Health, Prescription Drug, and Dental/Vision Insurance

Insurance carriers.

Blue Cross Blue Shield of Michigan (Group 59000) is the primary carrier for health insurance, Delta Dental (DD Group 3250) administers the dental plan, EyeMed administers vision coverage, and Catalyst Rx administers pharmacy coverage. Depending on where you live, you may be able to enroll in one of the health maintenance organizations (HMOs): Blue Care Network, Health Alliance Plan, or Priority Health. Refer to the Insurance Options Summary (R0379C) for more information on HMOs.  

The insurance carrier is your best bet for answers about an insurance claim or if you want to know if a particular service is covered.

Check out the Insurance Information (R0058C) document for information on enrollment, coverage, and eligibility for retirees. If you have questions or a problem with the insurance enrollment, contact ORS.

Insurance premium subsidies.

Whether or not the state helps cover insurance premium costs depends on when membership with the Michigan Public School Employees Retirement System began as well as other factors. See Premium Subsidies for details.

When your coverage begins.

Coverage always begins on the first day of a calendar month. Your insurance coverage as a retiree can begin on your retirement effective date if you apply online before your retirement effective date, and submit all required proofs within ten days of your online application. It takes 45 days after your pension eligibility determination for your insurance enrollment to be processed, so be sure to apply well ahead of time.

If you apply for retirement after your retirement effective date, your coverage begins on the first day of the month after you apply for your insurance(s) and submit all required proofs to ORS. However your enrollment will not be processed by that date because we must determine your pension eligibility first, and then allow the insurance carrier another 45 days to process. To avoid unpaid health care bills, we urge you to file your application three months in advance as recommended.

You can also choose to delay your insurance coverage up to 90 days past your retirement effective date. We suggest you check with your school employer to find out when your present insurance(s) will terminate. That way there won't be any break in your coverage and you won't be duplicating coverage. Determining the correct effective date is very important because we can't refund any premiums that were withheld from your pension.

Note: If you purchased service credit on or after July 1, 2008, the effective date of your insurance eligibility follows the rules described above. However, the date you are eligible for a premium subsidy may be delayed. See Premium Subsidies for details. 

There could be a waiting period if you enroll later.

If you decide not to enroll in the insurance plans at retirement, you can enroll later. Your coverage will begin on the first day of the sixth month after you apply and ORS receives all required proofs of eligibility. For example, if you apply online through miAccount, or we receive your Insurance Enrollment/Change Request (R0452C) and HMO Enrollment form (if applicable) with the necessary proofs on February 10, your coverage would begin August 1.

The waiting period does not apply if you or a dependent has an involuntary loss of other group coverage or a qualifying event such as a change in your family status. If you apply online through miAccount, or we receive your enrollment form, along with all required proofs within 30 days of your loss of coverage or qualifying event, there will be no gap in your coverage. 

If you have a qualifying event.

The following are considered qualifying events for the purpose of adding or deleting a dependent. ORS must receive the supporting documentation for a qualifying event by mail within 30 days of the qualifying event to waive the 6-month waiting period. Photocopies are acceptable.

Adoption.  Acceptable proof is adoption papers. In the case of legal adoption, a child is eligible for coverage as of the date of placement. Placement occurs when you become legally obligated for the total or partial support of the child in anticipation of adoption. A sworn statement with the date of placement or a court order verifying placement is required.
Birth. Acceptable proof is a birth certificate.
Death. Acceptable proof is a death certificate.
Divorce. Acceptable proof is divorce papers.
Marriage. Acceptable proof is a marriage certificate.
Involuntary loss of coverage in another group plan. Provide a statement on letterhead from the terminating group insurance plan explaining who was covered, why coverage is ending, and the date coverage ends.

ORS can waive the 6-month waiting period if you complete your insurance change request through miAccount and we receive, by mail, your confirmation page and required proofs, or an Insurance Enrollment/Change Request (R0452C)  and required proofs within 30 days of the qualifying event. Coverage can begin the first of the month following the month in which we receive your completed application and required proofs.

If you are changing insurance coverage, ORS will adjust your premiums, if needed, the month your insurance becomes effective. We cannot refund premiums withheld before or in the month you report the change. If you are adding a spouse or dependent, there is a six-month waiting period unless you have a qualifying event. The six-month waiting period may be waived if you complete your insurance change request through miAccount and we receive, by mail, your confirmation page and required proofs, or an Insurance Enrollment/Change Request (R0452C)  and required proofs within 30 days of the qualifying event.

If you enrolled in insurances before your insurance premium subsidy effective date and are paying the full premium, ORS will automatically reduce your insurance premium on your premium subsidy effective date.

If you have other health insurance.

The health, prescription drug, dental, and vision plans contain a coordination of benefits (COB) provision, which says you can't be reimbursed for more than the allowed cost of your care or service. If you or your dependents are covered under another group plan, the plans coordinate their reimbursement so that their combined payments don't exceed the allowed costs. 

It is your responsibility to keep ORS informed of any changes that may affect your own and your family's eligibility and/or coverage, so be sure to notify ORS when anyone on your insurance has coverage under another insurance plan. 

If you and your spouse are Michigan public school retirees, you will be covered together under one contract.

Sign up for Medicare.

As soon as you, your spouse, or anyone covered by your health plan insurance become eligible for Medicare, that person must enroll in both Part A and Part B. If that happens before age 65, send ORS a completed Insurance Enrollment/Change Request (R0452C) form. About three months before you turn 65, we will take steps to enroll you in the retirement system Medicare Advantage programs.

Your health coverage coordinates with Medicare. Medicare parts Part A (Hospital) and part B (Medical) tare requirements for enrollment in the Medicare Advantage programs (health care and prescription drug). Your retirement system health plan will continue to pay for any of the plan's covered benefits that are not covered by Medicare.

If you don't enroll in Medicare Part B, you will not be eligible to participate in the Medicare Advantage programs and you will be personally responsible for any Part B medical expenses that would be covered by Medicare.

When your Medicare coverage begins, you will likely see a decrease in the amount of your health insurance premiums. 

Medicare part D is a prescription drug program introduced by the federal government in 2006.  Do not sign up for Medicare Part D. Your health plan includes prescription coverage; your insurance carrier will automatically enroll you in Medicare part D if appropriate.

Your medical records are private.

The Health Insurance Portability and Accountability Act (HIPAA) and related rules require group health plans to protect the privacy of its members' health information. If you are concerned that your privacy rights have been compromised, or you need further information, please contact ORS.