General Information
Must be Retired for disability or service directly from active service with either 15 years of San José service or receive allowance that is at least 37.5% of final comp.
POLICE & FIRE RETIREES
Also eligible if member separates from service after 7/5/92, but prior to retirement with 20 years of San José service and leaves contributions in the retirement plan and former member receives an allowance (i.e., applies & qualifies for retirement).
Eligible retirees have two (2) medical providers available to choose from: Kaiser Permanente and Anthem Blue Cross. Visit your health plan's website to learn how benefits, claims, and payment of claims are covered, as well as the service limitations and exclusions that may apply. Some health plans are available only in certain counties and/or ZIP Codes. Contact the health plan before enrolling to make sure they cover your ZIP Codes and that their provider network is accepting new patients in your area.
Open Enrollment is an annual process that occurs every November 1 through November 30. During this time, you can enroll or change health plans, add eligible dependents, delete dependents, or cancel coverage. Changes made during Open Enrollment become effective January 1st.
QUALIFYING LIVE EVENTS
A Qualifying Life Event (QLE) is a specific life event that allows City of San José Retirees to request their benefit elections be changed outside of the annual Open Enrollment period. Qualifying events include, but are not limited to, the events below. An INS100 form and proof of the QLE are required within 30 days from the date of the event. Benefit changes will start the first of the month following the date of the event.
See: Qualifying Life Events Reference Guide
HEALTH IN-LIEU
Retirees now have an In-Lieu credit program. If you are eligible to enroll in medical insurance, but you choose to not take the insurance through City of San José, you can enroll in the Health In-Lieu credit program. These credits accumulate in an account for you. If in the future you decide to enroll in a City of San José Retiree medical plan coverage, you can use your in-lieu credits to pay premiums. Enrollment in the In-Lieu credit program does not carry over from year-to-year automatically. You must re-enroll for In-Lieu every year during Open Enrollment.
RATES AND EMPLOYER CONTRIBUTIONS
Retirement System pays 100% of lowest-cost plan that is available to active City employees. If retiree does not choose the lowest cost plan, retiree pays the difference between that premium and the premium for the lowest-cost plan. Medical Rates can be found under the Non-Medicare, Medicare, and VEBA tabs.
ABOUT OUR PLANS
- HMO - A Health Maintenance Organization (HMO) plan provides health care from specific doctors and hospitals under contract with the plan. You pay co-payments for some services, but you have no deductible, no claim forms, and a geographically restricted service area.
- PPO - A Preferred Provider Organization (PPO) is similar to a traditional "fee-for-service" plan, but you must use doctors in the PPO provider network or pay higher co-insurance (percentage of charges). You must usually meet an annual deductible before some benefits apply. You're responsible for a certain co-insurance amount and the medical plan pays the balance up to the allowable amount.
- SPLIT PLANS - A split plan means at least one family member is enrolled in a Medicare health plan and at least one family member is enrolled in a Non-Medicare health plan through the same health carrier. All family members must have the same health carrier.
Zip Code Requirements
HMO plans are California-only plans and have zip code service area requirements. Please verify your zip code on the applicable list prior to submitting insurance enrollment forms. If your zip code is not listed, you will need to select a different plan. If you are enrolled in a split plan and have moved, please verify your new zip code on a Commercial and Medicare list. Your zip code must be on both lists to continue enrollment in your current plan.
COBRA
The Consolidated Omnibus Budget Reconciliation Act (COBRA) allows you to continue health coverage for yourself and your dependents if you involuntarily lose your health benefits.
- Coverage must be continuous, and you'll be required to pay premiums from the date your CSJ coverage ended.
- You must submit a COBRA Election Form within 60 days following notification of eligibility. Eligibility packet will come directly from P&A Group and will be addressed to the individual losing coverage (which includes adult dependents ageing out of coverage).
- Your premium cannot exceed 102 percent of the group monthly premium rate.
- Effective May 1, 2023 ORS switched administration of COBRA coverage to P&A Group. With this change, all paperwork and billing related to COBRA coverage will be between the individual losing coverage and P&A Group. No paperwork or forms relating to COBRA will come from ORS nor should any COBRA related forms or payments be made to ORS.
Contact P&A Group:
P&A GROUP
6400 MAIN STREET, SUITE 210
WILLIAMSVILLE, NY 14221
716-852-2611
https://padmin.com
or email cobra@padmin.com
Ending COBRA Coverage:
COBRA coverage for you or your dependents remains in effect until one of the following events terminates the coverage:
- Coverage through another group health plan
- Coverage time limit ends
- Eligibility for Medicare coverage
- Failure to pay the required premium
- You request cancellation
- You must notify P&A Group to terminate coverage
Health In Lieu
Health In-Lieu and Dental In-Lieu Premium Credit Program
Annual Re-enrollment is Required!
Effective March 31, 2017 (P&F) and June 16, 2017 (FCERS), members and their surviving spouses, surviving domestic partners, and/or children who are eligible for medical insurance coverage may, instead of receiving such coverage, choose to receive a credit for an amount equal to twenty-five percent (25%) of the monthly premium of the lowest cost medical plan and the lowest cost dental plan. Such credited amounts can only be applied toward the cost of such person's healthcare premiums actually incurred in future years.
Frequently Asked Questions (FAQ)
Question: If my spouse and I are both eligible for insurance through the City of San Jose (either as a retiree and/or as an employee) can I enroll in the retiree In-Lieu Credit program and get insurance through my spouse?
Answer: Eligible retirees who receive healthcare coverage as a dependent of another City employee or retiree are eligible for the single in-lieu premium credit. He or she is not eligible for the family in-lieu premium credit.
Question: If I accumulate credits but I am unable to use them because my health insurance premiums are zero, can I receive my In-Lieu credits as a cash payment?
Answer: In no event can a member, surviving spouse, surviving domestic partner, and/or eligible dependent receive the in-lieu credits as cash. In-Lieu credits may only be applied to the cost of future premiums for coverage. If a member and/or the member's eligible dependents do not use the accumulated credits while eligible for healthcare coverage, any remaining credits will be forfeited.
Question: If I am enrolled in the retiree Health-In-Lieu credit program when I turn 65, do I have to enroll in Medicare Parts A&B?
Answer: Any member who is eligible for healthcare benefits and who waives coverage will not be required to enroll in Medicare Parts A&B when they turn 65. However, if such member later chooses to enroll in a healthcare plan, he or she will be required to enroll in Medicare Parts A&B and any charges or penalties imposed by Medicare associated with enrollment outside the "initial enrollment period" shall be borne by such member.
Question: If I enroll in the In-Lieu credit program and subsequently pass away, can my eligible dependents use my accumulated credits if they are eligible for medical coverage after my death?
Answer: Yes. The credits are earned by the family and can be used by your eligible dependents to cover future medical insurance premiums.
Question: Since dental insurance is a no-cost benefit for eligible retirees, how can I use my Dental In-Lieu credits?
Answer: Accumulated Dental in-lieu credits can be applied to future medical insurance premiums.
Question: Why do I have to re-enroll in the In-Lieu Credit program each year?
Answer: Annual re-enrollment is mandated by the San Jose Municipal Code. You must submit an annual Open Enrollment form to continue your enrollment in the In-Lieu Credit program each year.
Question: Where do I go to see my In-Lieu credit balance?
Answer: Your In-Lieu credit balances are shown on your monthly pay stub. Your stub includes your lifetime balance (if you have been in the program for more than one year) as well as your accumulated balance for the current year.
Question: Where can I see the monthly In-Lieu credit amounts?
Answer: Both the dental in-lieu and medical in-lieu monthly credit amounts are shown at the bottom of each page of the medical rate sheets and are posted on www.sjretirement.com. In-Lieu credits differ based on the level of coverage for which you are eligible i.e. Member Only, Member + Spouse/Domestic Partner, Member + Child(ren), and Member + Spouse/Domestic Partner and Children.
Question: I’m electing to go back onto the City’s medical coverage, will my premium be paid through my HIL balance?
Answer: One month must elapse before HIL credits are applied towards the monthly health premiums of a CSJ health plan.