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

Definitions

Participating Entity

Program

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).

Alternative Group Health Coverage Prohibited

Participation Election

Election to Discontinue
  1. Participate in the program until the fifth anniversary of the effective date of the entity's election to discontinue participation; or
  2. Discontinue the entity's participation after an election described by item 1 until the fifth anniversary of the effective date of that election.
Election to Continue

Optional Coverages

Other Health Coverage Programs

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.

Financial Statement

Small Employer Market Election

Employee Election — Spouses

Self-Funded Health-Care Plan

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

District 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 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
  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)

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

Coverage of Preexisting Conditions

TRS-ActiveCare

Federal Law

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. Subtitle A, Subchapter C.

Protected Health Information

  1. In education records covered by the Family Educational Rights and Privacy Act (FERPA), 20 U.S.C. 1232g. [See FL]
  2. In records described at 20 U.S.C. 1232g(a)(4)(B)(iv) (medical treatment records on a student who is at least 18 years of age).
  3. In employment records held by a covered entity in its role as employer.

Santo ISD

CRD(LEGAL)-P

UPDATE 118

DATE ISSUED: 11/3/2021