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TITLE 34PUBLIC FINANCE
PART 4EMPLOYEES RETIREMENT SYSTEM OF TEXAS
CHAPTER 81INSURANCE
RULE §81.5Eligibility

  (5) A person who is a surviving dependent of an annuitant may secure group health coverage after the death of the annuitant if the annuitant was eligible to participate in the group benefits program of a retirement system named in Chapter 1551, Insurance Code, but was not participating at the time of the individual's death.

  (6) A surviving spouse or dependent seeking group coverage under paragraphs (1) - (5) of this subsection must apply for coverage not later than the 30th day after the date on which the individual who was eligible to participate in the group benefits program dies; and shall pay for coverage at the group rate for other participants.

  (7) A surviving spouse or an eligible dependent child 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, shall be eligible for coverage in the Program as provided in subparagraphs (A) - (D) of this paragraph.

    (A) Coverage for a surviving spouse under this paragraph shall be at the same rate as the employee- or retiree-only coverage, and the surviving spouse shall be entitled to the benefit of the state contribution applied to employee- or retiree-only coverage.

    (B) Coverage for a surviving spouse with children shall be at the same rate as the employee- or retiree-with-children coverage, and the survivors shall be entitled to receive the benefit of the state contribution applied to coverage for an employee or retiree with children.

    (C) Where there is no surviving spouse, a surviving child eligible for coverage under this paragraph shall be entitled to the benefit of the state contribution for employee- or retiree-only coverage.

    (D) In order for a surviving spouse or children to receive coverage in the Program under this paragraph, they must pay the balance, if any, of all contributions due after applying the state contribution to such coverage. Any out-of-pocket premiums due from the survivor may be deducted by ERS from the survivor's annuity payment, if any, or must be paid to ERS by the survivor through electronic bank deduction or direct payment. The applicable state contributions will be paid to ERS by the state agency or department that employed the deceased law enforcement officer or custodial employee.

  (8) A surviving spouse and eligible dependents, and a surviving dependent child, continuing health insurance coverage under the provisions of this subsection are eligible for dental insurance coverage if such coverage was not in effect on the date of death of the deceased employee or retiree.

(g) Retiree under ORP.

  (1) A member of the ORP is eligible for health coverage on the day he or she receives or is eligible to receive an annuity under the ORP program or would have been eligible to receive an annuity had his or her membership been in the Teacher Retirement System rather than the ORP, and meets the age, length-of-service, and other requirements as provided in subsection (c) of this section.

  (2) A member of the ORP is eligible for additional coverages and plans which include optional and voluntary coverages in the Program as long as he or she receives or is eligible to receive an annuity under the ORP program or would have been eligible to receive an annuity had his or her membership been in the Teacher Retirement System rather than the ORP.

(h) Disability retirement. An applicant who is approved for disability retirement is entitled to retiree insurance coverages as provided in §81.7(c) of this chapter. An ORP participant authorized by the Act with at least 10 years of eligible service credit, and granted ORP disabled retiree status in the Program, as established by the disability test used by the system, is eligible to participate in the Program. Initial or continued eligibility for insurance coverage for an ORP disabled retiree will be determined by the system under the following provisions.

  (1) An ORP participant is eligible for ORP disabled retiree status in the Program if the ORP participant is not otherwise eligible to participate in the Program as an employee or retiree and is certified by a licensed physician designated by the system as disabled as provided in paragraph (2) of this subsection. An ORP participant may apply for disabled retiree status in the Program by filing a written application for ORP disabled retiree status in the Program or having an application filed with the system by the ORP participant's spouse, employer, or legal representative. In addition to an application for ORP disabled retiree status in the Program, an ORP participant must file with the system the results of a medical examination of the ORP participant. After an ORP participant applies for ORP disabled retiree status in the Program, the system may require the ORP participant to submit additional information about the disability. The system will prescribe forms for the information required by this section.

  (2) If a licensed physician designated by the system finds that the ORP participant is mentally or physically disabled from the further performance of duty and that the disability is probably permanent, the physician will certify the disability. The executive director is authorized to approve ORP disabled retiree status in the Program after a certification of disability is made. Once each year during the first five years after an ORP participant enrolls in the Program as an ORP disabled retiree, and once in each three-year period after that, the system may require an ORP disabled retiree to undergo a medical examination by a physician the system designates. If an ORP disabled retiree refuses to submit to a medical examination as provided by this section, the system will suspend the ORP disabled retiree's enrollment in the Program until the ORP disabled retiree submits to an examination. The system will terminate the ORP disabled retiree's coverage in the Program and notify the ORP participant in writing if:

    (A) the system concurs with a certification issued by the designated physician which finds that an ORP disabled retiree is no longer mentally or physically disabled from the further performance of duty; or

    (B) an ORP disabled retiree refuses for more than one year to submit to a required medical examination.

  (3) The effective date of coverage for an ORP disabled retiree in the Program is the first of the month following the date the application for ORP disabled retiree status in the Program is received by the system, or the first of the month following the date employment is terminated, whichever is later.

(i) Former members of the Legislature. A former member of the Legislature authorized by the Act to continue to participate in the Program is eligible for the coverage, other than disability income insurance coverage, in effect on the day before the member leaves office.

(j) Former employees of the Legislature. A former employee of the Legislature authorized by the Act to continue to participate in the Program is eligible for the coverage, other than disability income insurance coverage, in effect on the day before the employee terminates employment.

(k) Continuation of health and dental coverages only for certain spouses and dependent children of employee/retirees, and for certain terminating employees, their spouses, and dependent children (as provided by the Consolidated Omnibus Budget Reconciliation Act, Public Law 99-272).

  (1) The surviving spouse and/or dependent child/children of a deceased employee or retiree who are not eligible to continue coverage under the provisions of the Insurance Code or subsection (f) of this section, who are not entitled to benefits under the Social Security Act, Title XVIII, and who are not covered under any other group health plan, or who were covered by a plan that subjects them to a preexisting conditions limitation or exclusion that was not satisfied by the service credit provisions of Public Law 104-91 Health Insurance Portability and Accountability Act (HIPAA), may continue for up to 36 months the health and dental coverages only that were in effect immediately prior to the date of death of the employee/retiree. A formal election must be made to continue coverage by the surviving spouse and/or the dependent child/children. The formal election must be postmarked or received by the system within 60 days of the date of notice contained in the notice of right to continue coverage form or by the date coverage terminated, whichever is later.

  (2) An 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 Program as an employee, or whose coverage has ended following the maximum period of leave without pay as provided for in §81.7(m)(2)(A) of this chapter, except for those persons not eligible pursuant to §81.11(d) of this chapter (relating to Termination of Coverage), and/or his or her spouse and/or dependent child/children who are not eligible to continue coverage under the provisions of the Insurance Code or subsection (h) or (i) of this section, who are not entitled to benefits under the Social Security Act, Title XVIII, who are not covered under any other group health plan, or who were covered by a plan that subjects them to a preexisting conditions limitation or exclusion that was not satisfied by the service credit provisions of Public Law 104-91 (HIPAA), may continue for up to 18 months the health and dental coverages only without the basic term life that were in effect immediately prior to the date of the loss of coverage. A formal election must be made to continue coverage by the employee and/or his or her spouse and/or dependent child/children. The formal election must be postmarked or received by the system within 60 days of the date of notice contained in the notice of right to continue coverage form or by the date coverage terminated, whichever is later.

  (3) If an employee, spouse, or dependent child is determined by the Social Security Administration to have been disabled before or during the first 60 days of continuation coverage, all covered individuals may continue health and dental coverages extended up to an additional 11 months, for a total of 29 months. Notification of the Social Security Administration's determination must be received by the system before the end of the original 18 months of continuation coverage. Continuation coverage will be canceled the month that begins more than 30 days after the date the Social Security Administration determines that the participant is no longer disabled.

  (4) A spouse who is divorced from an employee/retiree and/or the spouse's dependent child/children who are not otherwise eligible to continue coverage under the provisions of the Insurance Code or subsection (d) of this section, who are not entitled to benefits under the Social Security Act, Title XVIII, who are not covered under any other group health plan, or who are covered by a plan that subjects them to a preexisting conditions limitation or exclusion that was not satisfied by the service credit provisions of Public Law 104-92 (HIPAA), may continue for up to 36 months the health and dental coverages only that were in effect immediately prior to the date the divorce decree is signed. The employee/retiree or the divorced spouse or the divorced spouse's dependent child/children must notify the system through the employing department or retiree benefits coordinator of the divorce within 60 days from the date the divorce decree is signed. A formal election must be made to continue coverage by the divorced spouse and/or the dependent child/children. The formal election must be postmarked or received by the system within 60 days of the date of notice contained in the notice of right to continue coverage form or by the date coverage is terminated, whichever is later.

  (5) A dependent child under 26 years of age who marries, who is not entitled to benefits under the Social Security Act, Title XVIII, who is not covered under any other group health plan, or who are covered by a plan that subjects the child to a preexisting conditions limitation or exclusion that was not satisfied by the service credit provisions of Public Law 104-91 (HIPAA), may continue for up to 36 months the health and dental coverages only that were in effect immediately prior to the date of the marriage. The married child or the employee/retiree must notify the system through the employing department or retiree benefits coordinator of the marriage within 60 days from the date of the marriage. A formal election must be made by the married child to continue coverage. The formal election must be postmarked or received by the system within 60 days of the date of notice contained in the notice of right to continue coverage form or by the date coverage is terminated, whichever is later.

  (6) A dependent child who has attained 26 years of age, who is not otherwise eligible to continue coverage indefinitely under the provisions of the Insurance Code or subsection (d) of this section, who is not entitled to benefits under the Social Security Act, Title XVIII, who is not covered under any other group health plan, or who is covered by a plan that subjects the child to a preexisting conditions limitation or exclusion that was not satisfied by the service credit provisions of Public Law 104-91 (HIPAA), may continue for up to 36 months the health and dental coverages only that were in effect immediately prior to the date of the child's 26th birthday. The child or employee/retiree must notify the system through the employing department or retiree benefits coordinator within 60 days of the child's 26th birthday. A formal election must be made by the 26-year-old child to continue coverage. The formal election must be postmarked or received by the system within 60 days of the date of notice contained in the notice of right to continue coverage form or by the date coverage is terminated, whichever is later.

Cont'd...

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