Glossary

accidental death & dismemberment (AD&D)
Also referred to as double-indemnity.
 
Accommpanies Group Term Life and Dependent Term Life and offers an additional amount (double the face-value) paid to the participant or beneficiary upon accidential death.
Act
The Texas Employees Group Benefits Act, Insurance Code, Chapter 1551, as amended.
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
Adjunct faculty members must meet several criteria to be eligible for GBP benefits.
They must:
  • receive compensation for services rendered to the institution,
  • have taught at the same institution in the preceding academic year and
  • have taught at least one course in the regular fall and spring semesters during the preceding academic year.
Each institution determines guidelines on how to meet the eligibility criteria. The State of Texas does not contribute to the cost of health insurance for adjunct faculty. Higher education institutions determine whether to fund the health premium for adjunct faculty or not.
allowable amount
The allowable amount is the most HealthSelectSM of Texas will pay for a service. Doctors and hospitals that contract with HealthSelect of Texas agree to accept these allowable amounts and your coinsurance as payment in full. If you use an out-of-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 benefits in the event of your death. You may designate any family member, a friend, a charity, or an organization as your beneficiary.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.
 
Changes to your beneficiaries for your Life Insurance can be made at any time, regardless if you are actively employed or retired:
  • Active employees can change their retirement account beneficiaries at any time.
  • Retirees can change their beneficiary for their retirement option at any time. But additional documentation may be required depending on the annuity option elected at retirement.
Contact ERS for more information if you would like to change your beneficiary for retirement.
benefits coordinator
Employer representatives responsible for coordinating benefits at an agency or higher education institution. Generally, benefits coordinators are part of the human resources division. 

Health and Human Services Commission (HHSC) agencies do not have benefits coordinators and instead go through the HHS Employee Service Center for benefits assistance.
Basic Term Life Insurance
Active employees get $5,000 of Basic Term Life when they enroll in a health plan. The plan has and AD&D provision. 

Retirees get $2,500 of Basic Term Life when they enroll in a health plan. The plan does not have an AD&D provision.
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 Texas Employees Group Benefits program (GBP). Health and optional insurance (dental, vision, life, accidental death and dismemberment, dependent life, and disability) carriers are also called a benefits provider, third party administrators or vendors.
child (GBP eligible)
A GBP eligible child must be under age 26 for health insurance, and can be married or unmarried. The child may fall under one of the following categories:
  • biological child,
  • adopted child,
  • stepchild,
  • Child of Managing Conservator,
  • foster child,
  • Legal Ward Child or
  • other child.
Note: Disabled dependent children age 26 and over may be eligible for insurance. 
See the eligible child dependents chart 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, dental, and vision coverage continuation to employees and covered dependents who lose health, dental and/or vision coverage due to a COBRA qualifying event. View the Continuation Coverage Notification.
coinsurance
Coinsurance is the percentage of the bill that 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.” See allowable amount for more information.
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. 
Examples:
  • 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
To enroll a common-law spouse in the Texas Employees Group Benefits Program (GBP) coverage, couples must: 
  • agree to live together, 
  • represent themselves to others as married and 
  • file a Common Law Marriage & Declaration of Informal Marriage.
copay
A set dollar amount you pay out-of-pocket for medical services at the time services are provided. The copay amount can vary by type of service. Copay is not the same thing as coinsurance or deductible amounts. 
deductible

A deductible is a set amount you must pay out-of-pocket before the health, prescription or 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.
double-indemnity
A provision in a life insurance plan that offers double the face-value of the benefit to the beneficiary when accidental death occurs. The Basic Term Life, Group Term Life and Dependent Term Life offered through ERS for employees has a double indemnity clause.

Also referred to as accidental death and dismemberment (AD&D).
employee ID number
Number assigned to you by ERS as a unique identifier.
evidence of insurability (EOI)
Also known as proof of good health.

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. Approval is not guaranteed.

Depending on when you apply, EOI may be required for short-term and long-term disability coverage, optional term life insurance and/or dependent term life insurance.
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. 

Note: EDS does not apply to health maintenance organizations (HMOs).
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. See qualifying life event for more information.
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 from your paycheck into and that you use to pay for certain out-of-pocket health care and/or dependent care costs. FSAs are tax-savings plans that are regulated by the IRS. Because your payroll deduction happens before taxes, you don't have to pay taxes on this money.

See TexFlex flexible spending accounts (FSA) for more information.
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.

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). If you work fewer than 30 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
Also known as the Texas Employees Group Benefits Program.

A program that provides 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,
  • vision coverage,
  • Basic Term Life insurance,
  • Optional Term Life insurance,
  • Voluntary Accidental Death and Dismemberment (AD&D),
  • Dependent Term Life insurance,
  • Short-term Disability insurance and
  • Long-term Disability insurance.
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

In order to be GBP-eligible, graduate students of universities who are not eligible for participation in TRS, as a condition of employment must be: 

  • enrolled in graduate level courses at the university, 
  • employed by that university at least 50% of the time and 
  • employed for a definite period of 4 ½ months or 
  • a semester of more than four months. 


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 Texas Employees Group Benefits Program (GBP). 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.

 

health savings account (HSA)
A health savings account (HSA) is a tax-advantaged medical savings account you can contribute to and draw money from to pay for certain medical expenses tax-free. HSAs can be used for out-of-pocket medical, prescription drug, dental and vision expenses.

An HSA typically accompanies a high deductible health plan (HDHP).
in-area coverage
Benefit level in HealthSelectSM of Texas for a participant who lives or works in Texas and isn't enrolled in Medicare. In-area participants must choose and use a primary care physician (PCP) from the HealthSelect of Texas network of providers and get referrals for specialty care to get the highest level benefits.

Out-of-area coverage for participants not enrolled in Medicare is referred to as “HealthSelect of Texas Out-of-State.

See network benefits and non-network benefits for more information on in-area.
interim insurance

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

If you retire before age 65, you may be eligible for up to 18 months of COBRA coverage. Once COBRA ends, a retiree and his or her dependents are eligible for GBP Interim Insurance until age 65. Premiums for interim insurance are much higher than COBRA premiums.

Interim insurance is only available through HealthSelect of Texas.
 

leave of absence (LOA)/leave without pay (LWP)/Family and Medical Leave (FML)
Status of an employee who is certified monthly by an agency administrator to be absent from duty who does not receive any compensation for time absent from active 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.

Note: An employee whose leave without pay (LWP) is a result of the Family and Medical Leave Act of 1993 will continue to receive the state contribution during such period of LWP.
lifetime maximum benefit
The total pool of money payable for coverage while you are insured.
maintenance medication

Also known as maintenance drug.
 
Maintenance medications are generally long-term medications. You can purchase these drugs at retail or mail order pharmacies.
 
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.

Purchasing a maintenance medication at retail can cost more. But, HealthSelectSM 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.
Note: EDS does not apply to health maintenance organizations (HMOs).

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 helps Medicare-eligible persons pay for health care costs.
Medicare Advantage Plan

Also known as Medicare Part C

Medicare Advantage (MA) Plan is a plan offered by a private company that contracts with Medicare to provide participants with Medicare Part A (Hospital), Part B (Medical) benefits and may offer additional benefits, such as wellness programs.

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. 

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, 
  • Judicial Retirement System II or
  • 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 HealthSelectSM of Texas that requires a participant to choose and use a primary care physician (PCP) from the HealthSelect of Texas network of providers, and usually has lower out-of-pocket costs than out-of-network benefits.
network provider

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

  • HealthSelectSM of Texas network,
  • Health Maintenance Organizations (HMOs),
  • HumanaDental DHMO,
  • State of Texas Dental Choice PlanSM* and
  • State of Texas VisionSM benefits.

* Members enrolled in State of Texas Dental Choice Plan don’t have to use a network provider but you will pay less out of pocket if you do.
 

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 retail pharmacy

A pharmacy that does not participate in the network. If you are in the HealthSelectSM Prescription Drug Program or HealthSelect Medicare Rx, you can fill a prescription at a non-participating retail 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 brand-name drug or generic drug.
opt-out credit

Designed for employees and retirees who don't need the state's health insurance because they are enrolled in other health insurance that is as good as or better than what the state provides. The Opt-out Credit provides a credit to participants who waive their GBP health insurance to apply toward:

  • dental,
  • vision and/or
  • Voluntary Accidental Death and Dismemberment (AD&D) premiums. 

The  prescription drug program and Basic Term Life Insurance are part of your health benefit. If you opt-out of your health plan, you are also giving up these coverages.
 

out-of-pocket expense
Health, dental or vision service costs that you pay rather than the health plan.
out-of-state
Benefit level of HealthSelect of TexasSM that does not require you to use a primary care physician or get referrals to see a specialist. Applies to participants living outside of Texas.

Note: Once you turn age 65 and are Medicare-eligible your coverage changes to HealthSelect of Texas Secondary coverage, regardless of where you live.
 
out-of-pocket maximums
The highest amount that a participant will pay out of pocket during the plan year and includes coinsurance and deductibles paid for eligible services, but does not include copays. 
participant

An individual (employee, retiree and/or dependent) enrolled in an ERS plan or program, including the following:

  • health,
  • dental,
  • vision,
  • Health Savings Account
  • Optional Term Life Insurance,
  • Voluntary Accidental Death and Dismemberment (AD&D),
  • Dependent Term Life,
  • short-term disability insurance,
  • long-term disability insurance,
  • long-term care insurance (LTC)*,
  • Texa$averSM 401(K) / 457 program  and/or
  • TexFlex.

* Existing accounts only. ERS does not offer long-term care insurance at this time.
 

plan year

For participants not enrolled in Medicare, the plan year is a 12-month period beginning from September 1-August 31.

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

primary care dentist (PCD)
A dentist who contracts with the DeltaCare USA DHMO Plan and the participant has contacted Delta Dental to designate them as their primary care dentist. 
primary care provider (PCP)
A medical doctor, including a D.O., M.D and OB/GYN, who contracts with a participant's health plan, and is chosen by the participant to direct his or her health care. 
  • Community First Health Plans and HealthSelectSM of Texas (in-area) participants must designate use a PCP to receive network benefits.
  • HealthSelect Out-of-State and HealthSelect Secondary do not require a PCP.
qualified domestic relations order (QDRO)
A QDRO is a legal order following 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. ERS’ General Counsel must receive a certified copy of the divorce decree and QDRO for review and approval. 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: 

  • Marriage,
  • Children (birth, adoption, gaining custody of and age of child),
  • Employment changes,
  • Moving (out of service area),
  • Medicare,
  • Medicaid, HIPP and Chip,
  • Significant change in costs of health or day care ,
  • Divorce / Court orders for health coverage and /or
  • Death.

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 benefits changes, you should:

referral
Process by which a primary care provider (PCP) informs the insurance plan that you need care from a specialist. You are required to obtain a referral to see a specialist if you are a HealthSelect of TexasSM (in-area) 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 Trust Fund 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 Texas Employees Group Benefits Program (GBP) contains four self-funded benefit plans: 

  • HealthSelectSM of Texas, 
  • State of Texas Dental Choice PlanSM
  • Short-term Disability Insurance and 
  • Long-term Disability Insurance.
spouse
Spouse as recognized by law.

Acceptable supporting documentation includes a: 
  • Government issued marriage certificate or 
  • Declaration of marriage.
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
Also known as an employer contribution. 

Funds provided by the state and applied to the health coverage premium of eligible employees and dependents. 
survivor (beneficiary)
Also referred to as a surviving dependent or beneficiary.

A Texas Employees Group Benefits Program (GBP)-eligible dependent (spouse or child) who continues health, dental, and vision coverage after the death of a member. 
Teacher Retirement System of Texas (TRS)

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

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

Texa$aver 401(k)/457 Program (Texasaver)
A voluntary deferred compensation retirement savings program offered through ERS. Allows you to invest a portion of your income before taxes. Available plans include:
  • 401(k), 
  • 457 and
  • you have the option to contribute pre-tax or Roth after-tax in both the 401(k) and 457 plans
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

A tobacco user is a person who has used any Tobacco Products five (5) or more times within the pasts three (3) consecutive 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.

Nicotine replacement products, such as gum and patches, are not considered tobacco products.

trust agreement

ERS accepts as a beneficiary designation either a Living Trust or a Revocable Living Trust. Any beneficiary designation of a trust must be to a currently existing trust, not one contemplated to be created in the future or at the member’s death by their Last Will and Testament.

TexFlex flexible spending account (FSA) program
Federal program that allows participants to pay certain health care or dependent care costs with money deducted from their salary pre-tax. 

The TexFlexSM FSA’s are:
  • dependent care, 
  • health care and
  • limited FSA.
You may participate in one or more TexFlex accounts.
 
TexFlex commuter spending account (CSA) programs
Federal program that allows participants to pay for transit and parking expenses incurred while commuting to and from the workplace. 

The TexFlex CSA’s are:
  • parking account and
  • transit account.
You may participate in one or more TexFlex CSA accounts.
 
vendor
Provides good and services to a State agency through a service contract.
Voluntary Accidental Death & Dismemberment (AD&D)
Insurance coverage for active employees and their dependents that provides benefits to the employee or the beneficiary if the employee or dependent suffers certain accidental injuries or an accidental death. 

Evidence of Insurability (EOI) is never required. 

This is in addition to Group Term Life and Dependent Term Life Insurance. 
Note: Voluntary AD&D is not available to former employees or retirees.