Section 81.12 - HealthSelectShoppERS(a) Description. The HealthSelectShoppERS program is designed to provide an incentive for eligible health benefit plan participants to select certain network facilities for specified elective, non-emergency medical services and procedures. The incentive will be limited to an amount that is compliant with applicable federal laws and regulations and will be publicly posted by ERS. The incentive is an employer contribution by a GBP member's health benefit plan to the GBP member's TexFlex health care reimbursement account or limited purpose health care reimbursement account, as set forth in §85.8. (b) Administration. The HealthSelectShoppERS program is administered by the Board. The Board may designate and contract with a vendor, administrator or firm to perform the day-to-day administrative responsibilities of the HealthSelectShoppERS program. The designated vendor, administrator or firm shall perform its duties as assigned by the program administrator and in accordance with its contract with the program administrator, the Code, rules and all applicable state and federal laws and regulations. (c) Eligibility. A GBP member and the member's dependents are eligible for the HealthSelectShoppERS program if all of the conditions of this subsection are met: (1) the GBP member is an employee on active duty on the date of a search described in subsection (d)(1) of this section and on the date of payment of an employer contribution described in subsection (d)(3) of this section; (2) the GBP member and any dependents participating in the HealthSelectShoppERS program are enrolled in Consumer Directed HealthSelect or the HealthSelect of Texas In-Area Benefits Plan or Out-of-State Plan on the date of a search described in subsection (d)(1) of this section, on the date of receipt of a service described in subsection (d)(2) of this section, and on the date of payment of an employer contribution described in subsection (d)(3) of this section; (3) neither the GBP member nor any dependents participating in the HealthSelect Shopp ERS program is receiving Medicare benefits as his or her primary coverage on the date of a search described in subsection (d)(1) of this section, on the date of receipt of a service described in subsection (d)(2) of this section, and on the date of payment of an employer contribution described in subsection (d)(3) of this section; and (4) the GBP member is eligible to receive an employer contribution to a TexFlex health care reimbursement account or limited purpose health care reimbursement account on the date of payment of an employer contribution described in subsection (d)(3) of this section. A previously established health care reimbursement account or limited purpose health care reimbursement account is not required as a condition of eligibility. (d) Program Requirements. Participants must complete all of the following steps to receive a HealthSelectShoppERS program incentive. (1) Conduct a search in which the participant is presented with a selection of network facilities that provide the medical service or procedure: (A) the search must be conducted, facilitated and documented in accordance with requirements established by ERS and the vendor, administrator, or firm with administrative responsibilities designated by the Board; (B) the medical service or procedure must meet all health benefit plan requirements to be a covered service when performed, including, but not limited to, applicable requirements related to referrals, prior authorizations and medical necessity; (C) the search must identify the participant who will receive the medical service or procedure; (D) on the date of the search, the GBP member must meet all eligibility requirements set forth in subsection (c)(1) of this section; and (E) on the date of the search, the participant and the GBP member, if the participant is not the GBP member, must meet all eligibility requirements set forth in subsection (c)(2) and (3). (2) Receive the medical service or procedure for which the described search was conducted: (A) the participant must receive the medical service or procedure at a facility included in a search described in subsection (d) of this section; (B) the participant must receive the medical service or procedure for which the described search was conducted within applicable program deadlines; and (C) on the date of the participant's medical service or procedure, the participant and the GBP member, if the participant is not the GBP member, must meet all program eligibility requirements set forth in subsection (c)(2) and (3) of this section. (3) Meet all HealthSelectShoppERS program requirements on the date that the employer contribution to the GBP member's TexFlex account is made by the health benefit plan. Once processed by ERS, a contribution in the amount specified in the related search applicable to the facility providing the medical service or procedure shall be made by the health benefit plan to the GBP member's TexFlex health care reimbursement account or limited purpose health care reimbursement account as provided herein. The contribution will be an employer contribution to the applicable TexFlex account. The employer contribution will be made only if, on the date of the contribution and as determined in the sole discretion of ERS: (A) all program requirements have been met; and (B) all eligibility requirements set forth in subsection (c) of this section are met. (e) Funding. (1) Funding of the employer contributions by the health benefit plan shall originate from the Employees Life, Accident, and Health Insurance and Benefits Fund specified in §1551.401 of the Act. (2) No GBP member may receive more employer contributions per plan year related to program participation by the GBP member and all of the GBP member's dependents than the designated amount set by the Employees Retirement System of Texas and publicly posted. (3) All employer contributions will be made by the health benefit plan solely at the discretion of ERS. (f) Standing. A person has no standing to submit a grievance or appeal regarding HealthSelectShoppERS under §81.9(c) or any other rule or statutory provision that provides for the submission of a grievance or appeal to ERS. (g) Termination. The HealthSelectShoppERS program may be terminated by the Board if the Board determines that the plan is no longer advantageous to the GBP or its participants.34 Tex. Admin. Code § 81.12
Adopted by Texas Register, Volume 45, Number 36, September 4, 2020, TexReg 6239, eff. 9/8/2020