Medical- Scott & White Health Plan

How to Determine Which Plan is Primary

These rules are applied in the order in which they appear until one resolves the issue.

• If a person is covered as an employee under one plan and as a dependent under another plan, the plan that covers the person as an employee is primary over the plan that covers the person as a dependent.
• If a child is covered under both parents’ plans, the plan of the parent whose birth date is earlier in the calendar year is primary. If both parents have the same birthday, the plan which has covered one parent longer is primary. If the other plan does not have this provision regarding birthdays, then the rules in that plan determine the order of benefits.
• The parent with financial responsibility for the child’s health care expenses under a court decree is primary. The other parent’s plan would be secondary.  In the case of joint custody with no specific requirements to provide health care expenses, the birthday rule as described above would apply. Dependent children of divorced or separated parents receive benefits payments in this order from the plan of the: (1) Parent with custody; (2) Stepparent with custody; (3) Parent without custody.
• The plan that covers a person as an active employee is primary over the plan that covers that person as a laid-off or retired employee.
• The plan covering the patient as an employee rather than a dependent is primary.

Eligibility:

All active Substitute and Non-Standard Hourly (NSHE) employees who work at least a minimum of 4 days per month are eligible for medical coverage.  The employee has the choice of:

(1) his or her actively-at-work date, or

(2) the first of the month following the employee’s actively-at-work date Premium is billed for the full month in which coverage begins.

New hires must choose the effective date of coverage within 31 days after the actively-at work date.  The online enrollment system will enroll you in Option #2.  If you are interested in coverage effective your actively-at-work date, you must email InsuranceBenefits@hayscisd.net within 31 days from your date of hire.

Dependent Eligibility

Your eligible dependents include : • Your spouse; • A child under the age of 26 who is: a natural child; an adopted child or child lawfully placed for adoption; a stepchild; a foster child; a child under your legal guardianship.

Common Law Spouse is not considered eligible for coverage unless there is a Declaration of Informal Marriage field with an authorized government agency. To add a Common Law Spouse, please have proof of Declaration of Informal Marriage from the government agency that it was filed with and contact HR Benefits at InsuranceBenefits@hayscisd.net.

Grandchild under age 26 whose primary residence is the household of the employee and who is a dependent of the employee for federal income tax purposes for the reporting year in which coverage of the grandchild is in effect. To add a Grandchild, please have proof of your current Income Tax return that was filed with the IRS and contact HR Benefits at InsuranceBenefits@hayscisd.net .

Any Other Dependent under the age of 26 in a regular parent-child relationship with the employee, MUST MEET ALL (4) four of the following requirements:

  1. The child’s primary residence is the household of the employee;
  2. The employee provides at least 50% of the child’s support;
  3. Neither of the child’s natural parents resides in that household; and
  4. The employee has the legal right to make decisions regarding the child’s medical care.*

*This requirement only applies to children under the age of 18.

A dependent does not include a brother or a sister of an employee, unless the brother or sister is an individual under age 26 who is either: (1) under the legal guardianship of an employee, or (2) in a regular parent-child relationship with an employee, as defined in the “any other dependent” category above. Parents and grandparents of the covered employee do not meet the definition of an eligible dependent.

Note: It is against the law to elect coverage for an ineligible person. Violations may result in prosecution and/or expulsion from the TRS Scott & White HMO program for up to five years.

Forms:

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