Fillable Retiree/cobra Pre-Payment Option Form printable pdf download

Retiree/COBRA PRE-PAYMENT Option Form

Employee’s Name: __________________________ Employee ID#: _____________________

Termination Pay Period Ending: ________________

Last Day worked _______________

The Pre-Payment Option is for those terminating employees who participate in the Pre-tax Plan and wish to

pay future retiree or COBRA benefits payments from their final paycheck on a pre-tax basis. This benefit is

limited to benefits payments for the months remaining in the current plan year. No refund of pre-paid

payments is available. This means that you should not select this option if there will be any chance you, a

covered spouse, or all covered children will cease to need, or become ineligible for, State Employee benefits

any time during the pre-paid period or if you or your spouse will become Medicare* eligible before the end of

your pre-pay period. *Note – If you have not received your Medicare card but are eligible and in the application

process, you may receive the lower Medicare rate through pre-paying; indicate your Medicare status on the

Retiree Statement of Current Coverage form. Avoid pre-payment if, during the period for which you would pre-

pay, any of the following could occur:

1. Last dependent child could lose eligibility for coverage;

2. Spouse could lose eligibility;

3. For COBRA members, you or your spouse could gain other employment which offers health care

benefits and lose eligibility for State COBRA benefits as a result; or

4. For retired members, you or your spouse could obtain employment which offers health care

benefits, so you no longer need State retiree benefits – including the possibility of re-employment

with the State and regaining employee coverage.

NOTE: The elections made on the Retiree or COBRA Statement of Current Coverage form (including choice of

dental plans) cannot be changed until the next Annual Change, effective the first day of the next year.

INSTRUCTIONS: In order to elect this pre-payment option, you must:

✓Complete the Employee Section of this Pre-Payment Option Form and return it to your agency

✓Complete the Retiree Statement of Current Coverage Form or the COBRA Statement of Current

Coverage Form and, if eligible, the Life Enrollment/Change Form and Beneficiary/Designation

change form

This Pre-Payment Option Form must be submitted to your Agency Payroll Office prior to your

termination date in order to have these deductions taken from your final paycheck.

Employee Complete:

☐ I will elect continuation in the Employee Group Benefits Plan under the COBRA provision.

☐ I will elect continuation in the Employee Group Benefits Plan as a RETIREE.

I elect to have ______ months of my elected health care benefits payments withheld from my final paycheck

(limited to remainder of current plan year and availability of funds in final paycheck).

Signature: __________________________________________ Date: ___________________________

For Agency Personnel Use Only: Determine the total additional amount to be withheld from the final

paycheck. List the month/year of coverage, payment amount for each type of coverage, and total payment for

each month (do not list the grandfathered month). Use the Medicare Eligible Medical Rates for Retirees

when applicable. FSA contributions – the member decides through what date to flex funds; Health Care and

Benefits Division then deducts accordingly from the final paycheck.

Vision

Basic

Medical

Dependent

Admin

Debit

Month/Year

Medical

Dental

Total

Hardware

Life

FSA

Fee

Card Fee

TOTALS:

HEALTH CARE AND BENEFITS USE ONLY

Wellness Discount:

Grandfather Month:

Grandfather Month Out of Pocket:

Half Month Collection:

L:HCBDEmployee BenefitsFormsPrepayment Option Form

Revised 11/14

Retiree/cobra Pre-Payment Option Form

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