Tex.
Educ. Code Section 22.004
Group Health Benefits for School Employees
(a)
A district shall participate in the uniform group coverage program established under Chapter 1579 (Texas School Employees Uniform Group Health Coverage), 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 (Texas Political Subdivisions Uniform Group Benefits Program), Local Government Code, or under a policy of insurance or group contract issued by an insurer, a company subject to Chapter 842 (Group Hospital Service Corporations), Insurance Code, or a health maintenance organization under Chapter 843 (Health Maintenance Organizations), Insurance Code. The coverage must meet the substantive coverage requirements of Chapter 1251 (Group and Blanket Health Insurance), Subchapter A (Definitions), Chapter 1364 (Coverage Provisions Relating to Hiv, Aids, or Hiv-related Illnesses), and Subchapter A (Definitions), Chapter 1366 (Benefits Related to Fertility and Childbirth), 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 (Texas Employees Group Benefits Act), Insurance Code. The following factors shall be considered 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 (Texas Political Subdivisions Uniform Group Benefits Program), Local Government Code, or that a district is capable of covering the assumed liabilities in the case of coverage provided through district self-insurance.(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 (State Assistance), Chapter 1579 (Texas School Employees Uniform Group Health Coverage), 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 (State Assistance), Chapter 1579 (Texas School Employees Uniform Group Health Coverage), Insurance Code, or Subchapter D.(d)
Each district that does not participate in the program described by Subsection (a) shall prepare a report addressing the district’s compliance with this section. The report must be available for review, together with the policy or contract for the group health coverage plan, at the central administrative office of each campus in the district and be posted on the district’s Internet website if the district maintains a website, 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 (Texas Political Subdivisions Uniform Group Benefits Program), 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)
information concerning the ease of completing the report.(e)
Repealed by Acts 2013, 83rd Leg., R.S., Ch. 1312, Sec. 99(1), eff. September 1, 2013.(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 (Group Hospital Service Corporations), 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 (Group Hospital Service Corporations), 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 (Texas School Employees Uniform Group Health Coverage), 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 (Texas School Employees Uniform Group Health Coverage), 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 (Texas School Employees Uniform Group Health Coverage), Insurance Code, from entering into contracts to provide optional insurance coverages for the employees of the district.(k)
Notwithstanding any other law, an employee of a district participating in the uniform group coverage program under Subsection (a) or providing group health coverage under Subsection (b) whose resignation is effective after the last day of an instructional year is entitled to participate or be enrolled in the uniform group coverage plan or the group health coverage through the earlier of:(1)
the first anniversary of the date participation in or coverage under the uniform group coverage plan or the group health coverage was first made available to district employees for the last instructional year in which the employee was employed by the district; or(2)
the last calendar day before the first day of the instructional year immediately following the last instructional year in which the employee was employed by the district.(l)
If an employee’s resignation is effective after the last day of an instructional year, the district may not diminish or eliminate the amount of a contribution available to the employee under Chapter 1581 (Employer Expenditures for School Employee Health Coverage Plans), Insurance Code, before the last date on which the employee is entitled to participation or enrollment under Subsection (k).(m)
Notwithstanding any other law, group health benefit coverage provided by or offered through a district to district employees under any law 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 Chapter 1507 (Consumer Choice of Benefits Plans), Insurance Code; and(2)
health and accident coverage provided through a risk pool established under Chapter 172 (Texas Political Subdivisions Uniform Group Benefits Program), Local Government Code.
Source:
Section 22.004 — Group Health Benefits for School Employees, https://statutes.capitol.texas.gov/Docs/ED/htm/ED.22.htm#22.004 (accessed May 18, 2024).
