Section 81.7 - Enrollment and Participation(a) Enrollment Categories. (1) Full-time employees and their dependents.(A) A new employee: (i) who is not subject to the health insurance waiting period and is eligible under the Act and as provided for in § 81.5(a)(1) of this chapter (relating to Eligibility) for automatic insurance coverage, shall be enrolled in the basic plan unless the employee completes an enrollment form to elect other coverage or to waive GBP health coverage as provided in § 81.8 of this chapter (relating to Waiver of Health Coverage). Coverage of an employee under the basic plan, and other coverage selected as provided in this paragraph, becomes effective on the date on which the employee begins active duty.(ii) who is subject to the health insurance waiting period and is eligible under the Act and as provided for in § 81.5(a)(1) of this chapter for automatic insurance coverage, shall be enrolled in the basic plan beginning on the first day of the calendar month following 60 days of employment unless, before this date, the employee completes an enrollment form to elect other coverage or to waive GBP health coverage as provided in § 81.8 of this chapter.(iii) who has existing, current, and continuous GBP health coverage as of the date the employee begins active duty is not subject to the health insurance waiting period and is eligible to enroll as a new employee in health insurance and additional coverage and plans which include optional coverage by completing an enrollment form before the first day of the calendar month after the date the employee begins active duty. Health and additional coverage selected before the first day of the calendar month after the date the employee begins active duty are effective the first day of the following month.(B) Dependent enrollment and optional coverage: (i) To enroll eligible dependents, to elect to enroll in an approved HMO, and to elect additional coverage and plans which include optional coverage, an employee not subject to the health insurance waiting period shall complete an enrollment form within 30 days after the date on which the employee begins active duty. Coverage selected within 30 days after the date on which the employee begins active duty becomes effective on the first day of the month following the date on which the enrollment form is completed. An enrollment form completed after the initial period for enrollment as provided in this paragraph is subject to the provisions of subsection (d) of this section.(ii) To enroll eligible dependents or to elect to enroll in an approved HMO, an employee subject to the health insurance waiting period shall complete an enrollment form before the first day of the month following 60 days of employment. Coverage selected before the first day of the month following 60 days of employment becomes effective on the first day of the month following 60 days of employment. An employee completing an enrollment form after the initial period for enrollment as provided in this paragraph is subject to the provisions of subsection (d) of this section. The provisions of subparagraph (A)(ii) of this paragraph apply to the election of additional coverage and plans, which include optional coverage, for an employee subject to the health insurance waiting period.(C) Except as otherwise provided in this section, an employee may not change coverage.(D) An eligible employee who enrolls in the GBP is eligible to participate in premium conversion and shall be automatically enrolled in the premium conversion plan. The employee shall be automatically enrolled in the plan for subsequent plan years as long as the employee remains on active duty.(E) Coverage for a newly eligible dependent, other than a dependent referred to in subparagraph (F) or (H) of this paragraph, will be effective on the first day of the month following the date the person becomes a dependent if an enrollment form is completed on or within 30 days after the date the person first becomes a dependent. If the enrollment form is completed and signed after the initial period for enrollment as provided in this paragraph, the enrollment form will be governed by the rules in subsection (d) of this section.(F) A member's newborn natural child will be covered immediately and automatically for 30 days from the date of birth in the health plan in effect for the employee/retiree. A member's newly adopted child will be covered immediately and automatically from the date of placement for adoption for 30 days in the health plan in effect for the employee/retiree. To continue coverage for more than 30 days after the date of birth or placement for adoption, an enrollment form for GBP health coverage must be submitted by the member within 30 days after the date of birth or placement for adoption.(G) The effective date of a newborn natural child's life and AD&D coverage will be the date of birth, if the child is born alive, as certified by an attending physician or a certified nurse-midwife. The effective date of a newly adopted child's life and AD&D coverage will be the date of placement for adoption. The effective date of all other eligible dependents' life and AD&D coverage will be as stated in subparagraph (E) of this paragraph.(H) GBP health coverage of a member's eligible child for whom a covered employee/retiree is court-ordered to provide medical support becomes effective on the date on which the member's benefits coordinator receives a valid copy of the qualified medical child support order.(I) The effective date of GBP health coverage for an employee's/retiree's dependent, other than a newborn natural child or newly adopted child, will be as stated in subparagraph (E) of this paragraph.(J) For purposes of this section, an enrollment form is completed when all information necessary to effect an enrollment has been transmitted to ERS in the form and manner prescribed by ERS.(2) Part-time employees. A part-time employee or other employee who is not automatically covered must complete an application/enrollment form provided by ERS authorizing necessary deductions for insurance required contributions for elected coverage. All other rules for enrollment stated in paragraph (1) of this subsection, other than the rule as to automatic coverage, apply to such employee: (A) If the employee is not subject to a health insurance waiting period, this form must be submitted to ERS either through ERS Online or through his/her benefits coordinator on, or within 30 days after, the date on which the employee begins active duty.(B) If the employee is subject to a health insurance waiting period, this form must be submitted to ERS either through ERS Online or through his/her benefits coordinator before the first day of the month following 60 days of employment.(C) If the employee has existing, current, and continuous GBP health coverage as of the date the employee begins active duty, the employee is not subject to the health insurance waiting period and is eligible to enroll as a new employee in health insurance and additional coverage and plans which include optional coverage by completing an enrollment form before the first day of the calendar month after the date the employee begins active duty. Health and additional coverage selected before the first day of the calendar month after the date the employee begins active duty are effective the first day of the following month.(3) Retirees and their dependents. (A) Provided the insurance required contributions are paid or deducted, an employee's GBP health, dental, vision and term life insurance coverage (including eligible dependent coverage) may be continued upon retirement as provided in § 81.5(b) of this chapter. The life insurance will be reduced to the maximum amount which the retiree is permitted to retain under the insurance plan as a retiree. All other coverage in force for an active employee, but not available to a retiree, will automatically be discontinued concurrently with the commencement of retirement status. Except as provided in subparagraph (E) of this paragraph, if a retiree retires directly from active duty and is not covered as an active employee on the day before becoming an annuitant, the retiree may enroll in the basic plan.(B) A retiree may enroll in GBP health, dental, vision and life insurance coverage for which the retiree is eligible as provided in § 81.5(b) of this chapter, including dependent coverage, by completing an enrollment form as specified in clauses (i) - (iii) of this subparagraph. For the purposes of this subparagraph, the effective date of retirement of a retiree who is eligible to receive, but who has not yet received, an annuity is the date on which ERS receives written notice of the retirement. An application/enrollment form received after the initial period for enrollment as provided in this subparagraph, is subject to the provisions of subsection (d) of this section. (i) A retiree who is not subject to the health insurance waiting period on the effective date of retirement as provided in § 81.5(b) of this chapter, may enroll in GBP health, dental, vision and life insurance coverage or waive GBP health coverage as provided in § 81.8 of this chapter for which the retiree is eligible, including dependent coverage, by completing an enrollment form or waiver of coverage as applicable before, on, or within 30 days after, the retiree's effective date of retirement.(ii) A retiree who is subject to the health insurance waiting period on the effective date of retirement as provided in § 81.5(b) of this chapter, may enroll in GBP health coverage or waive GBP health coverage as provided in § 81.8 of this chapter for which the retiree is eligible, including dependent coverage, by completing an enrollment form or waiver of coverage as applicable, before the first day of the calendar month following 60 days after the date of retirement or before the first day of the calendar month after the retiree's 65th birthday, whichever is later as appropriate. The effective date for such coverage shall be the first day of the calendar month following 60 days after the date of retirement or the first day of the calendar month following the retiree's 65th birthday, whichever is later as appropriate.(iii) A retiree who is ineligible for health insurance on the effective date of retirement as provided in § 81.5(b) of this chapter, may enroll in GBP health coverage or waive GBP health coverage as provided in § 81.8 of this chapter for which the retiree is eligible, including dependent coverage, by completing an enrollment form or waiver of coverage as applicable, before the first day of the calendar month after the retiree's 65th birthday. The effective date for such coverage shall be the first day of the calendar month following 60 days after the date of retirement or the first day of the calendar month following the retiree's 65th birthday, whichever is later.(C) A retiree who becomes eligible for minimum retiree optional life insurance coverage or dependent life insurance coverage as provided in § 81.5(b)(6) of this chapter, may apply for approval of such coverage by providing evidence of insurability acceptable to ERS.(D) Enrollments in and applications to change coverage become effective as provided in subparagraph (B) of this paragraph unless other coverage is in effect at that time. If other coverage is in effect at that time, coverage or waiver of coverage becomes effective on the first day of the month following the date of approval of retirement by ERS; or, if cancellation of the other coverage preceded the date of approval of retirement, the first day of the month following the date the other coverage was canceled.(E) A retiree who seeks enrollment in GBP health coverage after turning age 65 will be automatically enrolled in HealthSelect of Texas until Medicare enrollment is confirmed by CMS. A retiree who is enrolled in a health plan and turns age 65 will remain enrolled in that health plan until the retiree's Medicare enrollment can be confirmed by CMS. Once Medicare enrollment is confirmed, the retiree will be automatically enrolled in the Medicare Advantage Plan unless the retiree opts out of the Medicare Advantage Plan and enrolls in other coverage by completing an enrollment form as specified in subparagraph (B)(i) - (iii) of this paragraph. If the retiree is determined to be ineligible for Medicare coverage, then he/she will be returned to the coverage in place immediately before turning 65.(F) A Medicare-eligible retiree who seeks enrollment in GBP health coverage, or is retired and enrolled in a health plan and becomes eligible for Medicare, will be automatically enrolled in the HealthSelect of Texas Prescription Drug Program until Medicare enrollment is confirmed by CMS. Upon confirmation of Medicare enrollment, the retiree will be enrolled in HealthSelect Medicare Rx. A retiree who declines HealthSelect Medicare Rx loses all GBP prescription drug coverage. If the retiree is determined to be ineligible for Medicare coverage, then he/she will be returned to the coverage in place immediately before turning 65.(4) Medicare-eligible Dependents. (A) A dependent as defined in § 81.1 of this chapter (relating to Definitions) who becomes eligible for Medicare-primary coverage as specified in § 81.1 of this chapter, either through disability, age, or other requirements as set forth by CMS, will be automatically enrolled in the Medicare Advantage Plan, once Medicare enrollment is confirmed by CMS, unless the retiree and his/her dependents opt out of the Medicare Advantage Plan and enroll in other coverage by completing an enrollment form as specified in paragraph (3)(B)(i) - (iii) of this subsection. If the dependent is determined to be ineligible for Medicare coverage, then he/she will be returned to the coverage in place immediately before turning 65.(B) A Medicare-eligible dependent eligible for GBP health coverage will be automatically enrolled in HealthSelect Medicare Rx, once Medicare enrollment is confirmed by CMS. A Medicare-eligible dependent who declines HealthSelect Medicare Rx loses all GBP prescription drug coverage. If the dependent is determined to be ineligible for Medicare coverage, then he/she will be returned to the coverage in place immediately before turning 65.(5) Surviving dependents. (A) Provided that the insurance required contributions are paid or deducted, the health, dental, and vision insurance coverage of a surviving dependent may be continued on the death of the deceased employee/retiree if the dependent is eligible for such coverage as provided by § 81.5(e) of this chapter.(B) A surviving spouse who is receiving an annuity shall make insurance required contribution payments by deductions from the annuity as provided in subsection (h)(7) of this section. A surviving spouse who is not receiving an annuity may make payments as provided in subsection (h)(7) of this section.(C) A Medicare-eligible surviving dependent eligible for GBP health coverage will be automatically enrolled in the Medicare Advantage Plan, once Medicare enrollment is confirmed by CMS, unless the surviving dependent opts out of the Medicare Advantage Plan and enrolls in other coverage.(D) A Medicare-eligible surviving dependent eligible for GBP health coverage will be automatically enrolled in HealthSelect Medicare Rx, once Medicare enrollment is confirmed by CMS. A Medicare-eligible surviving dependent who declines HealthSelect Medicare Rx loses all GBP prescription drug coverage.(6) Former COBRA unmarried children. A former COBRA unmarried child must provide an application to continue GBP health, dental and vision insurance coverage within 30 days after the date the notice of eligibility is mailed by ERS. Coverage becomes effective on the first day of the month following the month in which continuation coverage ends. Insurance required contribution payments must be made as provided in subsection (h)(1)(A) of this section.(b) Premium conversion plans. (1) An eligible employee participating in the GBP is deemed to have elected to participate in the premium conversion plan and to pay insurance required contributions with pre-tax dollars as long as the employee remains on active duty. The plan is intended to be qualified under the Internal Revenue Code, §79 and §106.(2) Maximum benefit available. Subject to the limitations set forth in these rules and in the plan, to avoid discrimination, the maximum amount of flexible benefit dollars which a participant may receive in any plan year for insurance required contributions under this section shall be the amount required to pay the participant's portion of the insurance required contributions for coverage under each type of insurance included in the plan.(c) Special rules for additional coverage and plans which include optional coverage. (1) Only an employee/retiree or a former officer or employee specifically authorized to join the GBP may apply for additional coverage and plans. An employee/retiree may apply for or elect additional coverage and plans for which he/she is eligible without concurrent enrollment in GBP health coverage provided by the GBP. Additional coverage and plans, as determined by the Board of Trustees, may include: (D) short- and long-term disability;(E) voluntary accidental death and dismemberment;(G) health care and dependent care reimbursement;(H) commuter spending account;(J) limited purpose flexible spending account; or(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: (i) change or enroll themselves and any eligible dependents in an eligible health, dental or vision plan;(ii) enroll themselves and their eligible dependents in an eligible health, dental or vision plan from a waived or canceled status;(iii) add, decrease or cancel eligible coverage, unless prohibited by § 81.11(c)(3) of this chapter;(iv) apply for coverage as provided in paragraph (3) of this subsection; and(v) waive any or all GBP coverage including health as provided in § 81.8 of this chapter.(B) Surviving dependents and former COBRA unmarried children are not eligible to add dependents to coverage through annual enrollment. A surviving dependent or former COBRA unmarried child may enroll an eligible dependent in dental or vision insurance coverage if the dependent is enrolled in health insurance coverage.(C) Annual enrollment opportunities will be scheduled each year at times announced by ERS.(9) A participant who is a retiree or a surviving dependent, or who is in a direct pay status, may decrease or cancel any coverage at any time unless such coverage is health insurance coverage ordered by a court as provided in § 81.5(c) of this chapter.(10) A member and his/her dependents who are enrolled in the Medicare Advantage Plan may collectively enroll in HealthSelect of Texas, Consumer Directed HealthSelect or an HMO. (A) Such opportunity will be scheduled on at least an annual basis each year, at times announced by ERS.(B) Additional opportunities will occur each month prior to an annual enrollment period. Coverage selected during these opportunities will be effective on the first of the month following processing by CMS.(11) If a member drops coverage for his/her dependent because the dependent gained other coverage effective the first day of a month, then the effective date of the qualifying life event can be either the last day of the month preceding the gained coverage or on the first day of the month in which the gained coverage is effective.(e) Special provisions relating to term life benefits (1) An employee or annuitant who is enrolled in the group term life insurance plan may file a claim for an accelerated life benefit for himself or his covered dependent in accordance with the terms of the plan in effect at that time. An accelerated life benefit paid will be deducted from the amount that would otherwise be payable under the plan.(2) An employee or annuitant who is enrolled in the group term life insurance plan may make, in conjunction with receipt of a viatical settlement, an irrevocable beneficiary designation in accordance with the terms of the plan in effect at that time.(f) Re-enrollment in the GBP. (1) The provisions of subsection (a)(1) of this section shall apply to the enrollment of an employee who terminates employment and returns to active duty within the same fiscal year, who transfers from one employer to another, or who returns to active duty after a period of LWOP during which coverage is canceled.(2) An employee to whom paragraph (1) of this subsection applies shall be subject to the same requirements as a newly hired employee to re-enroll in the coverage in which the employee was previously enrolled. Provided that all applicable preexisting conditions exclusions were satisfied on the date of termination, transfer, or cancellation, no new preexisting conditions exclusions will apply. If not, any remaining period of preexisting conditions exclusions must be satisfied upon re-enrollment.(3) If an employee is a member of the Texas National Guard or any of the reserve components of the United States armed forces, and the employee's coverage is canceled during a period of LWOP or upon termination of employment as the result of an assignment to active military duty, the period of active military duty shall be applied toward satisfaction of any period of preexisting conditions exclusions remaining upon the employee's return to active employment.(g) Continuing coverage in special circumstances.(1) Continuation of coverage for terminating employees. A terminating employee is eligible to continue all coverage through the last day of the month in which employment is terminated.(2) Continuation of coverage for employees on LWOP status.(A) An employee in LWOP status may continue the coverage in effect on the date the employee entered that status for the period of leave, but not more than 12 months. The employee must pay insurance required contributions directly as provided in subsection (h)(1)(A) of this section.(B) An employee whose LWOP is a result of the Family and Medical Leave Act of 1993 will continue to receive the state contribution during such period of LWOP. The employee must pay insurance required contributions directly as defined in subsection (h)(1)(A) of this section. Failure to make the payment of insurance required contributions by the due date will result in the cancellation of all coverage except for member-only health and basic life coverage. The employee will continue in the health plan in which he/she was enrolled immediately prior to the cancellation of all other coverage.(3) Continuation of coverage for a former member or employee of the Legislature. Provided that the insurance required contributions are paid, the GBP health, dental, vision and life insurance coverage of a former member or employee of the Legislature may be continued on conclusion of the term of office or employment.(4) Continuation coverage for a former board member. Provided that the insurance required contributions are paid, the GBP health, dental, vision and life insurance coverage of 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, may be continued on conclusion of service if no lapse in coverage occurs after the term of office. Life insurance will be reduced to the maximum amount for which the former board member is eligible.(5) Continuation of coverage for a former judge. A former state of Texas judge, who is eligible for judicial assignments and who does not serve on judicial assignments during a period of one calendar month or longer, may continue the coverage that was in effect during the calendar month immediately prior to the month in which the former judge did not serve on judicial assignments. This coverage may continue for no more than 12 continuous months during which the former judge does not serve on judicial assignments as long as, during the period, the former judge continues to be eligible for assignment.(6) Continuation of coverage for a surviving spouse and/or dependent child/children of a deceased employee/retiree. The surviving spouse and/or dependent child/children of a deceased employee/retiree, who, in accordance with § 81.5(j)(1) of this chapter, elects to continue coverage may do so by submitting the required election notification and enrollment forms to ERS. The enrollment form, including all insurance required contributions due for the election/enrollment period, must be postmarked or received by ERS on or before the date indicated on the continuation of coverage enrollment form. Continuing coverage will begin on the first day of the month following the month in which the employee/retiree dies, provided all insurance required contributions due for the month in which the employee/retiree died and for the election/enrollment period have been paid in full.(7) Continuation of coverage for a covered 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 in paragraph (2)(A) of this subsection. An employee, his/her spouse and/or dependent child/children, who, in accordance with § 81.5(j)(2) of this chapter, elect to continue GBP health, dental and vision coverage may do so by submitting the required election notification and enrollment forms to ERS. The enrollment form, including all insurance required contributions due for the election/enrollment period, must be postmarked or received by ERS on or before the date indicated on the continuation of coverage enrollment form. Continuing coverage will begin on the first day of the month following the month in which the employee's coverage ends, provided all insurance required contributions due for the month in which the coverage ends and for the election/enrollment period have been paid in full.(8) Continuation of coverage for a spouse who is divorced from a member and/or the spouse's dependent child/children. The divorced spouse and/or the spouse's dependent child/children of an employee/retiree who, in accordance with § 81.5(j)(4) of this chapter, elect to continue coverage may do so by submitting the required election notification and enrollment forms to ERS. The enrollment form, including all insurance required contributions due for the election/enrollment period, must be postmarked or received by ERS on or before the date indicated on the continuation of coverage enrollment form. Continuing coverage will begin on the first day of the month following the month in which the divorce decree is signed, provided all insurance required contributions due for the month in which the divorce decree is signed and for the election/enrollment period have been paid in full.(9) Continuation of coverage for a dependent child who has attained 26 years of age. A 26-year-old dependent child (not provided for by § 81.5(c) of this chapter) of a member who, in accordance with § 81.5(j)(5) of this chapter, elects to continue coverage may do so by submitting the required election notification and enrollment forms to ERS. The enrollment form, including all insurance required contributions due for the election/enrollment period, must be postmarked or received by ERS on or before the date indicated on the continuation of coverage enrollment form. Continuing coverage will begin on the first day of the month following the month in which the dependent child of the member attains 26 years of age, provided all insurance required contributions due for the month in which the dependent child attained age 26 and for the election/enrollment period have been paid in full.(10) Extension of continuation of coverage for certain dependents of former employees who are continuing coverage under the provisions of paragraph (6) of this subsection. (A) The surviving dependent of a deceased former employee, who, in accordance with § 81.5(j)(6)(A) of this chapter, elects to extend continuation coverage may do so by submitting the required election notification and enrollment forms to ERS. The enrollment form, including all insurance required contributions due for the election/enrollment period, must be postmarked or received by ERS on or before the date indicated on the continuation enrollment form. The election/enrollment period begins on the first day of the month following the month in which the former employee died.(B) A spouse who is divorced from a former employee and/or the divorced spouse's dependent child/children, who, in accordance with § 81.5(j)(6)(B) of this chapter, elects to extend continuation coverage may do so by submitting the required election notification and enrollment forms to ERS. The enrollment form, including all insurance required contributions due for the election/enrollment period, must be postmarked or received by ERS on or before the date indicated on the continuation enrollment form. The election/enrollment period begins on the first day of the month following the month in which the divorce decree was signed.(C) A dependent child who has attained 26 years of age, who, in accordance with § 81.5(j)(6)(C) of this chapter, elects to extend continuation coverage may do so by submitting the required election notification and enrollment forms to ERS. The enrollment form, including all insurance required contributions due for the election/enrollment period, must be postmarked or received by ERS on or before the date indicated on the continuation enrollment form. The election/enrollment period begins on the first day of the month following the month in which the dependent child attained age 26.(11) Continuation coverage defined. Continuation coverage as provided for in paragraphs (6) - (10) of this subsection means the continuation of only GBP health, dental and vision coverage which meets the following requirements. (A) Type of benefit coverage. The coverage shall consist of only the GBP health, dental and vision coverage, which, as of the time the coverage is being provided, are identical to the GBP health, dental and vision coverage provided for a similarly situated person for whom a cessation of coverage event has not occurred.(B) Period of coverage. The coverage shall extend for at least the period beginning on the first day of the month following the date of the cessation of coverage event and ending not earlier than the earliest of the following:(i) in the case of loss of coverage due to termination of an employee's employment for other than gross misconduct, reduction in work hours, or end of maximum period of LWOP, the last day of the 18th calendar month of the continuation period;(ii) in the case of loss of coverage due to termination of an employee's employment for other than gross misconduct, reduction in work hours, or end of maximum period of LWOP, if the employee, spouse, or dependent child has been certified by the Social Security Administration as being disabled as provided in § 81.5(j)(3) of this chapter, up to the last day of the 29th calendar month of the continuation period;(iii) in any case other than loss of coverage due to termination of an employee's employment for other than gross misconduct, reduction in work hours, or end of maximum period of LWOP, the last day of the 36th calendar month of the continuation period;(iv) the date on which the employer ceases to provide any group health plan to any employee/retiree;(v) the date on which coverage ceases under the plan due to failure to make timely payment of any insurance required contribution as provided in subsection (h) of this section;(vi) the date on which the participant, after the date of election, becomes covered under any other group health plan under which the participant is not subject to a preexisting conditions limitation or exclusion; or(vii) the date on which the participant, after the date of election, becomes entitled to benefits under the Social Security Act, Title XVIII.(C) Insurance required contribution costs. The insurance required contribution for a participant during the continuation coverage period will be 102% of the employee's/retiree's GBP health, dental and vision coverage rate and is payable as provided in subsection (h) of this section. (i) The insurance required contribution for a participant eligible for 36 months of coverage will be 102% of the employee's/retiree's GBP health, dental and vision coverage rate and is payable as provided in subsection (h)(1)(A) of this section.(ii) The insurance required contribution for a participant eligible for 29 months of coverage will increase to 150% of the employee's/retiree's GBP health, dental and vision coverage rate for the 19th through 29th months of coverage and is payable as provided in subsection (h)(1)(A) of this section.(D) No requirement of insurability. No evidence of insurability is required for a participant who elects to continue GBP health coverage under the provisions of §81.5(j)(1) - (6) of this chapter.(E) Conversion option. An option to enroll under the conversion plan available to employees/retirees is also available to a participant who continues GBP coverage for the maximum period as provided in subparagraph (B)(i) - (iii) of this paragraph. The conversion notice will be provided to a participant during the 180-day period immediately preceding the end of the continuation period.(h) Payment of Insurance Required Contributions.(1) A member whose monthly cost of coverage is greater than the combined amount contributed by the state or employer for the member's coverage must pay a monthly contribution in an amount that exceeds the combined monthly contributions of the state or the employer. A member shall pay his/her monthly insurance required contributions through deductions from monthly compensation or annuity payments or by direct payment, as provided in this paragraph. (A) A member who is not receiving a monthly compensation or an annuity payment, or is receiving a monthly compensation or annuity payment that is less than the member's monthly insurance required contribution, shall pay his/her monthly insurance required contribution under this subparagraph. (i) An employee whose monthly compensation is less than the employee's monthly insurance required contribution shall pay his/her monthly insurance required contribution through his/her employer. A non-salaried board member of an employer shall pay his/her monthly insurance required contributions through the employer for which he/she sits as a board member.(ii) A retiree whose monthly annuity payment is less than the retiree's monthly insurance required contribution shall pay his/her monthly insurance required contributions directly to ERS.(B) If the member does not comply with subparagraph (A) of this subsection by the due date required, ERS will cancel all coverage not fully funded by the state contribution. If the state contribution is sufficient to cover the required insurance contribution for such coverage, the member will retain member-only health and basic life coverage. If the state contribution is not sufficient to cover the member-only coverage in the health plan selected, the member will be enrolled in the basic plan except as provided for in paragraph (2)(B) of this subsection.(2) An institution of higher education may contribute a portion or all of the insurance required contribution for its part-time employees described by §1551.101(e)(2) of the Act, if: (A) the institution of higher education pays the contribution with funds that are not appropriated from the general revenue fund;(B) the institution of higher education electing to pay the contribution for its part-time employees does so for all similarly situated eligible part-time employees; and(C) the contribution paid as provided in this paragraph is paid beginning on the first day of the month following the part-time employee's completion of any applicable waiting period.(3) A participant who continues GBP health, dental and vision coverage under COBRA as provided in § 81.5(j) of this chapter must pay his/her monthly insurance contributions on the first day of each month covered. (A) A participant's monthly insurance required contribution is 102% of the monthly amount charged for other participants in the same coverage category and in the same plan. All insurance required contributions due for the election/enrollment period must be postmarked or received by ERS on or before the date indicated on the continuation of coverage enrollment form. Subsequent insurance required contributions are due on the first day of each month of the participant's coverage and must be postmarked or received by ERS within 30 days of the due date to avoid cancellation of coverage.(B) A participant's monthly insurance required contribution for continuing coverage as provided in § 81.5(j)(3) of this chapter is increased after the 18th month of coverage to 150% of the monthly amount charged for other participants in the same coverage category and in the same plan. The participant's monthly insurance required contribution is due on the first day of each month covered, and must be postmarked or received by ERS within 30 days of the due date.(4) The full cost for GBP health, dental and vision coverage is required to be paid for a member's unmarried child who is over 26 years of age, whose coverage under COBRA expired, and who has reinstated coverage in the GBP pursuant to §1551.158 of the Act. No state contribution is paid for this coverage.(5) Survivors 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, are eligible for GBP coverage as provided in subparagraphs (A) - (C) of this paragraph. (A) The insurance required contribution due under this paragraph for a surviving spouse's GBP coverage is the same amount as a member-only contribution. The state contribution applicable to member-only coverage is applied to the surviving spouse's contribution for the coverage.(B) The insurance required contribution due under this paragraph for GBP coverage for a surviving spouse with dependent children is the same amount as the member-with-children contribution. The state contribution applicable to member-with-children coverage is applied to the contribution of the surviving spouse with dependent children for the coverage.(C) The insurance required contribution due under this paragraph for a surviving dependent child's GBP coverage, when there is no surviving spouse, is the same amount as member-only contribution. The state contribution applicable to member-only coverage is applied to the surviving dependent child's contribution for the coverage.(D) The surviving spouse or surviving dependent child must timely pay his/her insurance required contributions for the GBP coverage. The survivor's contribution must be either deducted by ERS from the survivor's annuity payment, if any, or submitted to ERS via direct payment. Any applicable state contribution will be paid directly to ERS by the employer that employed the deceased law enforcement officer or custodial employee.(6) If a retiree whose eligibility for health insurance is based on §§1551.102(i), 1551.111(e) or 1551.112(c) of the Act, obtains interim health insurance as provided in §1551.323 of the Act, the retiree must pay the total contribution for such coverage for as long as the retiree wants the coverage or until the first day of the month following the retiree's 65th birthday. The amount of contribution 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 such coverage. If a retiree who is eligible for coverage under this paragraph is also eligible for COBRA coverage, then COBRA coverage should be exhausted, if possible, before applying for the coverage under this paragraph.(7) A member's surviving spouse or surviving dependent who is receiving an annuity shall authorize deductions for insurance required contributions from the annuity as provided in paragraph (1) of this subsection. A member's surviving spouse or surviving dependent who is not receiving an annuity may make payments as provided in paragraph (1)(A) of this subsection.(i) The amount of state contribution for certain retirees is determined in accordance with §1551.3196 of the Act. (1) An individual is grandfathered at the time of retirement and not subject to §1551.3196 of the Act, if on or before September 1, 2014, the individual has served in one or more positions for at least five years for which the individual was eligible to participate in the GBP as an employee.(2) Records of ERS shall be used to determine whether or not an individual meets the grandfathering requirements specified in paragraph (1) of this subsection. ERS may, in its sole discretion, require an individual to provide additional documentation satisfactory to ERS that the individual meets the grandfathering requirements specified in paragraph (1) of this subsection.(j) Tobacco User Premium Differential. (1) Assessment. Pursuant to §1551.3075 of the Act, ERS shall assess a monthly tobacco user premium differential, in an amount determined by the Board of Trustees or as set in the General Appropriations Act, for participants enrolled in GBP health coverage who are certified as tobacco users or are age eighteen or older at the start of the current plan year and whose tobacco-use status has not been certified. ERS shall assess a single premium differential for each GBP member who is a tobacco user, a single premium differential for the member's dependent spouse who is a tobacco user, and a single premium differential for one or more of the member's dependent children who are tobacco users. A participant will not be subject to a premium differential assessment if the participant has been certified not to be a tobacco user or ERS has approved the participant for a one-year waiver under the Choose to Quit program. (2) Payment. The GBP member responsible for paying a tobacco user's insurance required contribution shall pay any assessed premium differential for the member and the member's dependents. (3) Certification of Tobacco-Use Status. Each GBP member with GBP health coverage must certify the tobacco-use status of the member and the member's enrolled dependents. (A) If participants certify that they are not a tobacco user, ERS shall not assess the premium differential. (B) ERS shall assess the premium differential monthly for any participant age eighteen or older at the start of the current plan year whose tobacco-use status has not been certified. (4) Choose to Quit Wellness Program. ERS may approve a one-year waiver for a participant who completes the Choose to Quit program for that plan year. (A) The participant must complete all of the following steps to have the premium differential waived: (i) participate in an office visit with a licensed physician to receive tobacco counseling and establish a tobacco cessation course of treatment under that physician's recommendation and supervision; (ii) complete the course of treatment, which may or may not result in cessation of tobacco use; (iii) participate in an office visit with the licensed physician following completion of treatment and obtain the physician's signature and the date of signature on the Choose to Quit certification form; and (iv) sign and submit the Choose to Quit certification form to ERS. (B) The Choose to Quit certification form must be signed by the physician during the plan year for which the waiver is requested and postmarked within thirty calendar days of the physician's signature date to be effective for that plan year. (C) Once processed and approved by ERS, the participant's premium differential will be waived for the remainder of the plan year and any premium differential previously paid for that plan year will be refunded. (D) A member with more than one dependent child certified as a tobacco user will not receive a refund of the premium differential paid for dependent children unless all dependent children certified as tobacco users complete the steps set forth in paragraph (4)(A) of this section. (E) At the beginning of each plan year, ERS shall reinstate the monthly assessment of the premium differential for the participant unless the participant has been separately certified not to be a tobacco user. (5) Sanctions. If any participant fails to accurately certify any participant's use of a tobacco product or submits false information to ERS regarding a participant's use of a tobacco product, ERS may impose one or more of the sanctions described in §1551.351(b) of the Act.34 Tex. Admin. Code § 81.7
The provisions of this §81.7 adopted to be effective September 1, 1985, 10 TexReg 2321; amended to be effective November 1, 1985, 10 TexReg 3850; amended to be effective September 1, 1986, 11 TexReg 3864; amended to be effective October 14, 1986, 11 TexReg 4115; amended to be effective October 28, 1986, 11 TexReg 4576; amended to be effective December 19, 1986, 11 TexReg 5138; amended to be effective January 9, 1987, 11 TexReg 5136; amended to be effective November 1, 1987, 12 TexReg 3480; amended to be effective December 13, 1988, 13 TexReg 5973; amended to be effective March 28, 1989, 14 TexReg 1371; amended to be effective August 24, 1989, 14 TexReg 3988; amended to be effectiveSeptember 29, 1989, 14 TexReg 4786; amended to be effective November 23, 1989, 14 TexReg 5935; amended to be effective May 25, 1990, 15 TexReg 2687; amended to be effective August 21, 1990, 15 TexReg 4504; amended to be effective November 28, 1990, 15 TexReg 6500; amended to be effective July 18, 1991, 16 TexReg 3777; amended to be effective October 29, 1991, 16 TexReg 5847; amended to be effective May 19, 1992, 17 TexReg 3252; amended to be effective September 2, 1993, 18 TexReg 5594; amended to be effective February 21, 1994, 19 TexReg 806; amended to be effective January 25, 1995, 20 TexReg 151; amended to be effective July 3, 1995, 20 TexReg 4409; amended to be effective September 6, 1996, 21 TexReg 8182; 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 13, 2001, 26 TexReg 6954; amended to be effective January 8, 2002, 27 TexReg 274; amended to be effective July 17, 2003, 28 TexReg 5538; 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 June 5, 2008, 33 TexReg 4332; amended to be effective March 15, 2010, 35 TexReg 2202; amended to be effective December 30, 2010, 35 TexReg 11707; 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; Amended by Texas Register, Volume 43, Number 37, September 14, 2018, TexReg 5987, eff. 9/18/2018; Amended by Texas Register, Volume 45, Number 36, September 4, 2020, TexReg 6239, eff. 9/8/2020