Accidental Death & Dismemberment (AD&D)
Insurance coverage for active employees that provides benefits to beneficiaries if the employee suffers certain accidental injuries or an accidental death. Coverage of $5,000 of AD&D is included with health insurance.
Act
Act means the Texas Employees Group Benefits Act (Chapter 1551 of the Texas Insurance Code).
active-employee benefits
Benefits offered to an active employee. When a return-to-work (RTW) retiree comes back to work, he or she can choose active employee benefits or continue with retiree benefits.
additional service credit (ASC)
A type of service credit available for purchase by an ERS member with 10 years of service. Purchasing ASC gives the member service credit for time not actually worked.
adjunct faculty
Teachers on a contract basis at a higher education institution. To be eligible for GBP health coverage, you must: receive pay from a participating higher education institution, taught at the same institution for past three academic years, and taught at least one course in each fall and spring semester. Offering health coverage to adjunct faculty members is optional. Each institution determines guidelines on how to meet the eligibility criteria.
allowable amount
The allowable amount is the most HealthSelect will pay for a service. Doctors and hospitals that contract with HealthSelect agree to accept these allowable amounts and your coinsurance as payment in full. If you use a non-network or non-ParPlan provider, you are responsible for coinsurance plus any charges over the allowable amount.
alternative care facility
A facility that provides 24-hour Custodial Care.
annuity
Retirement account set up to pay a monthly amount to a retiree. Sometimes referred to as a pension.
beneficiary
Person or persons to receive your life insurance and other benefits in the event of your death. You may designate any family member, a friend, a charity or an organization as your beneficiary to receive your retirement benefits and/or life benefits. Changes to your beneficiaries can be made at any time. When you designate a beneficiary, you must sign and return the designation form to ERS. For your protection, the beneficiary change will not be valid until the form is signed by you, witnessed, and returned to ERS.
benefits coordinator
Employer representatives responsible for coordinating benefits at an agency or institution. Generally, benefits coordinators are part of the human resources division. HHSC agencies do not have benefits coordinators and instead go through the HHS Employee Service Center for benefits assistance.
calendar year
January 1 to December 31 of the same year.
carrier
A company or organization that insures or administers health or optional coverage or benefits available through the state insurance program. Health and optional insurance (life, disability, accidental death and dismemberment, and dental) vendors are also called a benefits provider.
child (GBP eligible)
Definition of eligible child dependents for Texas Employees Group Benefits Program (GBP). Members cannot cover ineligible dependents.
COBRA
The Consolidated Omnibus Budget Reconciliation Act of 1985) Federal law that requires employers to offer health and dental coverage continuation to employees and covered dependents who lose health and dental coverage due to a COBRA qualifying event. View the Continuation Coverage Notification.
coinsurance
Coinsurance is the amount you pay for certain medical services, such as lab tests, x-rays, mammograms, and physical therapy. It is not the same thing as a copay or deductible. The coinsurance you pay is a percentage of something called “allowable amount.”
Commissioned Peace Officer/Custodial Officer (CPO/CO)
A "law enforcement officer" whose commission is recognized by the Texas Commission on Law Enforcement Officers Standards and Education. A "custodial officer" for the Texas Department of Criminal Justice - Institutional Division (TDCJ), certified as having normal duties that require you to have direct contact with inmates. A "parole officer or caseworker" employed and certified by the Board of Pardons and Paroles or TDCJ.
common-law spouse
Couples who agree to live together and represent themselves to others as married.
copay
Set dollar amount you pay out-of-pocket for medical services at the time services are provided.
deductible

A deductible is a set amount you must pay out-of-pocket before the health/dental plan begins to pay their share of expenses. This applies to services under:

  • HealthSelect non-network benefits
  • HealthSelect out-of-area benefits,
  • Prescription Drug Program, and
  • State of Texas Dental Choice PlanSM

Deductibles do not include:

  • health care copays,
  • coinsurance, or
  • charges not covered by the carrier.
employee ID number
Number assigned to you be ERS as a unique identifier.
evidence of insurability (EOI)

An application process in which you provide information on the condition of your health or your dependent's health in order to be approved for certain coverage. Sign up when health coverage is first offered and you will not need to provide proof of good health.

During the plan year, EOI is not required to add health coverage for yourself or dependents during your 90-day waiting period for insurance (as a new hire or retiree), or to add the appropriate dependents within 31 days of a qualifying life event such as a marriage or a birth. Other types of events may require EOI.

Also known as proof of good health.

Extended Days Supply (EDS) Network
Both HealthSelect Prescription Drug Program and HealthSelect Medicare Rx have an Extended Days Supply (EDS) network. Pharmacies in the EDS network will fill a 31- to 90-day supply of maintenance medicines at the same price as a mail order pharmacy. Prices are based on the mail order prescription drug costs. 
family status change

A life-changing event that allows you to make changes to your insurance and TexFlex enrollments, such as marriage, birth of a child, or divorce. A family status change is a type of qualifying life event.

 

fiscal year
A 12-month period which defines the accounting year of the company. The fiscal year for ERS is September 1st through August 31st.
flexible spending account (FSA)
A special account you put money into that you use to pay for certain out-of-pocket health care or day care costs. You don't have to pay taxes on this money. The name of this benefit is TexFlex flexible spending account.
full-time employee

As required by the federal Affordable Care Act, effective September 1, 2013, all state and higher education employees working at least 30 hours a week are considered full-time employees for health insurance coverage.

Beginning September 1, if you work at least 30 hours a week, the State will pay 100% of your health insurance premium if you are eligible for the Texas Employees Group Benefits Program (GBP). Until September 1, if you work fewer than 40 hours a week, you are still considered part-time, and the State pays only 50% of your health insurance premiums.

This does not include time off for vacation, sick time, holidays, leave without pay, or other leave.

GBP

(Texas Employees Group Benefits Program)
Program of insurance and other benefits administered by ERS. This group of benefits is commonly referred to as "the GBP". The program consists of:

  • health coverage,
  • dental coverage,
  • Basic Term Life insurance,
  • Optional Term Life insurance,
  • Dependent Term Life insurance,
  • Short-term Disability insurance,
  • Long-term Disability insurance,
  • vision insurance, and
  • Voluntary Accidental Death and Dismemberment (AD&D). 
generic drug

A chemically equivalent copy of a brand-name drug, generic drugs are pharmaceutically and therapeutically the same as brand-name drugs. Not all brand-name drugs have a generic equivalent.

Generic drugs usually cost less than brand-name drugs. You can ask your doctor to prescribe a generic (if available) or prescribe the least expensive medication available.

If you purchase a brand-name drug when a generic alternative is available (regardless of the reason), you will pay your generic copay plus the cost difference between the brand-name and the generic drug.

 

graduate student

For GBP purposes, an individual who:

  • has completed a bachelor's degree and is studying for his or her masters or doctorate degree, and
  • is employed by the higher education institution at least 50% of the time.

A GBP-eligible graduate student is considered a part-time employee.

health coverage waiting period
For all employees hired on or after September 1, 2003, this is a period of time during which you do not have health coverage with the Group Benefits Program. For most state employees, health and prescription drug coverage starts on the first of the month following your 60th day of employment.
Health Insurance Premium Payment (HIPP) Reimbursement Program
Program that reimburses Medicaid-eligible employees health coverage premium payments when the Health and Human Service Commission (HHSC) determines reimbursement is more cost effective than the employee receiving Medicaid benefits.
HMO

A Health Maintenance Organization (HMO) is a managed health care plan that provides health coverage and prescription drug benefits to HMO participants and their eligible dependents. HMOs are not available in all areas.

Coverage is provided through a network of doctors and specialists in approved service areas. You must designate and use a primary care physician to direct your care for benefits to be paid.

A dental HMO is also available through HumanaDental DHMO.

 

in-area coverage

Benefit level in HealthSelect for a participant who lives or works in Texas and isn't eligible for Medicare. In-area participants are eligible for network or non-network benefits.

  • Network benefits have lower out-of-pocket cost, and you must select and use a primary care physician (PCP) from the HealthSelect network of providers.
  • Non-network benefits have higher out-of-pocket cost, and allow you to use any valid physician or provider you choose.
interim insurance

Health coverage option for retirees who meet service credit criteria for health coverage, but are currently ineligible for GBP health coverage because they are under 65 years of age, and did not retire under the Rule of 80.

Interim insurance is only available through HealthSelect and evidence of insurability (EOI) is not required.

leave of absence / leave without pay
Status of an employee who is certified monthly by an agency administrator to be absent from duty and who has not received a refund of retirement contributions based upon the most recent term of employment. Such leave is limited to a maximum period of duration in the current Appropriations Act.
lifetime maximum benefit
The total pool of money payable for covered while you are insured.
maintenance drug

Prescription drug listed in a health plan's drug list as a maintenance drug. These drugs are usually taken on a regular basis and carry a higher copay if purchased at a retail pharmacy, unless purchasing a 31-90 supply using a HealthSelect EDS pharmacy.

Only drugs designated as maintenance drugs in a health plan's drug list are subject to the additional cost, regardless of the how often a participant takes the drug.

maintenance medication

Maintenance medications are generally long-term medications. You can purchase these drugs at retail or mail order pharmacies.

Purchasing a maintenance medication at retail can cost more. However, HealthSelect Prescription Drug Program EDS network and the HealthSelect Medicare Rx EDS network pharmacies allow you to purchase a 31- to 90-day supply of maintenance medications at the mail service price without paying an additional maintenance fee.

Medicaid
A federal and state funded health coverage program that pays certain medical expenses for those who meet income and other eligibility requirements.
Medicare
A federal government health insurance plan that pays health care costs for retired persons age 65 and over.
Medicare Advantage Plan

Medicare Advantage (MA) Plan is a plan offered by a private company that contracts with Medicare to provide Participants with Medicare Part A (Hospital) and Part B (Medical) benefits.

A MA plan offers a specific set of health benefits at the same premium and level of cost-sharing to all people with Medicare who live in the service area covered by the Plan. MA Plans are sometimes referred to as Medicare Part C.

member (retirement)

An individual that contributes or contributed in the past to the:

  • ERS Retirement Program
  • CPO/CO Supplemental Retirement Program
  • Elected Class Retirement program
  • Judicial Retirement System I, or
  • Judicial Retirement System II,

and has not request a withdrawal of funds.

name-brand drug or brand-name drug
A drug protected by a patent issued to the original company that invented or marketed the drug.
network benefits (in-area)
Benefit level of HealthSelect that requires a participant to choose and use a primary care physician (PCP) from the HealthSelect network of providers, and usually has lower out-of-pocket costs than non-network benefits.
network provider

Provider of medical or dental services that is in a plan's network of providers. Network providers apply to:

  • HealthSelect network benefits
  • HMOs
  • HumanaDental DHMO
  • State of Texas Dental Choice Plan
non-maintenance medication
Non-maintenance medications are generally short-term medications. You can purchase non-maintenance medication at retail or mail order pharmacies without paying an additional maintenance fee.
non-participating pharmacy

A pharmacy that does not participate in the network. If you are in the HealthSelect Prescription Drug Program or HealthSelect Medicare Rx, you can fill a prescription at a non-participating pharmacy, but it may cost you more than it would at a participating retail pharmacy.

If you use a non-participating pharmacy, you will pay the full amount of the prescription. Then you can submit a claim form to be reimbursed 60% of the lesser of:

  • the amount you pay for the prescription, minus your copay, or
  • average wholesale price of the drug, plus a dispensing fee, minus your copay.

Your deductible will be subtracted if not met.

HMO participants do not receive any benefits at a non-participating retail pharmacy. 

non-preferred name brand drug
Brand-name drug designated as non-preferred in the health plan's drug list. These drugs have a higher copay than a preferred name brand drug or generic drug.
opt-out credit

Designed for employees and retirees who don't need the State's health insurance now or in the future because they are enrolled in other health insurance that is as good as or better than what the State provides. Provides a credit to participants who waive their GBP health insurance to apply toward dental and/or Voluntary Accidental Death and Dismemberment (AD&D) premiums. 

Your drug benefits and basic term life coverage are part of your health benefit. If you opt-out of your health plan, you are also giving up these coverages.

out-of-area coverage

Benefit level of HealthSelect that does not require you to use a primary care physician. Applies to participants living outside of Texas, and retirees age 65 and over who have not returned to state employment.

Note: Once you turn age 65 and are Medicare-eligible your coverage changes to HealthSelect out-of-area coverage, regardless of where you live.

out-of-pocket expense
Health or dental service costs that you pay rather than the health plan. Includes coinsurance and deductibles, but does not include copays.
participant

An individual participating in:

  • health coverage,
  • dental coverage,
  • optional coverage,
  • Long-term Care insurance
  • Texa$aver,
  • TexFlex, and/or
  • vision coverage. 
plan year

For non-Medicare participants, the plan year is a 12-month period beginning from September 1 -August 31.

For Medicare participants, the plan year is a 12-month period beginning January 1-December 31.

primary care dentist (PCD)
Dentist who contracts with the HumanaDental DHMO Plan.
primary care physician (PCP)
A medical doctor who contracts with a participant's health plan and is chosen by the participant to direct his or her health care. HMO participants must use a PCP for services to receive benefits. HealthSelect participants must use a PCP to access network benefits.
proof of other coverage

Allows you and your dependents to enroll in HealthSelectSM of Texas during the plan year without proof of good health, if you or your dependents:

  • experience a qualifying life event (QLE), and
  • had other health insurance when the event happened.

You are required to:

  • make the change within 31 days of the event,
  • certify that you or your dependents had other health insurance on the day of the event, and
  • provide proof of the other coverage upon request from ERS.
qualified domestic relations order (QDRO)
A QDRO is a legal order subsequent to a divorce or legal separation that splits and changes ownership of a retirement plan to give the divorced spouse his or her share of the asset. A certified copy of the divorce decree and QDRO must be received for review and approval by ERS' General Counsel. Benefits are payable to an alternate payee only if the order is determined to be a valid ERS QDRO.
qualifying life event (QLE)

A specific event or change that allows you to make changes to your benefit elections within 31 days. Events include

  • Marital Status Change
  • Dependent Status Change
  • Employment Status Change
  • Address Change that Changes Eligibility
  • Eligibility Change related to Medicare, Medicaid, or CHIP
  • Significant Cost Change for Coverage
  • Court Ordered Coverage Change

Benefit changes must be made within 31 days of the event, and evidence of insurability (EOI) may be required. You may be asked to show proof of the QLE or proof of dependent eligibility.

If you have questions about what benefits changes can be made, contact your benefits coordinator, sign in to your account, or contact ERS.

referral
Authorization to see a specialty doctor from your primary care physician (PCP). You are required to obtain a referral to see a specialist if you are an HMO participant or a HealthSelect participant accessing network benefits.
retail pharmacy
Pharmacy located in a retail location such as a drug or grocery store.
Rule of 80
Option available to members of the ERS Retirement Program that allows you to retire when your age and service credit equal 80.
self-funded

Benefit whose premiums directly pay claims and other costs associated with the plan. The self-funded plan assumes the risk and profits associated with the plan.

The GBP contains four self-funded benefit plans: HealthSelect, Long-term Disability insurance, Short-term Disability insurance, and State of Texas Dental Choice Plan.

spouse
Spouse as recognized by law. Government issued marriage certificate or declaration of marriage is accepted as supporting documentation.
standard annuity

The maximum monthly amount of the lifetime annuity payments a retiree is eligible to receive from his or her annuity. The amount of the standard annuity is determined using a formula that includes the member's final average salary and amount of service credit.

The amount of the annuity payment is reduced if the member selects the partial lump sum option or any of the survivor options.

state contribution
Funds provided by the state and applied to the health coverage premium of eligible employees and dependents. Also known as an employer contribution.
survivor (beneficiary)
A GBP-eligible dependent (spouse or child) who continues health and dental coverage after the death of an employee or retiree. Also referred to as a surviving dependent or beneficiary.
Teacher Retirement System of Texas (TRS)

Organization that administers a retirement program for eligible Texas public education employees, their dependents, and their beneficiaries. TRS is a member of the Proportionate Retirement Program (PRP).

ERS is the administrator of insurance benefits for members of this program.

Texa$aver (Texasaver)
A voluntary deferred compensation retirement savings program offered through ERS. Allows you to invest a portion of your income before taxes. 401(k), 457, and Roth Plans available.
TexFlex

Federal program that allows participants to pay certain health care or day care costs with money deducted from their salary pre-tax. The TexFlex flexible spending accounts are TexFlex dependent care and TexFlex health care.

You may participate in one or both TexFlex accounts.

tier (drug tier)
Prescription Drug Program classifies prescription drugs into one of three Tiers, which determines a drug's copay. A health plan's drug list displays drugs with their corresponding Tier.
tobacco user

To be considered a tobacco user, you must have used a tobacco product more than four times in the previous three months.

A tobacco product is defined as cigarettes, cigars, pipe tobacco, chewing tobacco, snuff, dip, or any other product that contains tobacco. It does not include an electronic cigarette or e-cigarette that does not contain tobacco and is designed expressly for smoking cessation. 

trust agreement

A trust is an agreement among three people.

  • The grantor contributes property to the trust.
  • The trustee owns the property and carries out the purposes of the trust.
  • The beneficiary receives the benefits of the trust in accordance with the trust agreement.

One person can often serve as two of the three people in a trust agreement. That is, the same person can be the grantor and trustee, trustee and beneficiary, or grantor and beneficiary. It is even possible for the same person to be all three. The "person" does not even have to be a natural person. For example, the trustee can be the trust department of a bank and the beneficiary can be a charity.

ERS accepts either a Living Trust or a Revocable Living Trust for the member. We are not able to set up a trust for a minor child.

vendor
Provides good and services to a State agency through a service contract.