Texas Administrative Code › Title 34 - PUBLIC FINANCE › Part 3 - TEACHER RETIREMENT SYSTEM OF TEXAS › Chapter 41 - HEALTH CARE AND INSURANCE PROGRAMS › Subchapter C - TEXAS SCHOOL EMPLOYEES GROUP HEALTH (TRS-ACTIVECARE) › Section 41.51 - Appeals Relating to Eligibility

Current through Reg. 49, No. 28; July 12, 2024
(a) A
				  full-time or part-time employee ("Petitioner") whose application to enroll
				  themselves and/or their dependents in TRS-ActiveCare is denied by either TRS,
				  the administering firm, or a participating entity may appeal the denial to
				  TRS.
(b) An appeal made pursuant to
				  subsection (a) of this section shall be made in writing and must be received by
				  TRS no later than 45 days after the date of denial. The appeal shall be
				  directed to the TRS-ActiveCare Grievance Administrator. TRS may, at its sole
				  discretion, provide a copy of the appeal to the administering firm or the
				  participating entity that denied enrollment.
(c) An appeal made pursuant to subsection (a)
				  of this section shall state the basis for appeal and shall include all relevant
				  documents and correspondence that were considered by TRS, the administering
				  firm, or a participating entity when the enrollment was denied. The
				  administering firm or participating entity is required, upon request by TRS, to
				  participate in the process.
(d) The
				  TRS Appeal Committee ("Committee") is responsible for the review and
				  determination of appeals made pursuant to subsection (a) of this section. The
				  Committee shall be appointed by the TRS Deputy Director or, if the position of
				  the Deputy Director is vacant, the TRS Chief Financial Officer and shall serve
				  at the discretion of the Deputy Director or, if the position of the Deputy
				  Director is vacant, the Chief Financial Officer.
(e) In determining eligibility for
				  enrollment, the Committee shall apply the TRS-ActiveCare plan design and rules
				  in effect for the plan year in which the Petitioner is seeking enrollment. If
				  TRS finds that extraordinary circumstances constituting "good cause" prevented
				  the Petitioner from complying fully with a deadline established by TRS under
				  the TRS-ActiveCare plan design or rules, the appeal may be granted. For
				  purposes of this subsection, "good cause" means that a person's failure to act
				  was not because of a lack of due diligence the exercise of which would have
				  caused a reasonable person to take prompt and timely action. A failure to act
				  based on ignorance of the law or facts reasonably discoverable through the
				  exercise of due diligence does not constitute good cause. If a person was
				  reasonably prevented from complying with a deadline as a result of an
				  unexpected natural disaster or sudden catastrophic event, that event may
				  constitute "good cause" even though the event occurs on or near a deadline and
				  arguably Petitioner could have met the deadline if Petitioner had acted sooner.
				  Misinformation concerning a deadline provided to Petitioner by either TRS, the
				  health plan administrator of TRS-ActiveCare, or a participating entity, and
				  relied upon by Petitioner, may be grounds for "good cause" if the act of
				  providing misinformation to Petitioner is documented or substantiated and a
				  reasonable person would have relied on the information provided to Petitioner
				  and reasonably would not have known the information provided to Petitioner was
				  inaccurate.
(f) The Committee shall
				  notify the Petitioner, the administering firm, and the participating entity of
				  its decision in writing.
(g) If the
				  Committee determines that the enrollment should be allowed, it shall inform the
				  Petitioner, the administering firm, and the participating entity of the manner
				  and effective date of enrollment by the Petitioner.
(h) The Petitioner may appeal the written
				  decision of the Committee relating to eligibility to the executive director.
(1) A request for an appeal to the executive
				  director must be submitted by the Petitioner in writing and must be received by
				  TRS by the later of:
(A) 30 days after the
				  date the initial written decision by the Committee is mailed; or
(B) a number of days after the decision of
				  the Committee is mailed equal to the number of days it took the Committee to
				  issue its decision.