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 HealthSelect ^SM --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 HealthSelect ^SM of Texas, Consumer Directed HealthSelect ^SM , HMOs and Medicare Advantage plans, as applicable.

(23) Health insurance waiting period--The applicable waiting period defined in §1551.1055 of the Act.

(24) HealthSelect ^SM 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) HealthSelect ^SM 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.

Cont'd...