1. (a) Full-time employees. A full-time employee, elected officer, or appointed officer of the State of Texas is eligible for automatic coverage on the first day he or she begins active duty with the state. For an elected or appointed officer, the first day of active duty shall be the day he or she takes the oath of office.
2. (b) Part-time employees. A part-time employee or other employee who is not eligible for automatic coverage becomes eligible for coverage upon application to participate in the program, subject to the provisions of §81.7(b) of this title (relating to Enrollment).

3. (c) Retirees.

   1. (1) A retiree is eligible for health and dental coverage on the day he or she becomes an annuitant.
   2. (2) A retiree is eligible for optional life insurance and dependent life insurance coverage if the retiree was enrolled in such coverage on the day before becoming an annuitant. Except as provided in paragraph (3) of this subsection, a retiree may not increase the amount of life insurance for which the retiree was enrolled on the day before becoming an annuitant, but may cancel life insurance coverage at any time. Canceled life insurance coverages may never be reinstated. A retiree is not eligible for disability or AD&D coverage.
   3. (3) A covered retiree who was not enrolled in optional life insurance or dependent life insurance coverage on the day before becoming an annuitant becomes eligible for minimum retiree optional life insurance and dependent life insurance coverage on the date the retiree becomes an annuitant. Submission of evidence of insurability acceptable to the system shall be required for enrollment in such coverage.
   4. (4) A covered retiree who was not enrolled in dependent life insurance coverage on the day before becoming an annuitant becomes eligible for dependent life insurance coverage of a newly acquired dependent on the first day of the month following the date on which the individual becomes a dependent of the retiree.
   5. (5) Unless otherwise specifically authorized, persons who become insured as retirees will be ineligible for coverage as active employees as long as they remain eligible for coverage as retirees.
   6. (6) A retiree whose extended life insurance benefits are terminated is eligible for retiree life insurance coverage on the first day of the month following the extended life insurance benefits termination date.

4. (d) Dependents of employees and retirees.

   1. (1) The dependents of an employee or retiree are eligible for coverage on the same day that the employee or retiree becomes eligible. Except as otherwise provided in this paragraph, a newly acquired dependent is eligible for coverage on the first day of the month following the date on which the individual becomes a dependent of a covered employee or retiree. The employee or retiree must be enrolled for a particular coverage before the employee's or retiree's dependents are eligible for that type of coverage. An eligible child for whom a covered employee or retiree is court ordered to provide medical support becomes eligible for health coverage upon receipt by the department of a valid court order. A newborn natural child is eligible automatically on the date of birth. A newly adopted child is eligible automatically on the date of placement for adoption.

   2. (2) Except as otherwise provided in this paragraph, double coverage is not permitted for any participant in the program.

      1. (A) A dependent may not be simultaneously covered for basic term life and dependent term life. A family member who is covered as an employee or retiree is not eligible to be covered as a dependent in the program. Except as provided in subparagraph (B) of this paragraph, a dependent may not be covered by more than one employee or retiree for the same coverage.
      2. (B) A child who is an eligible dependent of two participants in the program may be enrolled in dependent life insurance coverage and accidental death and dismemberment coverage by both participants.

5. (e) Former COBRA unmarried children.

   1. (1) A former COBRA unmarried child is eligible to continue the health and dental insurance coverages in which the child was enrolled upon expiration of the child's continuation coverage under COBRA.
   2. (2) A former COBRA unmarried child continuing health insurance coverage under the provisions of this subsection is eligible for dental insurance coverage if such coverage was not in effect upon the expiration of the child's continuation coverage under COBRA.

6. (f) Surviving dependents.

   1. (1) The surviving spouse of a retiree or the surviving spouse of an active employee is eligible to continue coverage in the health and dental benefits plans in which the surviving spouse was enrolled on the day of death of the employee/retiree provided, however, the deceased active employee must have had at least 10 years of service credit, including 3 years of service as an eligible employee with a Program participating department, at the time of death. A surviving spouse who is also a state retiree or state employee shall not be eligible for surviving spouse benefits as long as he or she is eligible for coverage as an employee or retiree. Participants continuing coverage as surviving spouses are not eligible for life insurance coverages.
   2. (2) Dependent children of a deceased employee or retiree are eligible to continue coverage in the health and dental benefits plans in which the dependent children were enrolled on the day of death of the employee/retiree provided, however, the deceased active employee must have had, at the time of death, at least 10 years of service credit, including 3 years of service as an eligible employee with a Program participating department, as long as the surviving spouse is eligible and continues to participate in the program. Dependent children of deceased employees or retirees will be considered as dependents of the deceased employee's or retiree's surviving spouse for purposes of the program. Participants continuing coverage as surviving dependents are not eligible for life insurance coverage.
   3. (3) Dependent children of a deceased employee/retiree are eligible to continue coverage in the health and dental benefits plans in which the dependent children were enrolled on the day of death of the employee/retiree provided, however, the deceased active employee must have had at least 10 years of service credit, including 3 years of service as an eligible employee with a Program participating department, at the time of death. A surviving dependent child may continue such coverage until the dependent child becomes ineligible as defined in §81.1 of this title (relating to Definitions). Participants continuing coverage as surviving dependents are not eligible for life insurance coverage.
   4. (4) A surviving spouse or a 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 violent death in the course of performance of duty is eligible to continue or enroll in health and dental coverages. A surviving spouse or natural or adopted children eligible under this section may enroll within 90 days from the date of death. Other eligible dependent children may continue health and dental coverages in effect on the date of death.
   5. (5) 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.
7. (g) Retiree under ORP. A retiring member of the ORP is eligible to remain in the insurance program if he or she becomes an annuitant of the ORP and the member's age and amount of service on which the annuity is based is such that the retiree meets the age and length-of-service requirements used by the Teacher Retirement System for regular service retirements. A retiring member will remain eligible for coverage in the program as long as he or she would have been eligible to receive an annuity had his or her membership been in the Teacher Retirement System rather than the ORP.

8. (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 title (relating to Enrollment and Participation). An ORP participant granted ORP disabled retiree status in the program, as established by the disability test used by the system, is eligible to remain in the program for the amount of time the person would be eligible for benefits had retirement coverages been under the Teacher Retirement System of Texas. Initial or continued eligibility for insurance coverage for an ORP disabled retiree will be determined by the system under the following provisions.

   1. (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. (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 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:

      1. (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
      2. (B) an ORP disabled retiree refuses for more than one year to submit to a required medical examination.
   3. (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.
9. (i) Former members of the legislature. On application to the trustee and on arrangement for the payment of contributions, a person who has at least eight years of creditable legislative service, as defined in the Government Code, §812.002, on ending his or her service in the legislature, continues to be eligible for participation in the program under the Act. Except as provided in this section, former members of the legislature will be subject to the same eligibility rules and effective dates that apply to active members of the legislature.
10. (j) Former employees of the legislature. On application to the trustee and on arrangement for the payment of contributions, a person who has at least 10 years of creditable service in the system, as defined in the Government Code, §812.003, as an employee of the legislature, on ending his or her service for the legislature, continues to be eligible for participation in the program under the Act. Except as provided in this section, a former legislative employee will be subject to the same eligibility rules and effective dates that apply to an active employee of the State of Texas.

11. (k) Continuation of health and dental coverages only for certain spouses and dependent children of employees/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. (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 Act 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. (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(l)(2)(A) of this title, except for those persons not eligible pursuant to §81.11(c) of this title (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 Act 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. (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. (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 Act 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. (5) A dependent child under 25 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. (6) A dependent child who has attained 25 years of age, who is not otherwise eligible to continue coverage indefinitely under the provisions of the Act 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 25th 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 25th birthday. A formal election must be made by the 25-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.

    7. (7) Extension of continuation of coverage for certain spouses and/or dependent child/children of former employees who are continuing coverage under the provisions of paragraph (2) of this subsection is governed by the following provisions.

       1. (A) The surviving spouse and/or dependent child/children of a deceased former employee whose death occurred during the period of continuation coverage, who satisfy the provisions of paragraph (1) of this subsection and who notify the Employees Retirement System of Texas within 60 days of the date of death of the former employee are entitled to a total of 36 months of continuation coverage.
       2. (B) A spouse who is divorced from a former employee during the period of continuation coverage and/or the divorced spouse's dependent child/children who satisfy the provisions of paragraph (4) of this subsection are entitled to a total of 36 months of continuation coverage.
       3. (C) A dependent child under 25 years of age who marries during the period of continuation coverage and who satisfies the provisions of paragraph (5) of this subsection is entitled to a total of 36 months of continuation coverage.
       4. (D) A dependent child who attains the age of 25 years during the period of continuation coverage and who satisfies the provisions of paragraph (6) of this subsection is entitled to a total of 36 months of continuation coverage.
       5. (E) An employee, spouse, or dependent child determined by the Social Security Administration to be disabled at the time of termination of the employee's employment and who satisfies the provisions of paragraph (3) of this subsection is entitled to a total of 29 months of continuation coverage.
       6. (F) No person shall be allowed to continue health and dental coverages under the provisions of this subsection for more than 36 months.
    8. (8) A person who continues benefits under the provisions of paragraphs (1)-(7) of this subsection may change coverage levels or plans during the continuation period on the same basis as an employee/retiree participant, provided, however, that health and dental coverages which are canceled during the continuation period may not be reestablished.
    9. (9) In all situations deemed applicable by the Employees Retirement System of Texas where state or federal laws or regulations mandate specific terms or provisions which are omitted or conflict with specific terms or provisions of the group contracts or trustees' rules, the appropriate contracts and rules shall be interpreted and administered to comply with such laws or regulations.
12. (l) Former board members. A former member of a board or commission or of the governing body of an institution of higher education, as both are described in Section 3(a)(5) of the Act, is eligible to continue the coverage, other than disability income insurance coverage, in effect on the day before the member leaves office if no lapse in coverage occurs after the end of the term of office.

Source Note:The provisions of this §81.5 adopted to be effective September 1, 1985, 10 TexReg 2321; amended to be effective March 19, 1986, 11 TexReg 1149; amended to be effective October 14, 1986, 11 TexReg 3523; amended to be effective September 1, 1986, 11 TexReg 3863; amended to be effective December 19, 1986, 11 TexReg 5135; amended to be effective January 9, 1987, 11 TexReg 5133; amended to be effective November 1, 1987, 12 TexReg 3480; amended to be effective May 25, 1990, 15 TexReg 2687; amended to be effective August 21, 1990, 15 TexReg 4504; amended to be effective May 19, 1992, 17 TexReg 3252; amended to be effective July 1, 1993, 18 TexReg 4094; amended to be effective February 21, 1994, 19 TexReg806; amendedto be effective January 25, 1995, 20 TexReg 151; amended to be effective July 3, 1995, 20 TexReg 4409; amended to be effective February 16, 1998, 23 TexReg 1099; amended to be effective September 16, 1999, 24 TexReg 7276; amended to be effective March 26, 2000, 25 TexReg 2400.