Retiree Eligibility and Enrollment

If you retire after September 30, 2005 and go to work for another employer, you may be required to enroll in the other employer’s health insurance plan. If you are eligible for coverage in your new employer’s health insurance plan and your new employer contributes 50% or more of the individual premium, you will be required to drop the SEHIP as your primary coverage and enroll in the new health plan. The SEIB may offer you supplemental coverage to cover most of your out-of-pocket expenses.

In November of 2004, the Alabama Legislature enacted a new law (Act No.: 2004-648) that requires all employees who:

• retire after September 30, 2005, and
• become employed by another employer and
• the other employer provides employees at least 50 percent of the cost of single health insurance coverage and
• are eligible to receive the other employer group health insurance coverage through that employer,

shall be required to use the other employer's health benefit plan for primary coverage.

Special Enrollment is available for retirees who lose their other employer’s group health plan coverage.

Another employer that provides its employees and their spouses with other employer group health insurance coverage may not exclude a retiree, as defined under Section 36-29-1(11), or his or her spouse from coverage by application of a provision which does not also apply on the same terms and conditions to other retirees or their spouses.

Failure by a retiree to enroll in the other employer’s group health plan under the terms of the Act will result in the termination of coverage in the State Employees’ Health Insurance Plan and possible recall of claims back to the date the retiree was eligible for the other employer’s group heath plan.

You and your eligible dependents may participate in the plan if:

• You are a retired employee of the State of Alabama who has at least 10 years of creditable coverage in the SEHIP; and
• You receive a monthly benefit from the Employees' Retirement System or Teachers' Retirement System of Alabama or Judicial Retirement Fund.

• Your spouse (excludes divorced or common-law spouse);
• Your child(ren) under 26 years old is defined as:
  • your son or daughter,
  • legally adopted by you or your spouse,
  • your stepchild, or
  • a dependent for whom you, or your spouse, has legal and physical custody granted by a court of competent jurisdiction.
• An incapacitated dependent child* over age 25 will be considered for coverage provided the dependent is:
  • unmarried,
  • permanently mentally or physically disabled or incapacitated,
  • had the condition prior to the dependent’s 26th birthday,
  • incapable of self-sustaining employment,
  • dependent on you for 50% or more financial support,
  • otherwise eligible for coverage as a dependent except for age,
  • covered as a dependent on your Plan immediately prior to the child’s 26th birthday,
  • and not eligible for any other group health insurance benefits.
  *The above requirements must be met to be eligible for coverage as an incapacitated child. The SEIB shall decide whether an application for incapacitated status will be accepted and final approval of incapacitation will be determined by Medical Review conducted by BCBS. The SEIB reserves the right to periodically recertify incapacitation. Neither a reduction in work capacity nor the inability to find employment is, of itself, evidence of eligibility. If a mentally or physically incapacitated child is employed, the extent of their earning capacity will be evaluated.

• Your spouse or other dependents if they are independently covered as a state employee unless they are employed as a professional civil engineer trainee with ALDOT and their employment is part of their educational training
• An ex-spouse or ex-stepchildren, regardless of what the divorce decree may state
• Your biological child if the child has been adopted by someone other than your spouse and you have been relieved of your parental rights and responsibilities
• Children age 26 and older
• Incapacitated children age 26 and older who do not meet the Incapacitated Child eligibility requirements listed above under Eligible Dependent
• A child of a dependent child
• A daughter-in-law or son-in-law
• Grandchildren or other children related to the member by blood or marriage for which the member does not have legal and physical custody
• Grandparents
• Parents
• A fiancé(e) or live-in girlfriend or boyfriend

If your child meets the other Incapacitated Child eligibility requirements listed above under Eligible Dependent, you must contact the SEIB to obtain an Incapacitated Child Certification form. A completed Incapacitated Child Certification form and proof of incapacity must be provided to the SEIB no more than 60 days after the child’s 26th birthday. If you fail to submit the form and proof of incapacity within the required time period, or, if you do not maintain continuous coverage on the incapacitated child thereafter, your child is not eligible for future enrollment except in the following two situations:

1. When a new employee requests coverage for an incapacitated child within 60 days of employment; or
2. When an employee’s incapacitated child is covered under a spouse’s employer group health insurance for at least 18 consecutive months and:
   • the employee’s spouse loses the other coverage because the employer ceases operations, termination of employment or reduction of hours of employment, or employer stopped contributing to coverage.
   • a change form is submitted to the SEIB within 30 days of the incapacitated child’s loss of other coverage, and
   • Medical Review approved incapacitation status.

In these two situations, your child must meet all Incapacitated Child eligibility requirements.

A retiring employee may elect coverage under the SEHIP by agreeing to have the monthly premium amount (if applicable) deducted from his retirement check. To be eligible, you must provide a physical address to the SEIB.

If coverage is declined at the date of retirement, the SEIB will provide the retiree with a Declination of Coverage form that must be completed and returned to the SEIB to be eligible for special enrollment.

Tier 1 retirees who start receiving retirement benefits because they reach age 60 may or tier 2 retirees who start receiving retirement benefits because they reach age 62 may enroll in health insurance.

Retired employees who do not elect to continue their coverage under the SEHIP may enroll during the annual open enrollment held each November for coverage to be effective January 1. Retirees may elect to add family coverage. Contact the SEIB for details.

The Health Insurance Portability and Accountability Act of 1996 requires that a special enrollment period be provided in addition to the regular enrollment period for retired employees and eligible dependents if:

• The retired employee declined to enroll in the SEHIP because of other coverage and submitted a completed SEIB form declining coverage in the SEHIP; and
• The retiree gains a new dependent through marriage, birth, or adoption; or
• The retiree or dependent loses the other employer group coverage because:
  • COBRA coverage (if elected) is exhausted; or
  • loss of eligibility (including separation, divorce, death, termination of employment, or reduction of hours of employment); or
  • employer stopped contributing to coverage.

A request for special enrollment must be submitted to the SEIB within 60 days of the loss of other coverage or within 60 days of gaining a new dependent, along with a completed Enrollment form or Status Change form if only adding dependents. In addition, the following documentation must be submitted within 60 days of the qualifying event:

• proof of gaining a new dependent (e.g., marriage certificate, birth certificate, adoption papers); or
• proof of coverage loss listing the reason and the date of the coverage loss for all individuals affected (e.g., employment termination on company letterhead).

In the event of the death of a retired employee who carried family coverage, the eligible dependents may continue coverage by making appropriate premium payments to the SEIB. The SEIB must be notified within 90 days of the date of death.

Dependents may not be added to coverage after the death of the retired employee. To be eligible to continue coverage under this section, a dependent must be covered under the SEHIP immediately prior to the death of the retired employee.

If a dependent covered under this section cancels coverage for any reason, the dependent is ineligible for survivor coverage at a later date.

Re-employed state retirees must work an average of 10 hours or more per week to be eligible for re-employed state retiree coverage in the SEHIP. Re-employed state retirees who work less than 10 hours per week on average, may continue their retiree coverage in the SEHIP, and will not be classified as re-employed state retirees for health insurance purposes.

All re-employed state retirees must submit a Re-Employed State Retiree Health Insurance form to the SEIB if they are expected to work an average of 10 hours or more per week. If the employee and/or dependent are Medicare eligible, SEHIP will be the primary payer and premiums will be adjusted.

You must notify the SEIB when your employment ends so that the SEIB can change the coverage back to retiree coverage when applicable.