Fillable REQUEST FOR HEALTH INSURANCE CREDIT (Virginia Retirement System)

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REQUEST FOR HEALTH INSURANCE CREDIT (Virginia Retirement System)

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*VRS-000045*
VRS-45 (Rev. 07/21)
REQUEST FOR HEALTH INSURANCE CREDIT
Complete this form to request a health insurance credit or to notify VRS of changes to your insurance coverage and/or
premium amount.
Note: The information you provide on this form replaces all other insurance information at VRS and will be used to
determine your health insurance credit.
PART A. RETIREE INFORMATION (Please print)
4. Name (First, Middle Initial, Last)
5. Address (Street, City, State and ZIP+4)
6. Retirement Date (Only complete if you retired from an Optional Retirement Plan – ORP)
7. Are you covered by Part B of Medicare?
Yes No If yes, provide the following information:
E
ffective date of Medicare Part B: (mm/dd/yyyy)
Current premium: $148.50 $207.90 $297.00 $386.10 $475.20 Other: $ /month
Report supplemental Medicare plans and other types of insurance other than Medicare A and B, in Part C.
PART B. RETIREE CERTIFICATION
I understand that:
• I am responsible for repaying any overpayment of the health insurance credit. VRS may invoice me for the
overpayment or recoup the amount from my VRS retirement benefit.
• Upon my death or claim for accelerated life insurance benefits, any remaining balance will be recovered from the
proceeds of my group life insurance coverage.
• VRS may also recover the overpayment from any refund of retirement contributions and interest payable upon my
death.
I certify the information I have provided on this document is true, and I understand that any willful falsification of facts
presented may result in prosecution for a Class I misdemeanor as provided by law. I also understand that I must
immediately report any change in health insurance coverage to VRS.
Retiree Signature Date
1. Social Security Number
2. Phone Number
3. Reason for Request
New participant
Change in health insurance premium or
policy
VIRGINIA RETIREMENT SYSTEM
P.O. Box 2500
Richmond, VA 23218-2500
Toll-free 1-888-827-3847
Fax 804-786-9718
www.varetire.org
Clear Form
VRS-45 (Rev. 07/21)
PART C. INSURANCE POLICY INFORMATION
If you have health, dental, vision, or prescription drug insurance, complete Part C for each plan. Copy this page as
necessary to report all additional policies.
9. Provider and Plan Name
10. Policyholder
Self Spouse
11. Coverage Option
Single Two Family
12. Policy Type
Health Dental Vision Prescription Drug Other
13. Premium Information
a) How many times per year is the insurance premium paid?
b) How much is each premium payment? $
c) How much of each payment pays the retiree’s portion of the coverage? $
d) What is the current effective date of this premium amount?
14. If the plan is not provided by the Commonwealth of Virginia (COV), enter the plan address:
15. Does this policy cancel a previous policy?
Yes No, premium change only If Yes, enter the following:
Plan N
ame: Cancellation date:
ADDITIONAL POLICY
16. Provider and Plan Name
17. Policyholder
Self Spouse
18. Coverage Option
Single Two Family
19. Policy Type
Health Dental Vision Prescription Drug Other
20. Premium Information
a) How many times per year is the insurance premium paid?
b) How much is each premium payment? $
c) How much of each payment pays the retiree’s portion of the coverage? $
d) What is the current effective date of this premium amount?
21. If the plan is not provided by the Commonwealth of Virginia (COV), enter the plan address:
22. Does this policy cancel a previous policy?
Yes No, premium change only If Yes, enter the following:
Plan Name: C
ancellation date:
8. SSN
VRS-45 (Rev. 07/21)
INSTRUCTIONS FOR COMPLETING THE REQUEST FOR HEALTH INSURANCE CREDIT
Complete this form to request your initial health insurance credit or to notify VRS of changes to your insurance
coverage and/or premium amount. (If you retired from a position covered by VRS and you are currently
receiving a monthly benefit, you can update your health insurance premiums online at myVRS.varetire.org
rather than completing this form.)
K
eeping your information current ensures you receive the proper credit amount and are not at risk for receiving
an overpayment, which would require you to reimburse VRS.
Note: You may need to complete additional forms if you are making changes on policies with different effective
dates.
Part A. Retiree Information
Boxes 1-5: Enter your personal information.
Box 6: Please enter your retirement date if you were a political appointee, or a school superintendent or
were employed with an institution of higher education and you elected to participate in an Optional
Retirement Plan (ORP).
If you retired from a position covered by VRS, leave retirement date blank.
Box 7: If you are covered by Medicare, choose Yes and provide the additional information: the date you
started receiving Medicare Part B, and the amount paid each month for the Medicare Part B
coverage. If the amount paid is not listed, choose Other and enter the monthly amount.
Part B. Retiree Certification
Sign and date after reading the certification statement. Send the completed form to VRS at the address on the
top of the form. VRS will retroactively reimburse up to a maximum of 12 months from the date the completed
form is received by VRS as long as the necessary health insurance information is provided.
Part C. Insurance Policy Information
If you have health, dental, vision, or prescription drug insurance, complete Part C for each policy.
Note: Examples of policies not eligible for reimbursement include, but are not limited to, long-term disability,
home health care, long-term care, dread disease (such as cancer), hospital or other indemnity policies, limited
benefit plans, network discount programs, health care bill-sharing plans, or policies that restrict payment of
benefits to the treatment of specific illnesses.
To complete Part C, enter the necessary information from your policy. (Do not include information from policies
that are no longer in effect or that are not eligible for reimbursement.)
Box 9: Enter the plan name (e.g., Advantage 65)
Box 10: Indicate whether you or your spouse is the policyholder.
Box 11: Indicate the coverage option
Box 12: Indicate the policy type
Box 13: Explain how the premium is paid:
a) This is the number of times the insurance premium is paid. If paid monthly, enter 12; annually,
enter 1.
VRS-45 (Rev. 07/21)
b) This is how much you pay for the insurance each time premium is paid. If the annual premium
is $3,600 and you pay the premium 12 times, you would enter $300.
When determining this amount, remember to reduce the premium amount by any subsidies,
premium rewards or other amounts that may be paid by your employer. For instance, a state
retiree whose premium amount normally costs $237 per month and who also receives $34 per
month through a premium reward would pay $203 out of pocket, so $203 would be entered
here.
c) If you selected the coverage option of “Single” in Box 11, then 13c is the same amount entered
in 13b.
If the coverage option is “Two People” (or “Family”), then this is the portion of the amount
written in 13b that pays for only your coverage. For instance, you may have selected coverage
for “Two People” and pay $350 per month, but only $175 of the premium goes toward paying
for your portion of the coverage. In this case, $350 is reported in 13b and $175 is reported in
13c.
If you are not covered by the State health benefits, you may need to consult your private health
insurance company for this amount. For those covered by State health benefits, VRS will verify
the cost of the State health benefits for “Two People” or “Family” coverage to ensure the
maximum health insurance credit is paid.
d) This is the date the premium amount entered in 13b became effective.
Box 14: If the policy is not a COV policy, please provide the address of the plan provider.
Box 15: Enter the cancellation date for the previous policy used to determine the health insurance credit if it
applies.
Note: If you have more than one policy to report, complete boxes 16-22 in the same manner. This page may
be copied to provide additional policy information as necessary.
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REQUEST FOR HEALTH INSURANCE CREDIT (Virginia Retirement System)

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Completed 19 July 2021

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