Section 2170.110  Name of Program

 

The name of this Program is the Teachers' Retirement Insurance Program.

 

Section 2170.120  Purpose

 

The purpose of the Program is to provide health benefits to TRS Benefit Recipients and TRS Dependent Beneficiaries.

 

Section 2170.130  Definitions

 

Whenever used in this Part, the following terms shall have the meanings set forth in this Section unless otherwise expressly provided, and when the defined meaning is intended, the term is capitalized.

 

"Act" means the State Employees Group Insurance Act of 1971 [5 ILCS  375].

 

"Benefit Choice Period" means the annual benefit election period (usually May 1 through May 31 each year).

 

"Certificate of Creditable Coverage" means a document that indicates the length of time a person has been continuously covered under a qualifying previous healthcare plan.

 

"COBRA" means the federal Consolidated Omnibus Budget Reconciliation Act of 1985.

 

"Department" means any department, institution, board, commission, officer, court or any agency of the State government receiving appropriations and having power to certify payrolls to the Comptroller authorizing payments of salary and wages against such appropriations as are made by the General Assembly from any State fund, or against trust funds held by the State Treasurer and includes boards of trustees of the retirement systems created by Articles 2, 14, 15, 16 and 18 of the Illinois Pension Code.  "Department" also includes the Illinois Comprehensive Health Insurance Board, the Board of Examiners established under the Illinois Public Accounting Act, and the Illinois Finance Authority.

 

"CMS" means the Illinois Department of Central Management Services.

 

"Director" means the Director of the Illinois Department of Central Management Services or of any successor agency designated to administer the Act.

 

"Fiscal Year" means the State's fiscal year from July 1 through June 30.

 

"Fund" means the Teacher Health Insurance Security Fund.

 

"HFS" means the Illinois Department of Healthcare and Family Services.

 

"Participant" means a TRS Benefit Recipient and/or TRS Dependent Beneficiary enrolled in the Teachers' Retirement Insurance Program.

 

"Protected Health Information" or "PHI" means individually indentifiable health information as defined in 45 CFR 160.103 (2003) that is subject to the protections of the Health Insurance Portability and Accountability Act of 1996 (HIPAA) (P.L. 104-191).

 

"Plan Administrator" means an organization, company or other entity contracted by the Department to review and approve benefit payments, pay claims and perform other duties related to the administration of a specific plan.

 

"Program" means the Teachers' Retirement Insurance Program, as authorized by the State Employees Group Insurance Act of 1971.

 

"TCHP" means the Teachers' Choice Health Plan, the major medical coverage program offered under the Teachers' Retirement Insurance Program.

 

"TRIP" means the Teachers' Retirement Insurance Program, as authorized by the Act.

 

"TRS" means the Teachers' Retirement System.

 

"TRS Benefit Recipient" means a person who is not a "member", as defined in the Act and is receiving a monthly benefit or retirement annuity under Article 16 of the Illinois Pension Code [40 ILCS 5/Art. 16]; and:

 

has at least 8 years of creditable service under Article 16 of the Illinois Pension Code or was enrolled in the health insurance Program offered under that Article on January 1, 1996; or

 

is the survivor of a Benefit Recipient who had at least 8 years of creditable service under Article 16 of the Illinois Pension Code or was enrolled in the health insurance Program offered under that Article on June 21, 1995; or

 

is a recipient or survivor of a recipient of a disability benefit under Article 16 of the Illinois Pension Code.

 

"TRS Dependent Beneficiary" means a person who is not a "member" or "dependent" as defined in the Act, and is a:

 

TRS Benefit Recipient's spouse; or

 

dependent parent who is receiving at least half of his or her support from the TRS Benefit Recipient; or

 

unmarried natural, step or adopted child who is under age 19; or

 

enrolled as a full-time student in an accredited school, financially dependent upon the TRS Benefit Recipient, eligible to be claimed as a dependent for income tax purposes, and either is under age 24 or was, on January 1, 1996, participating as a Dependent Beneficiary in the health insurance Program offered under Article 16 of the Illinois Pension Code; or

 

age 19 or over who is mentally or physically handicapped; or

 

eligible for coverage pursuant to Section 356z.11 or 356z.12 of the Illinois Insurance Code [215 ILCS 5].

 

(Source:  Amended at 34 Ill. Reg. 838, effective December 31, 2009)

 

Section 2170.210  Determining Enrollment Policies

 

a)         Initial enrollment periods.  Initial enrollment in TRIP is limited to the following periods:

 

1)         When a TRS Benefit Recipient applies for annuity benefits;

 

2)         When a TRS Benefit Recipient or TRS Dependent Beneficiary turns age 65;

 

3)         When a TRS Benefit Recipient or TRS Dependent Beneficiary becomes eligible for Medicare;

 

4)         When coverage of a TRS Benefit Recipient or TRS Dependent Beneficiary is involuntarily terminated by a former group plan;

 

5)         During the Benefit Choice Period, if never previously enrolled.

 

b)         Re-enrollment periods.  Re-enrollment into the Program is limited to the following periods:

 

1)         When a TRS Benefit Recipient or TRS Dependent Beneficiary turns age 65;

 

2)         When a TRS Benefit Recipient or TRS Dependent Beneficiary becomes eligible for Medicare; or

 

3)         When coverage of a TRS Benefit Recipient or TRS Dependent Beneficiary is involuntarily terminated by a former employer.

 

c)         A TRS Benefit Recipient may change health plans only:

 

1)         When the TRS Benefit Recipient has a permanent address change and the previously selected managed care plan is not available at the new address;

 

2)         When the TRS Benefit Recipient's primary care physician leaves the managed care plan selected by the TRS Benefit Recipient; or

 

3)         During the Benefit Choice Period.

 

(Source:  Amended at 34 Ill. Reg. 838, effective December 31, 2009)

 

Section 2170.220  Determining Insurance Rates and Premiums

 

The Director of HFS will determine the insurance rates and premiums for TRS Benefit Recipients and TRS Dependent Beneficiaries and present to TRS the rate-setting methodology used to determine the amount of the health care premiums by April 15 of each calendar year.  Rates and premiums may be based in part on age and eligibility for federal Medicare coverage.  Pursuant to the Act, premiums are based on the plan selected by the Benefit Recipient.  The TRS Benefit Recipient shall pay the entire premium for any coverage for a TRS Dependent Beneficiary.

 

(Source:  Amended at 34 Ill. Reg. 838, effective December 31, 2009)

 

Section 2170.230  Determining Benefits

 

The Director will determine the benefits available to TRS Benefit Recipients and TRS Dependent Beneficiaries.

 

(Source:  Amended at 34 Ill. Reg. 838, effective December 31, 2009)

 

Section 2170.240  Provision for Benefits

 

The Director shall by contract, self-insurance, or otherwise make available the Program of health benefits for TRS Benefit Recipients and their TRS Dependent Beneficiaries.

 

Section 2170.250  Other Responsibilities

 

a)         CMS will offer an annual Benefit Choice Period for TRS Benefit Recipients to:

 

1)         Initially enroll into the Program;

 

2)         Add a Dependent Beneficiary, pursuant to enrollment policies;

 

3)         Change health plans.

 

b)         CMS will provide information regarding benefits and requirements of the Program in a TRIP Benefits Handbook and an annual Benefit Choice Options booklet.

 

            1)         The TRIP Benefits Handbook shall embrace the following topics:

 

A)        Eligibility guidelines pursuant to the definitions of Benefit Recipient and Dependent Beneficiary in Section 2170.130.

 

B)        Enrollment opportunities pursuant to Section 2170.210.

 

C)        Termination guidelines.

 

i)          Coverage for a Benefit Recipient terminates on the last day of the month when:

 

•    eligibility requirements are no longer met;

 

•    the TRIP program is terminated;

 

•     a written request is received by TRS that coverage should be terminated; or

 

•     the Benefit Recipient becomes eligible for and enrolls in the State of Illinois Employees Group Insurance Program.

 

ii)         Coverage for a Benefit Recipient terminates on the date of death. 

 

iii)        Coverage for a Dependent Beneficiary terminates:

 

•     on the last day of the month simultaneously with termination of a Benefit Recipient's coverage;

 

•     at the end of the month in which the enrolled Dependent Beneficiary no longer meets eligibility requirements;

 

•     on the date of death; or

 

•     on the first day of the month following receipt of the written request to terminate Dependent Beneficiary coverage.

 

D)        Covered Benefits under TCHP.

 

E)        TCHP claims filing deadlines and procedures.

 

2)         The Benefit Choice Options booklet shall detail information not provided in the Benefits Handbook (e.g., premium amounts, coverage changes, managed care plan availability and preferred provider information).

 

c)                 CMS will provide training seminars for TRS regarding benefits under TRIP.

 

(Source:  Amended at 34 Ill. Reg. 838, effective December 31, 2009)

 

Section 2170.260  Appeals Process Responsibilities

 

a)         If a Participant believes that an error has been made in the benefit amount allowed or disallowed, the Participant should contact the claims processing office of the Plan Administrator, pursuant to the appeal process detailed in the Benefits Handbook.  The Participant must utilize the Plan Administrator's review process to the fullest extent prior to contacting CMS.  The Participant must contact the appropriate Plan Administrator within 180 days after the date of the initial claim determination.

 

b)         If the Participant is not satisfied with the results of the review by the Plan Administrator, the Participant may submit a written request for review to CMS, within 60 days after the date of the initial claim determination, for a final determination.

 

c)         If, after receiving the final determination, the Participant is still not satisfied, an appeal of the determination may be made to an appeal committee, created by the Director, within 60 days after the final determination by CMS.  The findings of the appeal committee shall be final and binding on all parties.

 

d)         The Participant will be notified in writing of every decision rendered during the appeal process.

 

e)         The Participant retains all rights under Section 15(h) of the Act.

 

f)         Appeal committee members are appointed by the Director of CMS.

 

(Source:  Amended at 34 Ill. Reg. 838, effective December 31, 2009)

 

Section 2170.270  Health Insurance Portability and Accountability Act (HIPAA)

 

CMS and HFS shall comply with the uses and disclosures of Protected Health Information (PHI), permitted by HIPAA, where applicable as referenced in the plan documents.

 

a)         An annual notice of privacy practices shall be provided that outlines the legal duties and privacy practices concerning the PHI of Participants.

 

b)         PHI may be disclosed:

 

1)         to healthcare providers who take care of Participants;

 

2)         to process claims and make payments for covered services;

 

3)         for healthcare operations;

 

4)         to remind Participants of an upcoming appointment; and

 

5)         as required or authorized by law.

 

c)         Participants have the right to:

 

1)         request restrictions on how their PHI is used for purposes of treatment, payment and healthcare operations;

 

2)         receive confidential communications about their PHI;

 

3)         request to inspect information used to make decisions about them;

 

4)         request an amendment to their PHI;

 

5)         receive an accounting of disclosures that have been made of their PHI;

 

6)         obtain a paper copy of the annual notice of privacy practices; and

 

7)         file a complaint if they believe that their privacy rights have been violated. 

 

d)         PHI may not be disclosed:

 

1)         for any purpose other than administration of the benefit plan;

 

2)         for any fundraising activity; or

 

3)         for the marketing of any products or services.

 

(Source:  Amended at 34 Ill. Reg. 838, effective December 31, 2009)

 

Section 2170.310  Eligibility

 

TRS shall determine eligibility of TRS Benefit Recipients and TRS Dependent Beneficiaries pursuant to Section 2170.250(b)(1)(A).

 

Section 2170.320  Enrollments and Terminations

 

TRS shall enroll and terminate TRS Benefit Recipients and TRS Dependent Beneficiaries pursuant to Section 2170.210 and Section 2170.250(b)(1)(C).

 

Section 2170.330  Premium Collection and Payment

 

TRS shall be responsible for the collection and transmission of Participant premiums into the Teacher Health Insurance Security Fund.

 

(Source:  Amended at 34 Ill. Reg. 838, effective December 31, 2009)

 

Section 2170.340  Administering Consolidated Omnibus Budget Reconciliation Act of 1985 (COBRA)

 

TRS shall be responsible for compliance with the continuation of benefits requirements of COBRA.  All premiums must be collected and transmitted by TRS.

 

Section 2170.350  Other Responsibilities

 

a)         TRS shall provide enrollment, termination and change in status and/or address information to CMS.

 

b)         TRS shall inform TRS Benefit Recipients that they must:

 

1)         Notify TRS of coverage options chosen, and any changes that may affect eligibility or enrollment, including address changes;

 

2)         Notify TRS of the existence of, or change to, other group insurance coverage to ensure appropriate coordination of benefits; and 

 

3)         Review the TRIP Benefits Handbook, annual Benefit Choice Options booklet and any other materials provided by TRS or CMS and abide by all policies outlined in those publications.

 

(Source:  Amended at 34 Ill. Reg. 838, effective December 31, 2009)

 

Section 2170.360  Health Insurance Portability and Accountability Act (HIPAA)

 

TRS shall comply with the uses and disclosures of Protected Health Information, permitted by the Health Insurance Portability and Accountability Act (HIPAA), where applicable as outlined in the Program documents.

 

Section 2170.410  Teacher Health Insurance Security Fund

 

a)         The Director shall establish the Teacher Health Insurance Security Fund (Fund) (see 5 ILCS 375/6.6).  This Fund shall be a continuing fund not subject to Fiscal Year limitations.

 

b)         All active contributors to the Teachers' Retirement System who are not employees of a Department shall make contributions toward the cost of annuitant and survivor health benefits.  These contributions shall be at the following rates:  until January 1, 2002, 0.5% of salary; beginning January 1, 2002, 0.65% of salary; beginning July 1, 2003, 0.75% of salary; beginning July 1, 2005, 0.80% of salary; and, beginning July 1, 2007 through June 30, 2010, 0.84% of salary.  Future contributions shall be at a percentage of salary to be determined by the Director based on actual costs of the program, but in no Fiscal Year shall the salary required to be paid exceed 105% of the percentage of salary actually paid in the previous Fiscal Year.  These contributions shall be paid to TRS as service agent for CMS.

 

c)         Every employer of a teacher, other than an employer that is a Department, shall pay an employer contribution toward the cost of annuitant and survivor health benefits.  The contributions are computed as follows: January 1, 2002 through June 30, 2003, 0.4% of each teacher's salary; July 1, 2003, 0.5%; beginning July 1, 2005, 0.6% of each teacher's salary; and, beginning July 1, 2007 through June 30, 2010, 0.63% of each teacher's salary.  Future contributions shall be at a percentage of salary to be determined by the Director based on actual costs of the program, but in no Fiscal Year shall the salary required to be paid exceed 105% of the percentage of salary actually paid in the previous Fiscal Year.  These contributions shall be paid to TRS as service agent for CMS.

 

d)         TRS shall deposit all moneys collected pursuant to the terms of the Act and this Section into the Fund.

 

e)         On or before November 15 of each year, the Board of Trustees of TRS shall certify to the Governor, the Directors of CMS and HFS and the State Comptroller its estimate of the total amount of contributions to be paid for the next Fiscal Year.  The amount certified shall be increased or decreased each year by the amount that the actual active teacher contributions either fell short of or exceeded the estimate used by the Board in making the certification for the previous Fiscal Year.

 

f)         On the first day of each month, the State Treasurer and the State Comptroller shall transfer from the General Revenue Fund to the Fund 1/12 of the annual amount appropriated for that Fiscal Year to the State Comptroller for deposit into the Fund pursuant to 5 ILCS 375/6.6(c) and (d).

 

(Source:  Amended at 34 Ill. Reg. 838, effective December 31, 2009)