General Information for all Plan Members

Disability Participants

If you started working for the state of Tennessee or a participating local education agency for the first time on or after July 1, 2015, you are not eligible to continue or enroll in health insurance at retirement. If you experience an injury or illness which results in disability, your initial date of employment with the state of Tennessee or a participating local education agency was prior to July 1, 2015, and you have at least five years of creditable service, you will not be prohibited from continuing or enrolling in health coverage as a disability retiree, provided you did not accept a lump-sum payment from the TCRS before July 1, 2015 and that you satisfy all other eligibility requirements. There can be no lapse in coverage. The date retirement benefits start (retirement date) must be on or before the date your active state coverage ceased.

If you are eligible for a service retirement, you must prove that total disability existed at the time of retirement. Proof of total disability must be shown by submitting an award letter from the Social Security Administration or approval by TCRS based on review of medical records. The required proof must show total disability existed on or before the date your active coverage ended.

Once you are eligible for Medicare Part A, you may continue in the plan to the point at which Medicare eligibility would have been attained had the disability not occurred. You must remain eligible for the disability allowance and retain Medicare Part B. If you do not enroll in Part B at the first opportunity, coverage will be terminated as of May 1 following refusal to take Part B.

Medicare will be the primary coverage, and the local education plan will be secondary. Coverage will terminate once you reach the normal age for Medicare Part A.

If the effective date of your disability retirement is determined to be after the date that your active coverage ended, you are not eligible for reinstatement of health coverage.

 

Dependent Coverage

You may continue coverage for eligible dependents if they are covered at your retirement. If you want to cover newly acquired dependents, they must be added within 60 days. If you are no longer eligible for the group health plan you cannot add dependents to your coverage.

Dependent Eligibility

The following dependents are eligible for coverage:

  • Your spouse (legally married)
  • Natural or adopted children
  • Stepchildren
  • Children for whom you are the legal guardian, custodian or conservator

All eligible dependents must be listed by name on the application to Continue Insurance at Retirement, available here.  You are also required to provide a valid Social Security number for a dependent (if eligible for one). Other required information includes date of birth, relationship and gender.

A dependent can only be covered once within the local education plan but can be covered under two separate plans (state, local education or local government). Dependent children are usually eligible for coverage through the last day of the month of their 26th birthday. Orders for guardianship, custody or conservatorship may expire at an earlier age. If you have a dependent who is not your child, but is placed with you by a placement order, coverage will be terminated when the order expires unless additional eligibility requirements are met.  

Individuals Not Eligible for Coverage as a Dependent

  • Ex-spouse (even if court ordered)
  • Parents of the employee or spouse
  • Children in the care, custody or guardianship of the  Tennessee Department of Children’s Services or equivalent placement agency who are placed with the head of contract for temporary or long-term foster care
  • Children over age 26 (unless they meet qualifications for  incapacitation/disability)
  • Live-in companions who are not legally married to
    the employee

Children who are mentally or physically disabled and not able to earn a living may continue health, dental and vision coverage beyond age 26 if they were disabled before their 26th birthday and they were already insured under the State Group Insurance Program. The child must meet the requirements for dependent eligibility listed above. A request for extended coverage must be provided to Benefits Administration before the dependent’s 26th birthday. The insurance carrier will decide if a dependent is eligible based on disability. Coverage will end and will not be restored once the child is no longer disabled.

 

Adding New Dependents

To add new dependents to your coverage, submit a retiree insurance change application within 60 days of the date the dependent is acquired. The acquire date is the date of birth, marriage or, in case of adoption, when a child is adopted or placed for adoption. Application must be made within 30 days of a birth, adoption, or placement for adoption for the coverage to be retroactive to the date of birth/adoption. Proof of the dependent’s eligibility is required. Refer to the dependent definitions and required documents chart for the types of proof you must provide.

Premium changes start on the first day of the month in which a child is added due to birth, adoption or placement for adoption. Premium changes when adding a new spouse and/or a new stepchild, or a child pursuant to an order of guardianship, or for births or adoptions submitted between 30 and 60 days after the date acquired, will start the first day of the first calendar month after Benefits Administration receives the request for special enrollment. A child named under a qualified medical support order must be added within 40 days of the court order.

If adding dependents due to the birth, adoption or placement for adoption while on single coverage, you must request the correct family coverage tier for the month the dependent was acquired so claims are paid for that month. This change is retroactive if you submit the enrollment within 30 days, and you must pay the premium for the entire month the dependent is insured.

To add a dependent more than 60 days after the acquire date, see sections on Annual Enrollment period and special enrollment provisions in this guide.

 

Updating Personal Information

You must update personal information, such as home address and email, by contacting the Benefits Administration service center. You will be required to provide the last four digits of your Social Security number or Edison ID, date of birth and previous address. You must also confirm authorization of the change before our office can update your information. It is your responsibility to keep your address and phone number current with Benefits Administration. TCRS retirees must submit a separate request directly to TCRS.

 

Annual Enrollment Period

During the fall of each year, you can make changes in your health, vision or dental coverage. Information is mailed to your home address and provided on the Partners for Health website in detail prior to the enrollment period. The options you choose during the enrollment period will take effect on the following Jan. 1. Coverage will remain in effect through Dec. 31 subject to eligibility.

 

Canceling Health, Vision and Dental Coverage

You may only cancel coverage outside of the annual enrollment period for yourself and/or your dependents, if:

  • You lose eligibility for the State Group Insurance Program, or
  • You experience an event that results in you/your dependents becoming newly eligible for coverage under another plan, or
  • You are enrolled in the Dental Health Maintenance Organization-Prepaid Provider plan and there is not a participating general dentist within a 25-mile driving distance of your home address

Please notify Benefits Administration as soon as possible in any event that causes you or your dependents to become ineligible for coverage. You must repay any claims paid in error. Refunds for any premium overpayments are limited to three months from the date notice is received.

When canceled for loss of eligibility, coverage ends the last day of the month eligibility is lost. For example, coverage for a child generally ends on the last day of the month in which the child reaches age 26, unless otherwise stated in the plan. For voluntary coverage cancellation, coverage ends on the last day of the month in which you submit the enrollment form and proof to Benefits Administration.

The insurance cancel request application is available in the forms section of the Benefits Administration website under retirement. Cancellation reasons and the required documentation are shown on the application.

Divorce —If you submit a timely request to terminate coverage of a dependent due to a mid-year change event allowed by the plan or during annual enrollment while a divorce case is pending, the termination will be processed and final.  As the retiree, it is your responsibility to comply with all applicable law regarding termination of health insurance while a divorce action is pending.  The Plan shall not be  responsible for removal of a dependent if it is determined that your request was in violation of court orders or applicable law, or if you failed to provide proper notice to the dependent.  Consult your legal counsel if you have questions.

 

If You Do Not Apply When First Eligible

If you do not apply to continue health coverage within a full calendar month of your initial eligibility, you may only apply later if you experience a special qualifying event. To apply, you must still be eligible for retiree health coverage and meet the criteria to continue coverage at the time your employment ended. If you are no longer eligible for health coverage, you may not enroll your dependents through a special enrollment event.

 

Special Enrollment Provisions

If you or a dependent lose eligibility for coverage under any other group health insurance plan, or if you acquire a new dependent during the plan year, you may have additional opportunities to enroll in health coverage.

Enrollment opportunities for voluntary programs like dental and vision are available to you and your dependents if you meet the requirements stated in the certificates of coverage for those programs. Certificates of coverage are available on the Partners for Health website under Publications.

NOTE: Application for special enrollment must be made within 60 days of the loss of eligibility for other health insurance coverage or the new dependent’s acquire date. The application for special enrollment can be found on the forms page of the Partners for Health website. 

You must also submit proof as listed on the enrollment application.

Retroactive coverage Retroactive coverage is generally not allowed.

The only exception is for birth, adoption, or placement for adoption if you submit your application and proof within 30 days of the event.

For all other situations—or if you submit for birth/adoption between 30 and 60 days after the event—your health coverage will start on the first day of the month after Benefits Administration (BA) receives your completed enrollment and required documents.

Dental and vision coverage always start on a future date as stated in their certificates of coverage.

To get the earliest possible start date, submit your enrollment to BA as soon as possible.

 

Reinstatement Following Voluntary Cancellation

If you cancel coverage and change your mind, coverage can be reinstated if you meet all of the following conditions:

  • Premiums are paid current on the coverage termination date;
  • You and your dependents continue to meet the eligibility requirements; and
  • You submit a written request for reinstatement within one full calendar month of the coverage termination date.

 

Coverage for Dependents in the Event of Your Death

Survivor insurance is a continuation of insurance that allows covered dependents to apply to continue enrollment in the event of your death. There is no provision to allow enrollment of your non-covered dependents after your death.

Group Health
Your surviving dependents will receive up to six months of extended health insurance coverage without charge. Dependents must be covered at the time of your death and continue to meet eligibility rules. The surviving dependent must apply to continue coverage within 60 days of the expiration of the six months of extended coverage or within 60 days of the notice of the termination of coverage, whichever is later.

The Tennessee Plan
Coverage under your policy will terminate at the end of the month in which you pass away. Your surviving dependents may continue coverage if they were enrolled in The Tennessee Plan at the time of your death. Surviving dependents must apply to continue coverage within 60 days of the end of coverage under your enrollment or within 60 days of the notice of the termination of coverage, whichever is later.

Dental and Vision Coverage
Coverage under your policy will terminate at the end of the month in which you pass away. Your dependents may be eligible for continuation of dental and vision coverage through COBRA or the retirement program as outlined below.

Your surviving dependents covered under your dental and/or vision plan on the date of your death may continue their enrollment in the plan with one of the two options listed below.

  • If you are eligible for continuation of coverage as a retiree at the time of your death, your dependents may elect COBRA or retiree continuation of dental and/or vision elections in effect for them on the date of your death; or
  • If you are not eligible for continuation of coverage as a retiree at the time of your death, your dependents may elect COBRA continuation for dental and/or vision elections in effect for them on the date of your death.

The surviving spouse should contact BA to confirm eligibility. Application must be made within 60 days of the end of coverage under your enrollment or within 60 days of the notice of the termination of coverage, whichever is later.

Premiums for Surviving Dependents
Premiums will be deducted from any continuing TCRS retirement benefits. Otherwise, individuals will be billed directly. Dependents acquired by the survivor(s) after your death are not eligible for coverage.

 

Premium Payment

TCRS Retiree
Premiums are deducted from your monthly TCRS pension benefit. If the premium is greater than your retirement benefit, you will be billed directly by Benefits Administration each month. If the premium is greater than your retirement benefit, you can also choose to pay by bank draft.

Non-TCRS Retiree
You will be billed directly by Benefits Administration each month or you can choose to pay by bank draft.

Direct Billing
If you send a check for your premium, it must be received by the last day of the month for the next month’s coverage. For example, your January premium is due no later than Dec. 31.

If you pay your premiums by automatic deduction from your bank account, the premium is withdrawn for the current month on or after the 15th of the month. For example, your January premium will be withdrawn from your bank account on or after Jan. 15.

Non-payment of Premiums
The plan permits a period of one full calendar month deferral of premium for premiums being billed directly instead of through payroll deductions. Coverage will be canceled back to the last month paid if premiums are not paid in full within one full calendar month of the due date. If your coverage is canceled due to failure to pay premiums you may request a one-time-only exception for reinstatement within 30 days of being notified that coverage was canceled.

Claims
If continuing group health coverage, you will continue to use your current ID cards after you retire. You may receive a new card if changes are made. Questions regarding payment of claims should be directed to the insurance company. Questions about Medicare claims processing should be directed to Medicare.