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If the employer does not offer retiree coverage, retiring employees may be offered COBRA/State Continuation. Refer to COBRA for additional information.

Note: An employee is eligible for COBRA /State Continuation if he or she is Medicare-eligible. A second option is enrolling the employee in a group retiree segment through Prevea360 Health Plan, provided one has been previously approved for your group.

Retiree segment requirements and set up

The employer’s retiree policy must address and meet the following guidelines:

  • A formal, written policy outlining retiree benefits offered. 
    • Example: Insured employees who have at least 25 years of service and who are age 55 are eligible for retiree benefits. The definition must apply for all eligible insured employees within Prevea360 Health Plan's service area.
  • The definition must state how long a retiree can remain covered under the retiree segment. This is usually limited to age 65 or eligibility for Medicare.
  • The eligibility requirement should contain clarification on coverage for spouses/dependents.
    • Example: The spouse and dependents can remain covered under the retiree segment as long as they were insured prior to the employee’s retirement.
  • In addition, the policy should clarify what happens to coverage of the spouse/dependents should the retiree pass away.
  • If the employer offers health plans from other carriers, they must agree to allow the retiree coverage. If the other carriers do not agree to offer the retiree coverage or cancel the retiree coverage at a later date, you must notify Prevea360 Health Plan.
  • The employer's premium contribution to the retiree’s coverage must be at least 25% of the single premium across all tiers and must be the same for all insured. This may be achieved through pension benefits or accrued sick and vacation time the company allows to be used for health insurance premium payments.
  • The options for coverage changes at annual enrollment time must be noted.
    • Example: Can the retirees switch between health plans at annual enrollment, or are they required to remain on the plan chosen at retirement indefinitely?
  • Medicare – If Prevea360 Health Plan approves a policy that covers retirees who are Medicare-eligible, such retirees are required to enroll in both Medicare Parts A and B. Prevea360 Health Plan will pay secondary to Medicare whether or not the retiree elects Parts A and B.
  • Special enrollments – If a retiree acquires a new dependent as a result of marriage, birth, adoption or placement for adoption, the retiree may be able to enroll himself or his qualified dependents in the plan provided that we receive an application for enrollment within 31 days after the date of the event. If the retiree waives Prevea360 Health Plan retiree or dependent coverage when initially eligible for coverage under the retiree plan, one subsequent enrollment into the retiree plan will be allowed, but only if other group coverage (excluding dual choice coverage) is involuntarily lost and Prevea360 Health Plan receives an application for enrollment within 31 days following the date coverage was lost.
  • Standard retiree participation levels and ongoing monitoring – Maximum retiree participation levels have been established to control the amount of risk presented by retiree policies. For groups with two to 25 total employees, the standard maximum participation level for retirees may not exceed 10% of the total group enrollment with us. For groups with 26 or more employees the standard maximum participation level for Prevea360 Health Plan retirees may not exceed 25% of the total group enrollment with Prevea360 Health Plan.

Note: A group may elect to freeze retiree enrollment at any time to prevent retiree participation from growing further. In any case, rates would be adjusted to appropriately reflect the risk presented by the retiree population if it exceeds 10% and retirees may be rated separately if appropriate based on the below guidelines.

Enrolling in a retiree segment

An employee application for group coverage form (PDF) must be completed by the employee upon retirement.

The employee will check “transfer to retiree segment” under “Reasons for Application” and should indicate effective date of change.

The employee should also note in Section D of the application if he or she has enrolled in Medicare.

Because Medicare is the primary payer for members on the retiree segment, all retirees and dependents who qualify for Medicare are strongly advised to enroll in both Part A & B because Prevea360 Health Plan will pay claims as if they are enrolled.

The Employee Application for Group Coverage Form should be received by Prevea360 Health Plan within 31 days of the retirement date. Retirees will be noted on the billing statement under a separate group number (similar to COBRA enrollees).