Law:Title 8. Health Insurance And Other Health Coverages. Subtitle H. Health Benefits And Other Coverages For Governmental Employees from Chapter 1579. Texas School Employees Uniform Group Health Coverage (Texas)

From Law Delta

Jump to: navigation, search

Subtitle H. Health Benefits And Other Coverages For Governmental Employees

Contents

Chapter 1579. Texas School Employees Uniform Group Health Coverage

Subchapter A. General Provisions

Section  1579.001.  Short Title.

This chapter may be cited as the Texas School Employees Uniform Group Health Coverage Act.

Added by Acts 2003, 78th Leg., ch. 1276, Sec. 10A.471(a), eff. Sept. 1, 2003.



Section  1579.002.  General Definitions.

In this chapter:

(1)  "Administering firm" means any entity designated by the trustee to administer any coverages, services, benefits, or requirements under this chapter and the trustee's rules adopted under this chapter.

(2)  "Trustee" means the Teacher Retirement System of Texas.

(3)  "Charter school" means an open-enrollment charter school established under Subchapter D, Chapter 12, Education Code.

(4)  "Health coverage plan" means any group policy or contract, hospital service agreement, health maintenance organization agreement, preferred provider arrangement, or any similar group arrangement or any combination of those policies, contracts, agreements, or arrangements that provides for, pays for, or reimburses expenses for health care services.

(5)  "Participating entity" means an entity participating in the uniform group coverage program established under this chapter. The term includes:

(A)  a school district;

(B)  another educational district whose employees are members of the Teacher Retirement System of Texas;

(C)  a regional education service center; and

(D)  a charter school that meets the requirements of Section 1579.154.

(6)  "Program" means the uniform group coverage program established under this chapter.

(7)  "Regional education service center" means a regional education service center established under Chapter 8, Education Code.

Added by Acts 2003, 78th Leg., ch. 1276, Sec. 10A.471(a), eff. Sept. 1, 2003.



Section  1579.003.  Definition Of Employee.

In this chapter, "employee" means a participating member of the Teacher Retirement System of Texas who is employed by a participating entity and who is not receiving coverage from a program under Chapter 1551, 1575, or 1601. The term does not include an individual performing personal services as an independent contractor.

Added by Acts 2003, 78th Leg., ch. 1276, Sec. 10A.471(a), eff. Sept. 1, 2003.



Section  1579.004.  Definition Of Dependent.

In this chapter, "dependent" means:

(1)  a spouse of a full-time employee or part-time employee;

(2)  an unmarried child of a full-time or part-time employee if the child is younger than 25 years of age, including:

(A)  an adopted child;

(B)  a foster child, stepchild, or other child who is in a regular parent-child relationship; and

(C)  a recognized natural child;

(3)  a full-time or part-time employee's recognized natural child, adopted child, foster child, stepchild, or other child who is in a regular parent-child relationship and who lives with or has his or her care provided by the employee or the surviving spouse on a regular basis, regardless of the child's age, if the child is mentally retarded or physically incapacitated to an extent that the child is dependent on the employee or surviving spouse for care or support, as determined by the board of trustees; and

(4)  notwithstanding any other provision of this code, any other dependent of a full-time or part-time employee specified by rules adopted by the board of trustees.

Added by Acts 2003, 78th Leg., ch. 1276, Sec. 10A.471(a), eff. Sept. 1, 2003.



Section 1579.005.  Confidentiality.

(a) Section 825.507, Government Code, applies to records relating to an employee or dependent under the program and in the custody of the Teacher Retirement System of Texas or in the custody of an administrator, carrier, agent, attorney, consultant, or governmental body acting in cooperation with or on behalf of the system.

(b)  The Teacher Retirement System of Texas may disclose to a health care provider, benefit provider, or claims administrator information in the records of an individual that the system determines is necessary to administer the program.

Added by Acts 2005, 79th Leg., Ch. 1359, Sec. 48, eff. September 1, 2005.



Section 1579.006.  Exemption From Process.

(a) The following are exempt from execution, attachment, garnishment, or any other process:

(1)  benefit payments, including optional benefit payments;

(2)  contributions of active employees, the state, and a participating entity, and any other contributions;

(3)  any rights, benefits, or payments accruing to any person under this chapter; and

(4)  any money in the Texas school employees uniform group coverage trust fund.

(b)  The items listed in Subsection (a) may not be assigned except for direct payment to benefit providers as authorized by the trustee by contract, rule, or otherwise.

Added by Acts 2005, 79th Leg., Ch. 1359, Sec. 48, eff. September 1, 2005.



Section 1579.007.  Exemption From State Taxes And Fees.

A premium or contribution on a policy, insurance contract, or agreement authorized by this chapter is not subject to any state tax, regulatory fee, or surcharge, including a premium or maintenance tax or fee.

Added by Acts 2005, 79th Leg., Ch. 1359, Sec. 48, eff. September 1, 2005.



Section 1579.008.  Coverage Exempt From Insurance Law.

A coverage plan provided under this chapter is exempt from any other insurance law, including common law, that does not expressly apply to the plan or this chapter.

Added by Acts 2005, 79th Leg., Ch. 1359, Sec. 48, eff. September 1, 2005.



Subchapter B. Administration

Section  1579.051.  Administration Of Group Program.

The Teacher Retirement System of Texas, as trustee, shall implement and administer the uniform group coverage program described by this chapter.

Added by Acts 2003, 78th Leg., ch. 1276, Sec. 10A.471(a), eff. Sept. 1, 2003.



Section  1579.052.  Authority To Adopt Rules; Other Authority.

(a) The trustee may adopt rules relating to the program as considered necessary by the trustee.

(b)  The trustee may adopt rules to administer the program, including rules relating to adjudication of claims and expelling participants from the program for cause.

(c)  The trustee may contract with independent and experienced group insurance consultants and actuaries for advice and counsel in implementing and administering the program.

(d)  The trustee may enter into interagency contracts with any agency of the state, including the Employees Retirement System of Texas and the department, for the purpose of assistance in implementing the program.

(e)  The trustee shall take the actions it considers necessary to devise, implement, and administer the program.

Added by Acts 2003, 78th Leg., ch. 1276, Sec. 10A.471(a), eff. Sept. 1, 2003.

Amended by:

Acts 2005, 79th Leg., Ch. 1359, Sec. 49, eff. September 1, 2005.



Section  1579.053.  Personnel.

The trustee may hire and compensate employees as necessary to implement the program.

Added by Acts 2003, 78th Leg., ch. 1276, Sec. 10A.471(a), eff. Sept. 1, 2003.



Section  1579.054.  Competitive Bidding Requirements; Rules.

A contract to provide group health coverage under this chapter may be awarded only through competitive bidding under rules adopted by the trustee.

Added by Acts 2003, 78th Leg., ch. 1276, Sec. 10A.471(a), eff. Sept. 1, 2003.



Section  1579.055.  Contract Award; Considerations.

(a) In awarding a contract to provide group benefits under this chapter, the trustee is not required to select the lowest bid and may consider also any relevant criteria, including the bidder's:

(1)  ability to service contracts;

(2)  past experiences; and

(3)  financial stability.

(b)  If the trustee awards a contract to a bidder whose bid deviates from that advertised, the trustee shall record the deviation and fully justify the reason for the deviation in the minutes of the next board meeting.

Added by Acts 2003, 78th Leg., ch. 1276, Sec. 10A.471(a), eff. Sept. 1, 2003.



Section 1579.057.  Pharmacy Benefit Manager Contracts.

(a) In awarding a contract to provide pharmacy benefit manager services under this chapter, the trustee is not required to select the lowest bid but must select a contract that meets the criteria established by this section.

(b)  The contract must state that:

(1)  the trustee is entitled to audit the pharmacy benefit manager to verify costs and discounts associated with drug claims, pharmacy benefit manager compliance with contract requirements, and services provided by subcontractors;

(2)  the audit must be conducted by an independent auditor in accordance with established auditing standards; and

(3)  to conduct the audit, the trustee and the independent auditor are entitled access to information related to the services and the costs associated with the services performed under the contract, including access to the pharmacy benefit manager's facilities, records, contracts, medical records, and agreements with subcontractors.

(c)  The contract must define the information that the pharmacy benefit manager is required to provide to the trustee concerning the audit of the retail, independent, and mail order pharmacies performing services under the contract and describe how the results of these audits must be reported to the trustee, including how often the results must be reported.  The contract must state whether the pharmacy benefit manager is required to return recovered overpayments to the trustee.

(d)  The contract must state that any audit of a mail order pharmacy owned by the pharmacy benefit manager must be conducted by an independent auditor selected by the trustee in accordance with established auditing standards.

Added by Acts 2009, 81st Leg., R.S., Ch. 1207, Sec. 7, eff. September 1, 2009.



Subchapter C. Coverages

Section  1579.101.  Plans Of Group Coverages.

(a) The trustee by rule shall establish plans of group coverages for employees participating in the program and their dependents.

(b)  The plans must include at least two tiers of group coverage, with coverage at different levels in each tier, ranging from the catastrophic care coverage plan to the primary care coverage plan. Each tier must contain a health coverage plan.

(c)  The trustee by rule shall define the requirements of each coverage plan and tier of coverage.

(d)  Comparable coverage plans of each tier of coverage established must be offered to employees of all participating entities.

Added by Acts 2003, 78th Leg., ch. 1276, Sec. 10A.471(a), eff. Sept. 1, 2003.



Section 1579.102.  Catastrophic Care Coverage Plan.

The coverage provided under the catastrophic care coverage plan shall be prescribed by the trustee by rule and must provide coverage at least as extensive as the coverage provided under the TRS-Care 1 plan operated under Chapter 1575.

Added by Acts 2003, 78th Leg., ch. 1276, Sec. 10A.471(a), eff. Sept. 1, 2003.

Amended by:

Acts 2005, 79th Leg., Ch. 1359, Sec. 50, eff. September 1, 2005.



Section  1579.103.  Primary Care Coverage Plan.

The coverage provided under the primary care coverage plan must be comparable in scope and, to the greatest extent possible, in cost to the coverage provided under Chapter 1551.

Added by Acts 2003, 78th Leg., ch. 1276, Sec. 10A.471(a), eff. Sept. 1, 2003.



Section 1579.104.  Optional Coverages.

The trustee may not offer optional coverages, other than optional permanent life insurance, optional long-term care insurance, and optional disability insurance, to employees participating in the program.  This section does not affect the right of a participating entity to offer optional coverages to its employees under terms and conditions established by the participating entity.

Added by Acts 2003, 78th Leg., ch. 1276, Sec. 10A.471(a), eff. Sept. 1, 2003.

Reenacted by Acts 2005, 79th Leg., Ch. 1359, Sec. 51(a), eff. September 1, 2005.



Section  1579.105.  Preexisting Condition Limitation.

During the initial period of eligibility, coverage provided under the program may not be made subject to a preexisting condition limitation.

Added by Acts 2003, 78th Leg., ch. 1276, Sec. 10A.471(a), eff. Sept. 1, 2003.



Section 1579.106.  Prior Authorization For Certain Drugs.

(a) In this section, "drug formulary" means a list of drugs preferred for use and eligible for coverage by a health coverage plan.

(b)  A health coverage plan provided under this chapter that uses a drug formulary in providing a prescription drug benefit must require prior authorization for coverage of the following categories of prescribed drugs if the specific drug prescribed is not included in the formulary:

(1)  a gastrointestinal drug;

(2)  a cholesterol-lowering drug;

(3)  an anti-inflammatory drug;

(4)  an antihistamine drug; and

(5)  an antidepressant drug.

(c)  Every six months the trustee shall submit to the comptroller and the Legislative Budget Board a report regarding any cost savings achieved in the program through implementation of the prior authorization requirement of this section.  The report must cover the previous six-month period.

Added by Acts 2007, 80th Leg., R.S., Ch. 730, Sec. 1G.003, eff. April 1, 2009.



Section 1579.107.  Disease Management Services.

(a) In this section, "disease management services" means services to assist an individual manage a disease or other chronic health condition, such as heart disease, diabetes, respiratory illness, end-stage renal disease, HIV infection, or AIDS, and with respect to which the trustee identifies populations requiring disease management.

(b)  A health coverage plan provided under this chapter must provide disease management services or coverage for disease management services in the manner required by the trustee, including:

(1)  patient self-management education;

(2)  provider education;

(3)  evidence-based models and minimum standards of care;

(4)  standardized protocols and participation criteria; and

(5)  physician-directed or physician-supervised care.

Added by Acts 2007, 80th Leg., R.S., Ch. 730, Sec. 1G.003, eff. April 1, 2009.



Section 1579.108.  Limitations.

The trustee may not contract for or provide a health coverage plan that excludes from participation in the network a general hospital that:

(1)  is located in the geographical service area or areas of the health coverage plan that includes a county that:

(A)  has a population of at least 100,000 and not more than 175,000; and

(B)  is located in the Texas-Louisiana border region, as that term is defined in Section 2056.002(e), Government Code; and

(2)  agrees to provide medical and health care services under the plan subject to the same terms as other hospital providers under the plan.

Added by Acts 2007, 80th Leg., R.S., Ch. 730, Sec. 1G.003, eff. April 1, 2009.



Subchapter D. Participating Entities

Section  1579.151.  Required Participation Of School Districts With 500 Or Fewer Employees.

(a) Each school district with 500 or fewer employees and each regional education service center is required to participate in the program.

(b)  Notwithstanding Subsection (a), a school district otherwise subject to Subsection (a) that, on January 1, 2001, was individually self-funded for the provision of health coverage to its employees may elect not to participate in the program.

(c)  An educational district described by Section 1579.002(5)(B) that, on January 1, 2001, had 500 or fewer employees may elect not to participate in the program.

Added by Acts 2003, 78th Leg., ch. 1276, Sec. 10A.471(a), eff. Sept. 1, 2003.



Section  1579.152.  Participation Of Other School Districts.

Effective September 1, 2005, a school district with more than 500 employees may elect to participate in the program. A school district that elects to participate under this section shall apply for participation in the manner prescribed by the trustee by rule.

Added by Acts 2003, 78th Leg., ch. 1276, Sec. 10A.471(a), eff. Sept. 1, 2003.



Section  1579.153.  Participation By Certain Risk Pools.

(a) In determining the number of employees of a school district for purposes of Sections 1579.151 and 1579.152, school districts that, on January 1, 2001, were members of a risk pool established under the authority of Chapter 172, Local Government Code, as provided by Section 22.004, Education Code, may elect to be treated as a single unit. A school district shall elect whether to be considered as a member of a risk pool under this section by notifying the trustee not later than September 1, 2001.

(b)  A risk pool in existence on January 1, 2001, that, as of that date, provided group health coverage to 500 or fewer school district employees may elect to participate in the program.

(c)  A school district with 500 or fewer employees that is a member of a risk pool described by Subsection (a) that provides group health coverage to more than 500 school district employees must elect, not later than September 1, 2001, whether to be treated as a school district with 500 or fewer employees or as part of a unit with more than 500 employees. The school district must notify the trustee of the election, in the manner prescribed by the trustee, not later than September 1, 2001.

(d)  For purposes of this section, participation in the program by school districts covered by a risk pool is limited to school districts covered by the risk pool as of January 1, 2001.

Added by Acts 2003, 78th Leg., ch. 1276, Sec. 10A.471(a), eff. Sept. 1, 2003.



Section  1579.154.  Participation By Charter Schools; Eligibility.

(a) A charter school is eligible to participate in the program if the school agrees:

(1)  that all records of the school relating to participation in the program are open to inspection by the trustee, the administering firm, the commissioner of education, or a designee of any of those entities; and

(2)  to have the school's accounts relating to participation in the program annually audited by a certified public accountant at the school's expense.

(b)  A charter school must notify the trustee of the school's intent to participate in the program in the manner and within the time required by rules adopted by the trustee.

Added by Acts 2003, 78th Leg., ch. 1276, Sec. 10A.471(a), eff. Sept. 1, 2003.



Subchapter E. Participation By Employee

Section  1579.201.  Definition.

In this subchapter, "full-time employee" and "part-time employee" have the meanings assigned by rules adopted by the trustee.

Added by Acts 2003, 78th Leg., ch. 1276, Sec. 10A.471(a), eff. Sept. 1, 2003.



Section  1579.202.  Eligible Employees.

(a) Except as provided by Section 1579.204, participation in the program is limited to employees of participating entities who are full-time employees and to part-time employees who are participating members in the Teacher Retirement System of Texas.

(b)  An employee described by Subsection (a) who applies for coverage during an open enrollment period prescribed by the trustee is automatically covered by the catastrophic care coverage plan unless the employee:

(1)  specifically waives coverage under this chapter;

(2)  selects a higher tier coverage plan; or

(3)  is expelled from the program.

Added by Acts 2003, 78th Leg., ch. 1276, Sec. 10A.471(a), eff. Sept. 1, 2003.



Section  1579.203.  Selection Of Coverage.

(a) A participating employee may select coverage in any coverage plan offered by the trustee.

(b)  The employee is not required to continue participation in the coverage plan initially selected and may select a higher or lower tier coverage plan than the plan initially selected by the employee in the manner provided by rules adopted by the trustee.

(c)  If the combined contributions received from the state and the employing participating entity under Subchapter F exceed the cost of a coverage plan selected by the employee, the employee may use the excess amount of contributions to obtain coverage under a higher tier coverage plan or to pay all or part of the cost of coverage for the employee's dependents.

(d)  A married couple, both of whom are eligible for coverage under the program, may pool the amount of contributions to which the couple are entitled under the program to obtain coverage for themselves and dependent coverage.

Added by Acts 2003, 78th Leg., ch. 1276, Sec. 10A.471(a), eff. Sept. 1, 2003.



Section  1579.204.  Certain Part-time Employees.

A part-time employee of a participating entity who is not a participating member in the Teacher Retirement System of Texas is eligible to participate in the program only if the employee pays all of the premiums and other costs associated with the health coverage plan selected by the employee.

Added by Acts 2003, 78th Leg., ch. 1276, Sec. 10A.471(a), eff. Sept. 1, 2003.



Section  1579.205.  Payment By Participating Entity.

Notwithstanding Section 1579.204, a participating entity may pay any portion of what otherwise would be the employee share of premiums and other costs associated with the coverage selected by the employee.

Added by Acts 2003, 78th Leg., ch. 1276, Sec. 10A.471(a), eff. Sept. 1, 2003.



Subchapter F. Contributions

Section  1579.251.  State Assistance.

(a) The state shall assist employees of participating school districts and charter schools in the purchase of group health coverage under this chapter by providing for each covered employee the amount of $900 each state fiscal year or a greater amount as provided by the General Appropriations Act.  The state contribution shall be distributed through the school finance formulas under Chapters 41 and 42, Education Code, and used by school districts and charter schools as provided by Section  42.260, Education Code.

(b)  The state shall assist employees of participating regional education service centers and educational districts described by Section 1579.002(5)(B) in the purchase of group health coverage under this chapter by providing to the employing service center or educational district, for each covered employee, the amount of $900 each state fiscal year or a greater amount as provided by the General Appropriations Act.

Added by Acts 2003, 78th Leg., ch. 1276, Sec. 10A.471(a), eff. Sept. 1, 2003.

Amended by:

Acts 2009, 81st Leg., R.S., Ch. 1328, Sec. 83, eff. September 1, 2009.



Section  1579.252.  Contribution By Participating Entities.

A participating entity shall make contributions for the program as provided by Chapter 1581.

Added by Acts 2003, 78th Leg., ch. 1276, Sec. 10A.471(a), eff. Sept. 1, 2003.



Section  1579.253.  Contribution By Employee. (a)

An employee covered by the program shall pay that portion of the cost of coverage selected by the employee that exceeds the amount of the state contribution under Section 1579.251 and the participating entity contribution under Section 1579.252.

(b)  The employee may pay the employee's contribution under this subsection from the amount distributed to the employee under Subchapter D,  Chapter 22, Education Code.

(c)  Notwithstanding Subsection (a), a participating entity may pay any portion of what otherwise would be the employee share of premiums and other costs associated with the coverage selected by the employee.

Added by Acts 2003, 78th Leg., ch. 1276, Sec. 10A.471(a), eff. Sept. 1, 2003.

Amended by:

Acts 2005, 79th Leg., Ch. 899, Sec. 18.04, eff. September 1, 2005.

Acts 2005, 79th Leg., Ch. 1359, Sec. 52, eff. September 1, 2005.



Section 1579.254.  Contributions Held In Trust For Fund.

A participating entity:

(1)  shall hold contributions required by this subchapter in trust for the Texas school employees uniform group coverage trust fund and its participants; and

(2)  may not divert the contributions for any other purpose.

Added by Acts 2005, 79th Leg., Ch. 1359, Sec. 53, eff. September 1, 2005.



Section 1579.255.  Interest Assessed On Late Payment Of Contributions By Participating Entities.

(a) A participating entity that does not remit to the trustee all contributions required by this subchapter before the seventh day after the last day of the month shall pay to the Texas school employees uniform group coverage trust fund:

(1)  the contributions; and

(2)  interest on the unpaid amounts at the annual rate of six percent compounded monthly.

(b)  On request, the trustee may grant a waiver of the deadline imposed by this section based on a participating entity's financial or technological resources.

Added by Acts 2005, 79th Leg., Ch. 1359, Sec. 53, eff. September 1, 2005.



Subchapter G. Texas School Employees Uniform Group Coverage Trust Fund

Section  1579.301.  Fund; Administration.

The Texas school employees uniform group coverage trust fund is a trust fund with the comptroller.

Added by Acts 2003, 78th Leg., ch. 1276, Sec. 10A.471(a), eff. Sept. 1, 2003.



Section  1579.302.  Composition Of Fund.

The fund is composed of:

(1)  all contributions made to the fund under this chapter from employees, participating entities, and the state;

(2)  contributions made by employees or participating entities for optional coverages;

(3)  investment income;

(4)  any additional amounts appropriated by the legislature for contingency reserves, administrative expenses, or other expenses; and

(5)  any other money required or authorized to be paid into the fund.

Added by Acts 2003, 78th Leg., ch. 1276, Sec. 10A.471(a), eff. Sept. 1, 2003.



Section  1579.303.  Payments From Fund.

The trustee may use amounts in the fund only to provide group coverages under this chapter and to pay the expenses of administering the program.

Added by Acts 2003, 78th Leg., ch. 1276, Sec. 10A.471(a), eff. Sept. 1, 2003.



Section  1579.304.  Investment Of Fund.

The trustee may invest assets of the fund in the manner provided by Section 67(a)(3), Article XVI, Texas Constitution.

Added by Acts 2003, 78th Leg., ch. 1276, Sec. 10A.471(a), eff. Sept. 1, 2003.


Personal tools
Laws
Variants
Actions
Navigation
Toolbox