Texas Education Code - Section 22.004. Group Health Benefits For School Employees
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§ 22.004. GROUP HEALTH BENEFITS FOR SCHOOL
EMPLOYEES. (a) A district shall participate in the uniform group
coverage program established under Chapter 1579, Insurance Code, as
provided by Subchapter D of that chapter.
(b) A district that does not participate in the program
described by Subsection (a) shall make available to its employees
group health coverage provided by a risk pool established by one or
more school districts under Chapter 172, Local Government Code, or
under a policy of insurance or group contract issued by an insurer,
a company subject to Chapter 842, Insurance Code, or a health
maintenance organization under Chapter 843, Insurance Code. The
coverage must meet the substantive coverage requirements of Chapter
1251, Subchapter A, Chapter 1364, and Subchapter A, Chapter 1366,
Insurance Code, and any other law applicable to group health
insurance policies or contracts issued in this state. The coverage
must include major medical treatment but may exclude experimental
procedures. In this subsection, "major medical treatment" means a
medical, surgical, or diagnostic procedure for illness or injury.
The coverage may include managed care or preventive care and must be
comparable to the basic health coverage provided under Chapter
1551, Insurance Code. The board of trustees of the Teacher
Retirement System of Texas shall adopt rules to determine whether a
school district's group health coverage is comparable to the basic
health coverage specified by this subsection. The rules must
provide for consideration of the following factors concerning the
district's coverage in determining whether the district's coverage
is comparable to the basic health coverage specified by this
subsection:
(1) the deductible amount for service provided inside
and outside of the network;
(2) the coinsurance percentages for service provided
inside and outside of the network;
(3) the maximum amount of coinsurance payments a
covered person is required to pay;
(4) the amount of the copayment for an office visit;
(5) the schedule of benefits and the scope of
coverage;
(6) the lifetime maximum benefit amount; and
(7) verification that the coverage is issued by a
provider licensed to do business in this state by the Texas
Department of Insurance or is provided by a risk pool authorized
under Chapter 172, Local Government Code, or that a district is
capable of covering the assumed liabilities in the case of coverage
provided through district self-insurance.
Text of subsec. (c) as amended by Acts 2005, 79th Leg., ch. 728,
§ 11.108
(c) The cost of the coverage provided under the program
described by Subsection (a) shall be paid by the state, the
district, and the employees in the manner provided by Chapter 1579,
Insurance Code. The cost of coverage provided under a plan adopted
under Subsection (b) shall be shared by the employees and the
district using the contributions by the state described by
Subchapter F, Chapter 1579, Insurance Code, or by Chapter 1580,
Insurance Code.
Text of subsec. (c) as amended by Acts 2005, 79th Leg., ch. 899,
§ 18.01
(c) The cost of the coverage provided under the program
described by Subsection (a) shall be paid by the state, the
district, and the employees in the manner provided by Subchapter F,
Chapter 1579, Insurance Code. The cost of coverage provided under a
plan adopted under Subsection (b) shall be shared by the employees
and the district using the contributions by the state described by
Subchapter F, Chapter 1579, Insurance Code, or Subchapter D.
(d) Each district shall report the district's compliance
with this section to the executive director of the Teacher
Retirement System of Texas not later than March 1 of each
even-numbered year in the manner required by the board of trustees
of the Teacher Retirement System of Texas. For a district that does
not participate in the program described by Subsection (a), the
report must be based on the district group health coverage plan in
effect during the current plan year and must include:
(1) appropriate documentation of:
(A) the district's contract for group health
coverage with a provider licensed to do business in this state by
the Texas Department of Insurance or a risk pool authorized under
Chapter 172, Local Government Code; or
(B) a resolution of the board of trustees of the
district authorizing a self-insurance plan for district employees
and of the district's review of district ability to cover the
liability assumed;
(2) the schedule of benefits;
(3) the premium rate sheet, including the amount paid
by the district and employee;
(4) the number of employees covered by the health
coverage plan offered by the district; and
(5) any other information considered appropriate by
the executive director of the Teacher Retirement System of Texas.
(e) Based on the criteria prescribed by Subsection (b), the
executive director of the Teacher Retirement System of Texas shall,
for each district that does not participate in the program
described by Subsection (a), certify whether a district's coverage
is comparable to the basic health coverage provided under Chapter
1551, Insurance Code. If the executive director of the Teacher
Retirement System of Texas determines that the group health
coverage offered by a district is not comparable, the executive
director shall report that information to the district and to the
Legislative Budget Board. The executive director shall submit a
report to the legislature not later than September 1 of each
even-numbered year describing the status of each district's group
health coverage program based on the information contained in the
report required by Subsection (d) and the certification required by
this subsection.
(f) A school district that does not participate in the
program described by Subsection (a) may not contract with an
insurer, a company subject to Chapter 842, Insurance Code, or a
health maintenance organization to issue a policy or contract under
this section, or with any person to assist the school district in
obtaining or managing the policy or contract unless, before the
contract is entered into, the insurer, company, organization, or
person provides the district with an audited financial statement
showing the financial condition of the insurer, company,
organization, or person.
(g) An insurer, a company subject to Chapter 842, Insurance
Code, or a health maintenance organization that issues a policy or
contract under this section and any person that assists the school
district in obtaining or managing the policy or contract for
compensation shall provide an annual audited financial statement to
the school district showing the financial condition of the insurer,
company, organization, or person.
(h) An audited financial statement provided under this
section must be made in accordance with rules adopted by the
commissioner of insurance or with generally accepted accounting
principles, as applicable.
(i) Notwithstanding any other provision of this section, a
district participating in the uniform group coverage program
established under Chapter 1579, Insurance Code, may not make group
health coverage available to its employees under this section after
the date on which the program of coverages provided under Chapter
1579, Insurance Code, is implemented.
(j) This section does not preclude a district that is
participating in the uniform group coverage program established
under Chapter 1579, Insurance Code, from entering into contracts to
provide optional insurance coverages for the employees of the
district.
(k), (l) [Blank].
(m) Notwithstanding any other law, group health benefit
coverage provided by or offered through a district to district
employees under any law other than Subsection (a) is subject to the
requirements of Sections 1501.102-1501.105, Insurance Code. This
section applies to all group health benefit coverage provided by or
offered through a district to district employees, including:
(1) a standard health benefit plan issued under
Article 3.80 or 20A.09N or Chapter 1507, Insurance Code; and
(2) health and accident coverage provided through a
risk pool established under Chapter 172, Local Government Code.
Added by Acts 1995, 74th Leg., ch. 260, § 1, eff. May 30, 1995.
Amended by Acts 1997, 75th Leg., ch. 1416, § 37, eff. Sept. 1,
1997; Acts 1999, 76th Leg., ch. 1540, § 28, eff. Sept. 1, 1999;
Acts 2001, 77th Leg., ch. 1187, § 3.18, eff. Sept. 1, 2001; Acts
2003, 78th Leg., ch. 785, § 56, eff. Sept. 1, 2003; Acts 2003,
78th Leg., ch. 1276, § 10A.511, eff. Sept. 1, 2003; Acts 2005,
79th Leg., ch. 386, § 1, eff. Sept. 1, 2005; Acts 2005, 79th
Leg., ch. 728, § 11.108, eff. Sept. 1, 2005; Acts 2005, 79th
Leg., ch. 899, § 18.01, eff. Sept. 1, 2005; Acts 2005, 79th
Leg., ch. 1359, § 4, eff. Sept. 1, 2005.
Section: 21.704 21.705 21.706 21.707 22.001 22.002 22.003 22.004 22.005 22.006 22.007 22.051 22.0511 22.0512 22.0513
Last modified: August 10, 2007
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