CRD(LEGAL) - INSURANCE AND ANNUITIES MANAGEMENT: HEALTH AND LIFE INSURANCE

Coverage Requirements

Districts with 500 or Fewer Employees

Self-Funded Districts

Districts with More Than 500 Employees

TRS-Activecare

Employee Eligibility

Full-Time Employees

Part-Time Employees

Optional Coverages

Other Programs

Financial Statement

Small Employer Market Election

Insurance Code 1501.009

Employee Election — Spouses

Self-Funded Health-Care Plan

Comparability

Compliance Report

Education Code 22.004(d); 34 TAC 41.91

Cost of Coverage

TRS-Activecare

State Contribution

Employee Contribution

Insurance Code 1579.253

Other Programs

District Contribution

Designation of Compensation for Benefits

Use

Written Election

Continuation Coverage

After Resignation

The first anniversary of the date participation in or coverage under the uniform group coverage plan or the group health coverage was first made available to district employees for the last instructional year in which the employee was employed by the district; or

The last calendar day before the first day of the instructional year immediately following the last instructional year in which the employee was employed by the district.

Education Code 22.004(k), (l)

During Military Leave

The 24-month period beginning on the date on which the person's absence begins; or

The day after the date on which the person fails to apply for or return to a position of employment. [See DECB]

38 U.S.C. 4317

During FMLA Leave

Upon Termination or Other Qualifying Event (COBRA)

To the employee for 18 months after a termination (other than for gross misconduct) or reduction in hours. An employee providing notice of being disabled under Title II or XVI of the Social Security Act before the end of the initial 18 months of coverage shall be offered up to 29 months of continuation coverage.

To dependents of the covered employee for 36 months after the employee becomes eligible for Medicare benefits.

To dependents of the covered employee for 36 months after the employee's death or the divorce or legal separation of the employee from a spouse.

To a dependent child for 36 months after the child ceases to be a dependent under the terms of the plan.

42 U.S.C. 300bb-1, 300bb-2, 300bb-3

Premium

Notice

Termination of Coverage

The required period of coverage expires.

A district ceases to provide any group health plan to any employee.

Coverage ceases for failure to pay the premium.

The qualified beneficiary becomes covered under any other group plan.

The qualified beneficiary becomes entitled to Medicare benefits.

42 U.S.C. 300bb-2(2)

Note: See also DEB for continuation benefits that are available to survivors of district peace officers under certain conditions.

Coverage of Pre-Existing Conditions

TRS-Activecare

Federal Law

The exclusion relates to a condition (whether physical or mental), regardless of the cause of the condition, for which medical advice, diagnosis, care, or treatment was recommended or received within the six-month period ending on the enrollment date;

The exclusion extends for a period of not more than 12 months (or 18 months in the case of a late enrollee) after the enrollment date; and

The period of any such preexisting condition exclusion is reduced by the aggregate of the periods of creditable coverage (if any) applicable to the participant or beneficiary as of the enrollment date.

42 U.S.C. 300gg(a)(1); 45 C.F.R. 146.111(a)

Health Insurance Portability and Accountability Act (HIPAA)

Certificate of Creditable Coverage

At the time an individual ceases to be covered under the plan or otherwise becomes covered under a COBRA continuation provision. This certification may be provided, to the extent practicable, at a time consistent with notices required under any applicable COBRA continuation provision;

In the case of an individual covered under COBRA, at the time the individual's COBRA coverage ceases; and

On the request on behalf of an individual made not later than 24 months after the date of cessation of coverage.

The period of creditable coverage of the individual under such plan and the coverage (if any) under such COBRA continuation provision; and

The waiting period (if any) (and affiliation period, if applicable) imposed with respect to the individual for any coverage under such plan.

42 U.S.C. 300gg(e)

Other HIPAA Requirements

Limitations on preexisting condition exclusion periods;

Special enrollment periods for individuals;

Prohibitions against discriminating against individual participants and beneficiaries based on health status;

Standards relating to benefits for mothers and newborns; and

Parity in the application of certain limits to mental health benefits.

Election to Be Exempted

Limitations on preexisting condition exclusion periods;

Special enrollment periods for individuals;

Prohibitions against discriminating against individual participants and beneficiaries based on health status;

Standards relating to benefits for mothers and newborns;

Parity in the application of certain limits to mental health benefits; and

Required coverage for reconstructive surgery and certain other services following a mastectomy under section 2706 of the Public Health Service Act.

Form of Election

Timing of Election

Contents of Notice

42 U.S.C. 300gg-21; 45 C.F.R. 146.180

Privacy of Health Information

'Covered Entity' Defined

A health plan;

A health-care clearinghouse; or

A health-care provider who transmits any health information in electronic form in connection with a transaction covered by the Privacy Rule.

45 C.F.R. 160.103

'Protected Health Information' Defined

Education records covered by the Family Educational Rights and Privacy Act (FERPA), as amended.

Medical treatment records, as described at 20 U.S.C. 1232g(a)(4)(B)(iv), on a student who is at least 18 years of age.

Employment records held by a covered entity in its role as employer.

Sponsors of Group Health Plans

1.Summary health information, consistent with the requirements of the Privacy Rule; and

2.Enrollment and disenrollment information relating to an individual participating in the plan.

45 C.F.R. 164.504(f)

'Plan Sponsor' Defined

Self-Funded Plans

Midland ISD

CRD(LEGAL)-P

UPDATE 100

DATE ISSUED: 7/31/2014