Page 74 - 2021 Medical Plan SPD

Texas Mutual Insurance Company Medical Plan

Your Benefits may also be reduced if you are enrolled in a Medicare Advantage (Medicare Part C) plan
but do not follow the rules of that plan. Please see Medicare Eligibility in Section 8: General Legal
Provisions for more information about how Medicare may affect your Benefits.

Who Is Eligible for Coverage?

The Plan Sponsor determines who is eligible to enroll and who qualifies as a Dependent.

Eligible Person
Eligible Person usually refers to an employee of the Plan Sponsor who (or other person whose
connection with the Plan Sponsor) meets the eligibility rules. When an Eligible Person enrolls, the Claims
Administrator refers to that person as a Participant.
You are eligible to enroll in the Plan if you are a regular full-time employee who is scheduled to work at
least 30 hours per week, or part-time employee who is scheduled to work at least 20 hours per week.
Eligible Persons must live within the United States.

If both spouses are Eligible Persons of the Plan Sponsor, each must enroll as a Participant

Dependent

Dependent generally refers to the Participant's spouse and children. When a Dependent enrolls, the
Claims Administrator refers to that person as an Enrolled Dependent.

Dependents of an Eligible Person may not enroll unless the Eligible Person is also covered under the
Plan.

Your eligible Dependents may also participate in the Plan. An eligible Dependent is considered to be:
• Your Spouse.

• Your or your Spouse's child who is under age 26, including a natural child, stepchild, a legally
adopted child, a child placed for adoption or a child for whom you or your Spouse are the legal
guardian.
• Your or your Spouse’s grandchild who is your dependent for federal income tax purposes at the
time enrollment is requested; however, coverage for the grandchild may not be terminated solely
because he is no longer your dependent for federal income tax purposes.
• An unmarried child age 26 or over who is or becomes disabled and dependent upon you.

A Dependent also includes a child for whom health care coverage is required through a Qualified Medical
Child Support Order or other court or administrative order.

To be eligible for coverage under the Plan, a Dependent must reside within the United States.
Note: Your Dependents may not enroll in the Plan unless you are also enrolled. If you and your Spouse
are both covered under the Plan, only one parent may enroll your child as a Dependent. A Dependent
does not include anyone who is also enrolled as a Participant.

When Do You Enroll and When Does Coverage Begin?
Except as described below, Eligible Persons may not enroll themselves or their Dependents.

71 Section 3: When Coverage Begins