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

Eligibility

Full-Time Employees

Certain Part-Time Employees

  1. Is currently employed by a district for ten hours or more each week;
  2. Is employed in a position that is not eligible for membership in TRS or is not eligible for membership in TRS because of a service or disability retirement; and
  3. Is not receiving coverage as an employee or retiree from a uniform group insurance or health benefits program under Insurance Code Chapters 1551, 1601, or 1575 (TRS-Care).

Optional Coverages

Other Health Coverage Programs

Financial Statement

Small Employer Market Election

Employee Election — Spouses

Self-Funded Health-Care Plan

Comparability

  1. The deductible amount for service provided inside and outside of the network;
  2. The coinsurance percentages for service provided inside and outside of the network;
  3. The maximum amount of coinsurance payments a covered person is required to pay;
  4. The amount of the copayment for an office visit;
  5. The schedule of benefits and the scope of coverage;
  6. The lifetime maximum benefit amount; and
  7. Verification that the coverage is issued by a provider licensed to do business in this state by the Texas Department of Insurance (TDI) or is provided by an authorized risk pool or that a district is capable of covering the assumed liabilities in the case of coverage provided through district self-insurance.

Compliance Report

  1. Appropriate documentation of:
    1. The district's contract for group health coverage with a provider licensed to do business in this state by TDI or an authorized risk pool; or
    2. A resolution of the board authorizing a self-insurance plan for district employees and of the district's review of district ability to cover the liability assumed;
  2. The schedule of benefits;
  3. The premium rate sheet, including the amount paid by the district and employee;
  4. The number of employees covered by the health coverage plan offered by the district; and
  5. Information concerning the ease of completing the report.

Cost of Coverage

TRS-ActiveCare

State Contribution

Employee Contribution

Other Health Coverage Programs

District Required Minimum Effort

Designation of Compensation for Benefits

Use

Written Election

Continuation Coverage

After Resignation

  1. The first anniversary of the date participation in or coverage under TRS ActiveCare or the district's 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
  2. 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.

During Military Leave

  1. The 24-month period beginning on the date on which the person's absence begins; or
  2. The day after the date on which the person fails to apply for or return to a position of employment. [See DECB]

During FMLA Leave

Upon Termination or Other Qualifying Event (COBRA)

"Qualifying Event"

  1. The death of the covered employee.
  2. The termination, other than by reason of such employee's gross misconduct, or reduction of hours, of the covered employee's employment.
  3. The divorce or legal separation of the covered employee from the employee's spouse.
  4. The covered employee becoming entitled to benefits under Medicare, 42 U.S.C. 1395 et seq.
  5. A dependent child ceasing to be a dependent child under the generally applicable requirements of the plan

Period of Coverage

  1. In the case of the termination or reduction of hours of a covered employee as described at item 2 at "Qualifying Event" above, the date which is 18 months after the date of the termination or reduction of hours.
  2. If a qualifying event occurs during the 18 months after the date of the termination or reduction of hours, the date which is 36 months after the date of the termination or reduction of hours.
  3. In the case of a qualifying event other than termination or reduction of hours, the date which is 36 months after the date of the qualifying event.
  4. In the case of the termination or reduction of hours of a covered employee as described at item 2 at "Qualifying Event" that occurs less than 18 months after the date the covered employee became entitled to benefits under Medicare, 42 U.S.C. 1395 et seq., the period of coverage for qualified beneficiaries other than the covered employee shall not terminate under this provision before the close of the 36-month period beginning on the date the covered employee became so entitled.
  5. In the case of a qualified beneficiary who is determined, under Title II or XVI of the Social Security Act, 42 U.S.C. 401 et seq., 1381 et seq. (the Social Security Act), to have been disabled at any time during the first 60 days of continuation coverage, any reference in paragraph 1 or 2 to 18 months is deemed a reference to 29 months with respect to all qualified beneficiaries, but only if the qualified beneficiary has provided notice of such determination under 42 U.S.C. 300bb–6(3) before the end of such 18 months.
  6. The date on which the employer ceases to provide any group health plan to any employee.
  7. The date on which coverage ceases under the plan by reason of a failure to make timely payment of any premium required under the plan with respect to the qualified beneficiary.
  8. The date on which the qualified beneficiary first becomes, after the date of the election, covered under any other group health plan that satisfies 42 U.S.C. 300bb-2(2)(D)(i), or entitled to benefits under Title XVIII of the Social Security Act [42 U.S.C. 1395 et seq.].
  9. In the case of a qualified beneficiary who is disabled at any time during the first 60 days of continuation coverage under this subchapter, the month that begins more than 30 days after the date of the final determination under the Social Security Act that the qualified beneficiary is no longer disabled.

Premium

Notice

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

Coverage of Preexisting Conditions

TRS-ActiveCare

Federal Law

Health Insurance Portability and Accountability Act (HIPAA)

  1. Limitations on preexisting condition exclusion periods in accordance with section 2701 of the PHS Act as codified before enactment of the Affordable Care Act;
  2. Special enrollment periods for individuals and dependents described under section 2704(f) of the PHS Act;
  3. Prohibitions against discriminating against individual participants and beneficiaries based on health status under section 2705 of the PHS Act, except that the sponsor of a self-funded non-federal governmental plan cannot elect to exempt its plan from requirements under section 2705(a)(6) and 2705(c) through (f) that prohibit discrimination with respect to genetic information;
  4. Standards relating to benefits for mothers and newborns under section 2725 of the PHS Act;
  5. Parity in mental health and substance use disorder benefits under section 2726 of the PHS Act;
  6. Required coverage for reconstructive surgery following mastectomies under section 2727 of the PHS Act; and
  7. Coverage of dependent students on a medically necessary leave of absence under section 2728 of the PHS Act.

Exemption Election

Form of Election

  1. Be made in an electronic format in a form and manner as described by the U.S. Secretary of Health and Human Services in guidance.
  2. Be made in conformance with all of the plan sponsor's rules, including any public hearing requirements.
  3. Specify the beginning and ending dates of the period to which the election is to apply. This period is a single specified plan year, as defined in 45 C.F.R. 144.103.
  4. Specify the name of the plan and the name and address of the plan administrator, and include the name and telephone number of a person the Centers for Medicare and Medicaid Services (CMS) may contact regarding the election.
  5. State that the plan does not include health insurance coverage, or identify which portion of the plan is not funded through health insurance coverage.
  6. Specify each requirement described in 45 C.F.R. 146.180(a)(1) of this section from which the plan sponsor elects to exempt the plan.
  7. Certify that the person signing the election document, including, if applicable, a third party plan administrator, is legally authorized to do so by the plan sponsor.
  8. Include, as an attachment, a copy of the notice described in 45 C.F.R. 146.180(f).

Timing of Election

Contents of Notice

Privacy of Health Information

Definitions

"Covered Entity"

  1. A health plan;
  2. A health-care clearinghouse; or
  3. A health-care provider who transmits any health information in electronic form in connection with a transaction covered by 45 C. F. R. Chapter A, Subchapter C.

"Protected Health Information"

  1. Education records covered by the Family Educational Rights and Privacy Act (FERPA), 20 U.S.C. 1232g.
  2. 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.
  3. Employment records held by a covered entity in its role as employer.

"Plan Sponsor"

Sponsors of Group Health Plans

  1. Obtaining premium bids from health plans for providing health insurance coverage under the group health plan; or
  2. Modifying, amending, or terminating the group health plan.

Corpus Christi ISD

CRD(LEGAL)-P

UPDATE 111

DATE ISSUED: 7/6/2018