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. AD&D coverage is in addition member life insurance or dependent term life insurance. Evidence of Insurability (EOI) is never required.
Note: AD&D is not available to former employees or retirees.
The Texas Employees Group Benefits Act, Insurance Code, Chapter 1551, as amended.
Benefits offered to an active employee. When a retiree goes back to work, return-to-work (RTW) retiree can choose active employee benefits or continue with retiree benefits if eligible.
A type of retirement service credit available for purchase by an ERS member with 10 years of service, not including military and unused sick/annual leave, and the member has purchased all other service credit available. Purchasing ASC gives the member retirement service credit for time not actually worked.
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.
The allowable amount is the most a GBP health plan will pay for a service. Doctors and hospitals that contract with the health plan agree to accept these allowable amounts and your coinsurance as payment in full. If you use a non-network or non-contracted provider provider, you are responsible for coinsurance plus any charges over the allowable amount.
A facility that provides 24-hour Custodial Care.
Retirement account set up to pay a monthly amount to a retiree. Sometimes referred to as a pension.
Active employees get $5,000 of Basic Term Life when they enroll in a health plan. The plan has an 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.
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 and a witness must sign and then return the designation form to ERS. For your protection, the beneficiary change will not be valid until the signed, witnessed form is received and approved by 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. For some options, it can only be changed in a few situations that may require additional documentation.
Contact ERS for more information if you would like to change your beneficiary for retirement.
A person employed by an Employer to provide assistance for Participants with various benefits programs. ERS is the Benefits Coordinator for Retirees.
Health and Human Services Commission (HHSC) agencies do not have benefits coordinators and instead go through the HHS Employee Service Center for benefits assistance.
January 1 to December 31 of the same year.
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.
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.
The Consolidated Omnibus Budget Reconciliation Act of 1985 is a 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.
The percentage of the Allowable Amount that you are required to pay for certain medical services, such as lab tests, x-rays and physical therapy. It is not the same thing as a copay or deductible.
An "officer” that contributes to the Law Enforcement and Custodial Officer Supplemental retirement fund.
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.
To enroll a common-law spouse or a spouse of an informal marriage in the Texas Employees Group Benefits Program (GBP) coverage, couples must:
- file a Common Law Marriage & Declaration of Informal Marriage with the county courthouse
- submit the Declaration of Informal Marriage Certificate to ERS for approval.
A high deductible health plan for active employees not enrolled in Medicare. Participants do not have to choose a PCP nor are required to have a referral to see a specialist. Participants may also open a Health Savings Account to pay for qualified medical expenses.
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.
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,
- Consumer Directed HealthSelect as required by law
- Prescription Drug Program and
- State of Texas Dental Choice PlanSM
Deductibles do not include:
- health care copays or
- coinsurance.
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).
Your county of residence, for insurance eligibility purposes. An employee of a state agency or higher education institution can use the county they work in for their eligibility basis.
Number assigned to you by ERS as a unique identifier.
The state of Texas and all its agencies, certain political subdivisions or Institutions of Higher Education that employ or employed a member.
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.
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.
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.
A 12-month period which defines the accounting year of the company. The fiscal year for ERS is September 1st through August 31st.
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.
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), and 50% of your eligible dependent health insurance premium. If you work fewer than 30 hours a week, you are considered part-time, and the state pays only 50% of your health insurance premium, and 25% of your eligible dependent health insurance premium.
This does not include time off for:
- vacation,
- sick time,
- holidays,
- leave without pay or
- other leave.
A chemically equivalent copy of a brand-name drug, or a drug identified by the TPA as a generic 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 have less out-of-pocket cost than brand-name drugs. You may 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.
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.
The time between the hire date and the health coverage begin date. For many new employees, health coverage starts on the first of the month after their 60th day on the job. If the 60th day of employment falls on the first of the month, then health coverage will begin that day.
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.
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. Only Consumer Directed HealthSelect Participants may open a HSA account.
Benefit level in HealthSelect 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 coverage.
A non-Medicare advantage health plan for GBP Participants who are eligible for Medicare that have chosen not to enroll in the HealthSelect Medicare Advantage Plan. The HealthSelect Secondary plan pays secondary to original Medicare.
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.
A public junior college, senior college or university, or any other agency of higher education within the meaning and jurisdiction of Chapter 61, Texas Education Code. It does not include an entity in The University of Texas System, as described in Section 65.02, Texas Education Code and an entity in The Texas A&M University System, as described in Subtitle D, Title 3, Texas Education Code, including the Texas Veterinary Medical Diagnostic Laboratory.
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.
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 been terminated of employment.
Such leave is limited to a maximum period of duration in the current Appropriations Act.
Note: An employee whose leave without pay (LWOP) is a result of the Family and Medical Leave Act of 1993 will continue to receive the state contribution during such period of LWOP.
The total pool of money payable for certain GBP coverages while you are insured.
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 maintenance fee, 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).
A federal government health insurance plan that helps Medicare-eligible persons pay for health care costs.
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.
An individual that has funds in one of the following retirement system accounts:
- ERS Retirement Program
- CPO/CO Supplemental Retirement Program
- Elected Class Retirement program
- Judicial Retirement System I
- Judicial Retirement System II
A drug manufactured and marketed under a trademark or name by a specific drug manufacturer; or a drug identified by the TPA as a brand-name drug.
Benefits that a GBP health plan pays for certain medical services provided by a Network Provider. Network benefits usually have lower out-of-pocket costs than non-network benefits.
Provider of medical, dental or vision services that is in a plan's network of providers. Usually, a Participant will pay less out of pocket if they use a Network Provider.
Network providers apply to:
- HealthSelect of Texas® (in-area)network,
- HealthSelect of Texas (Out-of-State) network
- HealthSelect Secondary network
- Consumer Directed HealthSelect network
- State of Texas Dental Choice PlanSM
- DeltaCare® USA Dental Health Maintenance Organization (DHMO) and
- State of Texas VisionSM benefits.
A pharmacy that participates in the HealthSelectSM Prescription Drug Program or HealthSelect Medicare Rx network. Usually, a Participant will pay less out of pocket if they use a Network Retail Pharmacy.
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.
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-network retail pharmacy, but it may cost you more than it would at a network retail pharmacy.
If you use a non-network 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.
Brand-name drug designated as non-preferred in the health plan's drug list. These drugs usually have a higher out-of-pocket cost than a Preferred Brand-name Drug or generic drug.
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 premiums for the following insurance plans:
- Dental
- Vision
- Voluntary Accidental Death and Dismemberment (AD&D)
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.
Health, dental or vision service costs that you pay rather than the health plan.
The highest amount a health plan Participant will pay out of pocket during the calendar year; includes copays, coinsurance and deductibles paid for eligible services, but does not include premium payments. When a health plan Participant reaches the Out-of-Pocket Maximum, the plan pays 100% of eligible expenses until the end of the calendar year.
Benefit level of HealthSelect of Texas® that does not require you to use a primary care provider or get referrals to see a specialist. Applies to participants living or working outside of Texas.
Note: Once you turn age 65 and are Medicare-eligible your coverage changes to HealthSelectSM Secondary coverage, regardless of where you live.
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.
For Participants enrolled in HealthSelect of Texas (in-area), HealthSelect of Texas (Out-of-State), HealthSelect Secondary and Consumer Directed HealthSelect, the plan year is a 12-month period beginning from September 1 through August 31.
For Participants enrolled in HealthSelect Medicare Advantage, the plan year is a 12-month period beginning January 1 through December 31.
Brand-name drug designated as preferred in the health plan's drug list. These drugs usually have a lower out-of-pocket cost than a Non-Preferred Brand-name Drug, but a higher out-of-pocket cost than a Generic Drug.
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.
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.
- HealthSelect of Texas® (in-area) participants must designate a PCP to receive network benefits.
- HealthSelect of Texas (Out-of-State), Consumer Directed Health Select, and HealthSelect Secondary do not require a PCP.
A QDRO is a legal order typically following a divorce or legal separation that awards a portion of a retirement account to an alternate payee . ERS must receive a copy of the divorce decree and a certified copy of the QDRO for review and approval. Benefits are payable to an alternate payee only if the order is approved by ERS.
A life-changing event experienced by you or your eligible dependent that allows enrollment in benefits or changes to benefits. 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:
- visit the ERS website,
- contact your benefits coordinator or
- Contact ERS.
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 Texas® (in-area) participant accessing network benefits.
Pharmacy located in a retail location such as a drug or grocery store.
Option available to members of the ERS Retirement Trust Fund that allows you to retire when your age and service credit equal 80.
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:
- HealthSelect of Texas®,
- Consumer Directed HealthSelect
- HealthSelect Secondary
- State of Texas Dental Choice PlanSM
- State of Texas Vision
- Short-term Disability Insurance and
- Long-term Disability Insurance.
A Physician who has a majority of his or her practice in areas other than general pediatrics, internal medicine, family practice or general medicine.
Spouse as recognized by law.
Acceptable supporting documentation includes a:
- Government issued marriage certificate or
- Declaration of marriage.
The maximum monthly amount of the lifetime monthly 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 highest average salary, amount of service credit and an age reduction, if applicable
Also known as an employer contribution. State contribution can also be the portion the state contributes to the trust on behalf of a member.
Funds provided by the state of Texas and applied to the health coverage premium of eligible employees and dependents.
Also referred to as a surviving dependent.
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. A beneficiary may also receive your retirement account and life insurance benefits in the event of your death.
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.
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.
A program that provides insurance and other benefits administered by ERS.
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,
- Long-term Disability insurance.
An account you can set aside pre-tax money from your paycheck to pay for eligible out-of-pocket health care, dental, vision or dependent care expenses. FSAs are tax-savings plans that are regulated by the IRS. Your contribution is deducted from your paycheck pre-tax and deposited into your account.
The TexFlexSM FSAs are:
- dependent care,
- health care and
- limited purpose FSA.
HealthSelect of Texas Participants may not participate in the limited purpose FSA. Consumer Directed HealthSelect Participants may not participate in the health care FSA. You may participate in the dependent care FSA at the same time as either the health care or limited purpose FSA.
Prescription Drug Program classifies prescription drugs into one of three tiers, which determines a drug's out-of-pocket cost. A health plan's drug list displays drugs with their corresponding tier.
A Tobacco User is a person who has used any tobacco products five or more times within the past three consecutive months.
Tobacco products are all types of tobacco, including but not limited to cigarettes, cigars, pipe tobacco, chewing tobacco, snuff, dip and all e-cigarettes and vaping products.
Nicotine replacement products, such as gum and patches, are not considered tobacco products.
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.
Provides goods and services to ERS through a service contract.
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.