Retiree/Cobra Pre-payment Option Form

This "Retiree/Cobra Pre-payment Option Form" is a United States-specific form released by the U.S. Department of Health and Human Services on November 1, 2014.

Download the form by clicking the link below, fill it out by hand, and mail it as per the guidelines provided by the department or the applicable legal instructions.

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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
FSA
Fee
Card Fee
TOTALS:
HEALTH CARE AND BENEFITS USE ONLY
Wellness Discount:
Grandfather Month:
Grandfather Month Out of Pocket:
Half Month Collection:
L:\HCBD\Employee Benefits\Forms\Prepayment Option Form
Revised 11/14
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
FSA
Fee
Card Fee
TOTALS:
HEALTH CARE AND BENEFITS USE ONLY
Wellness Discount:
Grandfather Month:
Grandfather Month Out of Pocket:
Half Month Collection:
L:\HCBD\Employee Benefits\Forms\Prepayment Option Form
Revised 11/14

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