependent on the first day of the month following the date on which the individual becomes a dependent of the retiree.(8) A retiree who returns to work for an employer may continue coverage for which he/she is eligible as a retiree, or, subject to subsection (a) of this section, elect to participate in the GBP as a full-time or part-time employee. Time spent in an eligible position as a return to work retiree may not be used to meet eligibility requirements for retiree health insurance coverage. A return to work retiree who elected active employee coverage will be re-enrolled in retiree coverage for which he/she is eligible and may elect new retiree coverage for which he/she is eligible at the time of separation from active duty.(9) A retiree whose extended life insurance benefits are terminated for reasons other than termination pursuant to §1551.351 of the Act is eligible for retiree life insurance coverage on the first day of the month following the extended life insurance benefits termination date.(c) Dependents of employees and retirees. (1) The dependents of an employee/retiree are eligible for coverage on the same day that the employee/retiree becomes eligible. Except as otherwise provided in this paragraph, a newly acquired dependent is eligible for coverage on the first day of the month following the date on which the individual becomes a dependent of a covered employee/retiree . The employee/retiree must be enrolled for a particular coverage before the employee's/retiree's dependents are eligible for that type of coverage. An eligible child for whom a covered employee/retiree is court-ordered to provide medical support becomes eligible for GBP health coverage upon receipt by the employer of a valid court order. A newborn natural child is eligible automatically on the date of birth. A newly adopted child is eligible automatically on the date of placement for adoption.(2) Except as otherwise provided in this paragraph, double coverage is not permitted for any participant in the GBP. (A) A participant may not be simultaneously covered by basic or optional term life insurance as an employee/retiree and dependent term life insurance as a dependent. A family member who is covered as an employee/retiree is not eligible to be covered as a dependent in the GBP. Except as provided in subparagraph (B) of this paragraph, a dependent may not be covered by more than one employee/retiree for the same coverage.(B) A child who is an eligible dependent of two employees/retirees in the GBP may be enrolled in dependent life insurance coverage and accidental death and dismemberment coverage by both employees/retirees, if otherwise eligible.(d) Former COBRA unmarried children. (1) A former COBRA unmarried child is eligible to continue the GBP health, dental and vision insurance coverage in which the child was enrolled upon expiration of the child's continuation coverage under COBRA.(2) A former COBRA unmarried child continuing health insurance coverage under the provisions of this subsection is eligible for dental and vision insurance coverage if such coverage was not in effect upon the expiration of the child's continuation coverage under COBRA.(3) A former COBRA unmarried child is eligible to enroll a newly acquired dependent child within 30 days of the child's date of birth or placement for adoption. Otherwise, he/she cannot enroll any other dependents in GBP health coverage.(e) Surviving dependents. (1) The surviving spouse of a deceased retiree or an active employee is eligible to continue coverage in the GBP health, dental and vision plans in which the surviving spouse was enrolled on the day of death of the employee/retiree provided, however, the deceased active employee must have had at least 10 years of service credit, including at least 3 years on August 31, 2001 or at least 10 years after August 31, 2001 of service as an eligible employee with an employer, at the time of death. A deceased active employee described by §1551.114 of the Act must have had at least 10 years of eligible service credit, as determined by ERS, before his/her surviving spouse is eligible to continue coverage. A surviving spouse who is also an annuitant or employee shall not be eligible for surviving spouse benefits as long as he/she is eligible for coverage as an employee/retiree. Participants continuing coverage as surviving spouses are not eligible for life insurance coverage.(2) The dependent child of a deceased retiree or an active employee is eligible to continue coverage in the GBP health, dental and vision plans in which the dependent children were enrolled on the day of death of the employee/retiree provided, however, the deceased active employee must have had, at the time of death, at least 10 years of service credit, including at least 3 years on August 31, 2001 or at least 10 years after August 31, 2001 of service as an eligible employee with an employer, as long as the surviving spouse is eligible and continues to participate in the GBP. A deceased active employee described by §1551.114 of the Act must have had at least 10 years of eligible service credit, as determined by ERS, before his/her dependent children are eligible to continue coverage. Dependent children of deceased employees/retirees will be considered as dependents of the deceased employee's/retiree's surviving spouse for purposes of the GBP. Participants continuing coverage as surviving dependents are not eligible for life insurance coverage.(3) If a retiree or active employee does not have a spouse covered in the GBP at the time of his/her death, dependent children of the deceased retiree or active employee are eligible to continue coverage in the GBP health, dental and vision plans in which the dependent children were enrolled on the day of death of the employee/retiree provided, however, the deceased active employee must have had at least 10 years of service credit, including at least 3 years on August 31, 2001 or at least 10 years after August 31, 2001 of service as an eligible employee with an employer, at the time of death. A deceased retiree or active employee described by §1551.114 of the Act, must have had at least 10 years of eligible service credit, as determined by ERS, before his/her dependent children are eligible to continue coverage. A surviving dependent child may continue such coverage until the dependent child becomes ineligible as defined in § 81.1 of this chapter (relating to Definitions). Participants continuing coverage as surviving dependents are not eligible for life insurance coverage.(4) A person who is the surviving spouse or dependent of a member may secure GBP health coverage if the individual was eligible to participate in the GBP under §§1551.101, 1551.102 or 1551.155(a) of the Act, but was not participating at the time of the individual's death.(5) A surviving spouse or dependent seeking group coverage under paragraphs (1) - (4) of this subsection must apply for coverage not later than the 30th day after the date on which the individual who was eligible to participate in the GBP dies; and shall pay for coverage at the group rate for other participants.(6) A surviving spouse or an eligible dependent child of a paid law enforcement officer employed by the state or a custodial employee of the institutional division of the Texas Department of Criminal Justice who suffers a death in the line of duty as provided by Chapter 615, Government Code, shall be eligible for coverage in the GBP as provided in subparagraphs (A) - (D) of this paragraph.(A) Coverage for a surviving spouse under this paragraph shall be at the same rate as the employee-/retiree-only coverage, and the surviving spouse shall be entitled to the benefit of the state contribution applied to employee-/retiree-only coverage.(B) Coverage for a surviving spouse with children shall be at the same rate as the employee-/retiree-with-children coverage, and the survivors shall be entitled to receive the benefit of the state contribution applied to coverage for an employee-/retiree-with-children .(C) Where there is no surviving spouse, a surviving child eligible for coverage under this paragraph shall be entitled to the benefit of the state contribution for employee-/retiree-only coverage.(D) In order for a surviving spouse or children to receive coverage in the GBP under this paragraph, they must pay the balance, if any, of all contributions due after applying the state contribution to such coverage. Any out-of-pocket insurance required contributions due from the survivor may be deducted by ERS from the survivor's annuity payment, if any, or must be paid to ERS by the survivor through electronic bank deduction or direct payment. The applicable state contributions will be paid to ERS by the employer that employed the deceased law enforcement officer or custodial employee.(7) A surviving spouse and eligible dependents, and a surviving dependent child, continuing GBP health coverage under the provisions of this subsection are eligible for dental and vision insurance coverage if such coverage was not in effect on the date of death of the deceased employee/retiree. Any insurance required contributions are the sole responsibility of the surviving spouse and dependents.(f) Disability retiree. An ORP participant who applies and is approved for disability retirement is entitled to retiree insurance coverage as provided in § 81.7(a)(3) of this chapter. An ORP participant authorized by the Act with at least 10 years of eligible service credit, and granted ORP disabled retiree status in the GBP, as established by ERS, is eligible to participate in the GBP. Initial or continued eligibility for insurance coverage for an ORP disabled retiree will be determined by ERS under the following provisions. (1) An ORP participant is eligible for ORP disabled retiree status in the GBP if the ORP participant is not otherwise eligible to participate in the GBP as an employee/retiree and is certified by a licensed physician designated by ERS as disabled as provided in paragraph (2) of this subsection. An ORP participant may apply for disabled retiree status in the GBP by filing a written application for ORP disabled retiree status in the GBP or having an application filed with ERS by the ORP participant's spouse, employer, or legal representative. In addition to an application for ORP disabled retiree status in the GBP, an ORP participant must file with ERS the results of a medical examination of the ORP participant. After an ORP participant applies for ORP disabled retiree status in the GBP, ERS may require the ORP participant to submit additional information about the disability. ERS will prescribe forms for the information required by this section.(2) If a licensed physician designated by ERS finds that the ORP participant is mentally or physically disabled from the further performance of duty and that the disability is probably permanent, the physician will certify the disability. The executive director is authorized to approve ORP disabled retiree status in the GBP after a certification of disability is made. Once each year during the first five years after an ORP participant enrolls in the GBP as an ORP disabled retiree, and once in each three-year period after that, ERS may require an ORP disabled retiree to undergo a medical examination by a physician ERS designates. If an ORP disabled retiree refuses to submit to a medical examination as provided by this section, ERS will suspend the ORP disabled retiree's enrollment in the GBP until the ORP disabled retiree submits to an examination. ERS will terminate the ORP disabled retiree's coverage in the GBP and notify the ORP participant in writing if: (A) ERS concurs with a certification issued by the designated physician which finds that an ORP disabled retiree is no longer mentally or physically disabled from the further performance of duty; or(B) an ORP disabled retiree refuses for more than one year to submit to a required medical examination.(3) The effective date of coverage for an ORP disabled retiree in the GBP is the first of the month following the date the application for ORP disabled retiree status in the GBP is approved by ERS, or the first of the month following the date employment is terminated, whichever is later.(g) Former members of the Legislature. A former member of the Legislature authorized by §1551.108(1) of the Act to continue to participate in the GBP is eligible for the coverage, other than disability income insurance coverage, in effect on the day before the member leaves office.(h) Former employees of the Legislature. A former employee of the Legislature authorized by §1551.108(2) of the Act to continue to participate in the GBP is eligible for the coverage, other than disability income insurance coverage, in effect on the day before the employee terminates employment.(i) Former board members. Subject to the limitations of this subsection, a former member of a board or commission or of the governing body of an institution of higher education, as both are described in §1551.109 of the Act, is eligible to continue the coverage, other than disability income insurance coverage, in effect on the day before the member leaves office if no lapse in coverage occurs after the end of the term of office. Life insurance overage may not exceed Election II.(j) Continuation of GBP health, dental and vision coverage only for certain spouses and dependent children of employee/retirees, and for certain terminating employees, their spouses, and dependent children (as provided by COBRA). (1) The surviving spouse and/or dependent child/children of a deceased employee/retiree who are not eligible to continue coverage under the provisions of the Act or subsection (e) of this section, who are not entitled to benefits under the Social Security Act, Title XVIII, and who are not covered under any other group health plan, may continue for up to 36 months the GBP health, dental and vision coverage only that were in effect immediately prior to the date of death of the employee/retiree. A formal election must be made to continue coverage by the surviving spouse and/or the dependent child/children. The formal election must be postmarked or received by ERS within 60 days of the date of notice contained in the notice of right to continue coverage form or by the date coverage terminated, whichever is later.(2) An employee whose employment has been terminated voluntarily or involuntarily (other than for gross misconduct), whose work hours have been reduced such that the employee is no longer eligible for the GBP as an employee, or whose coverage has ended following the maximum period of LWOP as provided for in § 81.7(g)(2)(A) of this chapter, except for those persons not eligible pursuant to § 81.11(f) of this chapter (relating to Cancellation of Coverage and Sanctions), and/or his/her spouse and/or dependent child/children who are not eligible to continue coverage under the provisions of the Act or subsection (f), (g) or (h) of this section, who are not entitled to benefits under the Social Security Act, Title XVIII, who are not covered under any other group health plan, may continue for up to 18 months the GBP health, dental and vision coverage only without the basic term life that were in effect immediately prior to the date of the loss of coverage. A formal election must be made to continue coverage by the employee and/or his/her spouse and/or dependent child/children. The formal election must be postmarked or received by ERS within 60 days of the date of notice contained in the notice of right to continue coverage form or by the date coverage terminated, whichever is later.(3) If an employee, spouse, or dependent child is determined by the Social Security Administration to have been disabled before or during the first 60 days of continuation coverage, all covered individuals may continue GBP health, dental and vision coverage extended up to an additional 11 months, for a total of 29 months. Notification of the Social Security Administration's determination must be received by ERS before the end of the original 18 months of continuation coverage. Continuation coverage will be canceled the month that begins more than 30 days after the date the Social Security Administration determines that the participant is no longer disabled.(4) A spouse who is divorced from an employee/retiree and/or the spouse's dependent child/children who are not otherwise eligible to continue coverage under the provisions of the Act or subsection (c) of this section, who are not entitled to benefits under the Social Security Act, Title XVIII, who are not covered under any other group health plan, may continue for up to 36 months the GBP health, dental and vision coverage only that were in effect immediately prior to the date the divorce decree is signed. The employee/retiree or the divorced spouse or the divorced spouse's dependent child/children must notify ERS through the benefits coordinator of the divorce within 60 days from the date the divorce decree is signed. A formal election must be made to continue coverage by the divorced spouse and/or the dependent child/children. The formal election must be postmarked or received by ERS within 60 days of the date of notice contained in the notice of right to continue coverage form or by the date coverage is terminated, whichever is later.(5) A dependent child who has attained 26 years of age, who is not otherwise eligible to continue coverage indefinitely under the provisions of the Act or subsection (c) of this section, who is not entitled to benefits under the Social Security Act, Title XVIII, who is not covered under any other group health plan, may continue for up to 36 months the GBP health, dental and vision coverage only that were in effect immediately prior to the date of the child's 26th birthday. The child or employee/retiree must notify ERS through the benefits coordinator within 60 days of the child's 26th birthday. A formal election must be made by the 26-year-old child to continue coverage. The formal election must be postmarked or received by ERS within 60 days of the date of notice contained in the notice of right to continue coverage form or by the date coverage is terminated, whichever is later.(6) Extension of continuation of coverage for certain spouses and/or dependent child/children of former employees who are continuing coverage under the provisions of paragraph (2) of this subsection is governed by the following provisions. (A) The surviving spouse and/or dependent child/children of a deceased former employee whose death occurred during the period of continuation coverage, who satisfy the provisions of paragraph (1) of this subsection and who notify ERS within 60 days of the date of death of the former employee are entitled to a total of 36 months of continuation coverage.(B) A spouse who is divorced from a former employee during the period of continuation coverage and/or the divorced spouse's dependent child/children who satisfy the provisions of paragraph (4) of this subsection are entitled to a total of 36 months of continuation coverage.(C) A dependent child who attains the age of 26 years during the period of continuation coverage and who satisfies the provisions of paragraph (5) of this subsection is entitled to a total of 36 months of continuation coverage.(D) An employee, spouse, or dependent child determined by the Social Security Administration to be disabled at the time of termination of the employee's employment and who satisfies the provisions of paragraph (3) of this subsection is entitled to not more than 29 months of continuation coverage.(E) No person shall be allowed to continue GBP health, dental and vision coverage under the provisions of this subsection for more than 36 months.(7) A person who continues benefits under the provisions of paragraphs (1) - (6) of this subsection may change coverage levels or plans during the continuation period on the same basis as an employee/retiree participant, provided, however, that GBP health coverage which is canceled during the continuation period may not be reestablished.(8) In all situations deemed applicable by ERS where state or federal laws or regulations mandate specific terms or provisions which are omitted or conflict with specific terms or provisions of the plan documents or ERS' rules, the appropriate plan documents and rules shall be interpreted and administered to comply with such laws or regulations.34 Tex. Admin. Code § 81.5
The provisions of this §81.5 adopted to be effective September 1, 1985, 10 TexReg 2321; amended to be effective March 19, 1986, 11 TexReg 1149; amended to be effective October 14, 1986, 11 TexReg 3523; amended to be effective September 1, 1986, 11 TexReg 3863; amended to be effective December 19, 1986, 11 TexReg 5135; amended to be effective January 9, 1987, 11 TexReg 5133; amended to be effective November 1, 1987, 12 TexReg 3480; amended to be effective May 25, 1990, 15 TexReg 2687; amended to be effective August 21, 1990, 15 TexReg 4504; amended to be effective May 19, 1992, 17 TexReg 3252; amended to be effective July 1, 1993, 18 TexReg 4094; amended to be effective February 21, 1994, 19TexReg806; amended to be effective January 25, 1995, 20 TexReg 151; amended to be effective July 3, 1995, 20 TexReg 4409; amended to be effective February 16, 1998, 23 TexReg 1099; amended to be effective September 16, 1999, 24 TexReg 7276; amended to be effective March 26, 2000, 25 TexReg 2400; amended to be effective July 10, 2000, 25 TexReg 6557; amended to be effective September 11, 2003, 28 TexReg 7780; amended to be effective December 31, 2003, 28 TexReg 11612; amended to be effective June 29, 2004, 29 TexReg 6120; amended to be effective May 3, 2006, 31 TexReg 3588; amended to be effective March 15, 2010, 35 TexReg 2202; amended to be effective December 22, 2011, 36 TexReg 8574; amended to be effective December 26, 2013, 38 TexReg 9374; Amended by Texas Register, Volume 41, Number 36, September 2, 2016, TexReg 6755, eff. 9/5/2016