34 Tex. Admin. Code § 81.1 – Definitions

The following words and terms, when used in this chapter, shall have the following meanings, unless the context clearly indicates otherwise.

(1) Accelerated life benefit--An amount of term life insurance to be paid in advance of the death of an insured employee, annuitant, or dependent, as requested by the employee or annuitant and approved by the carrier, in accordance with the terms of the group term life plan as permitted by §1551.254, Insurance Code. Accelerated life benefit payment may be requested only upon diagnosis of a terminal condition and only once during the lifetime of the insured employee, annuitant, or dependent. A terminal condition is a non-correctable health condition that with reasonable medical certainty will result in the death of the insured within 12 months.
(2) Act--The Texas Employees Group Benefits Act, Act of the 77th Legislature, 2001, as amended, Insurance Code, Chapter 1551.
(3) Active duty--The expenditure of time and energy in the service of the state of Texas. An employee will be considered to be on active duty on each day of a regular paid vacation or regular paid sick leave or on a non-working day, if the employee was on active duty on the last preceding working day.
(4) AD&D--Accidental death and dismemberment.
(5) Age of employee--The age to be used for determining optional term life and voluntary AD&D insurance premiums will be the employee's attained age as of the employee's first day of active duty within a contract year.
(6) Annuitant--A person authorized by the Act to participate in the Program as an annuitant.
(7) Basic plan--The plan of group insurance determined by the trustee, currently HealthSelect participant only and basic term life insurance coverage, in which every full-time employee, or non-Medicare eligible retiree or dependent who is eligible for group insurance at the time of retirement, is automatically enrolled after completion of any required waiting period or unless participation is expressly waived.
(8) Board or trustee--The board of trustees of the Employees Retirement System of Texas.
(9) Contract year--A contract year begins on the first day of September and ends on the last day of the following August.
(10) Department--Commission, board, agency, division, institution of higher education, or department of the state of Texas created as such by the constitution or statutes of this state, or other governmental entity whose employees or retirees are authorized by the Act to participate in the Program.
(11) Dependent--The spouse of an employee or retiree and unmarried children under 25 years of age, including:
1. (A) the natural child of an employee/retiree;
2. (B) a legally adopted child (including a child living with the adopting parents during the period of probation);
3. (C) a stepchild whose primary place of residence is the employee/retiree's household;
4. (D) a foster child whose primary place of residence is the employee/retiree's household and who is not covered by another governmental health program;
5. (E) a child whose primary place of residence is the household of which the employee/retiree is head and to whom the employee/retiree is legal guardian of the person;
6. (F) a child who is in a parent-child relationship to the employee/retiree, provided the child's primary place of residence is the household of the employee/retiree, the employee/retiree provides the necessary care and support for the child, and if the natural parent of the child is 21 years of age or older, the natural parent does not reside in the same household;
7. (G) a child who is considered a dependent of the employee/retiree for federal income tax purposes and who is a child of the employee/retiree's eligible child;
8. (H) an eligible child, as defined in this subsection, for whom the employee/retiree must provide medical support pursuant to a valid order from a court of competent jurisdiction; or
9. (I) a child eligible under §1551.004, Insurance Code, provided that the child's mental disability or physical incapacity is a medically determinable condition which prevents the child from engaging in self-sustaining employment, that the condition commences before the date of the child's 25th birthday, and that satisfactory proof of such condition and dependency is submitted by the employee/retiree within 31 days following such child's attainment of age 25 and at such intervals thereafter as may be required by the system.
(12) Dependent--EFFECTIVE SEPTEMBER 1, 2010, paragraph (11) of this section, shall apply to an individual claimed as a dependent for a plan year that began before September 1, 2010.
1. (A) In this chapter, "dependent," with respect to an individual eligible to participate in the group benefits program, means the individual's:
  1. (i) spouse;
  2. (ii) child younger than 26 years of age;
  3. (iii) child of any age who the board of trustees determines lives with or has the child's care provided by the individual on a regular basis if the child is mentally or physically incapacitated to the extent that the child is dependent on the individual for care or support, as determined by the board of trustees;
  4. (iv) child of any age who is unmarried, for purposes of health benefit coverage under Insurance Code, Chapter 1551, on expiration of the child's continuation coverage under the Consolidated Omnibus Budget Reconciliation Act of 1985 (Pub. L. No. 99-272) and its subsequent amendments; and
  5. (v) a child under age 26 who is a ward, as that term is defined by §601, Texas Probate Code.
2. (B) In this section, "child" includes:
  1. (i) a natural child, adopted child, stepchild, foster child; or a child in the possession of a participant who is designated as managing conservator of the child under an irrevocable or unrevoked affidavit of relinquishment under Chapter 161 of the Texas Family Code; or
  2. (ii) a child who is related by blood or marriage and was claimed as a dependent on the federal income tax return of an individual who is eligible to participate in the group benefits program for the calendar year preceding the plan year in which the child is first enrolled as a dependent under Insurance Code, Chapter 1551, and for each subsequent year in which the child is enrolled as a dependent.
3. (C) The requirement in subparagraph (B)(ii) of this paragraph that a child must be claimed as a dependent on a federal income tax return in the calendar year preceding the child's enrollment does not apply if:
  1. (i) the child is born in the year in which the child is first enrolled; or
  2. (ii) the participant can demonstrate good cause for not claiming the child as a dependent in the preceding calendar year.
4. (D) In this section, "spouse" means a person recognized as a spouse under Texas law and includes only a ceremonially married spouse or an informally married spouse whose marriage is memorialized by a Declaration of Informal Marriage as authorized by Texas law and filed of record with an appropriate governmental authority prior to the date of the dependent spouse's enrollment in the GBP.
(13) Eligible to receive an annuity--Refers to a person who, in accordance with the Act, meets all requirements for retirement from a state retirement program or the Optional Retirement Program.
(14) Employee--A person authorized by the Act to participate in the Program as an employee.
(15) Employing office--For a retiree covered by this Program, the office of the Employees Retirement System of Texas in Austin, Texas or the retiree's last employing department; for an active employee, the employee's employing department.
(16) Evidence of insurability--Such evidence required by a qualified carrier for approval of coverage or changes in coverage other than coverage in HealthSelect, HMO or Medicare Advantage Plan pursuant to the rules of §81.7(i) of this chapter (relating to Enrollment and Participation).
(17) Former COBRA unmarried child--A child of an employee or retiree who is unmarried; whose GBP coverage as a dependent has ceased; and who upon expiration of continuation coverage under the Consolidated Omnibus Budget Reconciliation Act, Public Law 99-272 (COBRA) reinstates GBP coverage.
(18) HealthSelect^SM of Texas--The statewide health benefit plan self-insured by the Employees Life, Accident and Health Insurance and Benefits Fund, as administered by the Employees Retirement System of Texas and a qualified carrier or administering firm.
(19) HealthSelect Medicare Rx--A plan, approved by the Board, that provides prescription coverage designed for Medicare participants in the GBP as permitted by the federal Centers for Medicare and Medicaid Services (CMS) or its successor agency.
(20) HMO--A health maintenance organization approved by the board to provide health care benefits to eligible participants in the Program in lieu of participation in the Program's HealthSelect of Texas plan.
(21) Insurance premium expenses--Any out-of-pocket premium incurred by a participant, or by a spouse or dependent of such participant, as payment for coverage provided under the Program that exceeds the state's or institution's contributions offered as an employee benefit by the employer. The types of premium expense covered by the premium conversion plan include out-of-pocket premium for group term life, health (including HMO premiums), AD&D, and dental, but do not include out-of-pocket premium for long or short term disability or dependent term life.
(22) Leave without pay--The status of an employee who is certified by a department administrator to be absent from duty for an entire calendar month, who does not receive any compensation for that month, and who has not received a refund of retirement contributions based upon the most recent term of employment.
(23) Medicare Advantage Plan--A plan, approved by the board, that provides health benefits that are administered as a Medicare Advantage Plan as permitted by the federal Centers for Medicare and Medicaid Services (CMS) or its successor agency, through:
1. (A) a health maintenance organization; or
2. (B) any other plan or organization approved by the board for Medicare-eligible participants.
(24) Medicare-eligible--The status of a participant who is eligible for primary coverage under Medicare Part A and B in return for a monthly premium. Eligibility may extend to a dependent that is qualified to receive Medicare benefits as his/her primary coverage as permitted by CMS or its successor agency.
(25) ORP--The Optional Retirement Program as provided in the Government Code, Chapter 830.
(26) Participant--An eligible individual who participates in the group benefits program.
(27) Placement for adoption--A person's assumption and retention of a legal obligation for total or partial support of a child in anticipation of the person's adoption of such child.
(28) Preexisting condition--Any injury or sickness, for which the employee received medical treatment, or services, or took prescribed drugs or medicines during the three-month period immediately prior to the effective date of such coverage. However, if the evidence of insurability requirements set forth in §81.7(i) of this chapter must first be satisfied, the three-month period for purposes of determining the preexisting conditions exclusion will be the three-month period immediately preceding the date of the employee's completed application for coverage.
(29) Premium conversion plan--A separate plan, under the Internal Revenue Code, §79 and §106, adopted by the board of trustees and designed to provide premium conversion as described in §81.7(g) of this chapter.
(30) Program--The Texas Employees Group Benefits Program as established by the Board pursuant to the Act and known as the Group Benefits Program (GBP).
(31) Retiree--An employee who retires or is retired and who:
1. (A) is authorized by the Act to participate in the Program as a retiree;
2. (B) on August 31, 1992, was a participant in a group insurance program administered by an institution of higher education; or
3. (C) on the date of retirement, meets the service credit requirements of the Insurance Code for participation in the Program as an annuitant; and
  1. (i) on August 31, 2001, was an eligible employee with a department whose employees are authorized to participate in the Program and, on the date of retirement has three years of service with such a department;
  2. (ii) on August 31, 2001, had three years of service as an eligible employee with a department whose employees are authorized to participate in the Program; or
  3. (iii) is determined by ERS to be eligible as described by §1551.102 and §1551.114, Insurance Code.
(32) Salary--The salary to be used for determining optional term life and disability income limitations will be the employee's regular salary, including longevity, shift differential, hazardous duty pay, and benefit replacement pay, received by the employee as of the employee's first day of active duty within a contract year. No other component of compensation shall be included. Non-salaried elective and appointive officials and members of the Legislature may use the salary of a state district judge or their actual salary as of September 1 of each year.
(33) System--The Employees Retirement System of Texas.
(34) TRS--The Teacher Retirement System of Texas.

Source Note:The provisions of this §81.1 adopted to be effective September 1, 1985, 10 TexReg 2321; amended to be effective October 14, 1986, 11 TexReg 4114; amended to be effective December 13, 1988, 13 TexReg 5972; amended to be effective July 18, 1991, 16 TexReg 3777; amended to be effective August 19, 1991, 16 TexReg 4285; amended to be effective May 19, 1992, 17 TexReg 3252; amended to be effective September 2, 1993, 18 TexReg 5594; amended to be effective February 21, 1994, 19 TexReg 806; amended to be effective January 25, 1995, 20 TexReg 151; amended to be effective September 6, 1996, 21 TexReg 8182; amended to be effective February 16, 1998, 23 TexReg 1099; amended to be effective September 16, 1999, 24TexReg 7276; amended to be effective March 26, 2000, 25 TexReg 2400; amended to be effective September 13, 2001, 26 TexReg 6954; amended to be effective September 11, 2003, 28 TexReg 7780; amended to be effective December 31, 2003, 28 TexReg 11612; amended to be effective June 29, 2004, 29 TexReg 6120; amended to be effective May 3, 2006, 31 TexReg 3588; amended to be effective June 5, 2008, 33 TexReg 4332; amended to be effective March 15, 2010, 35 TexReg 2202; amended to be effective December 30, 2010, 35 TexReg 11707; amended to be effective December 22, 2011, 36 TexReg 8574; amended to be effective December 26, 2013, 38 TexReg 9374.