Ariz. Admin. Code § R2-8-206 - Six-Month Reimbursement Program

A. For a retired member or Disabled member who is eligible for a Premium Benefit pursuant to R2-8-202(A)(4) or (B), the ASRS shall remit the Premium Benefit to the retired member or Disabled member pursuant to subsection (B).

B. Pursuant to subsection (A), the ASRS shall remit the Premium Benefit to the retired member or Disabled member every six months, payable in July and January. For purposes of this Section, the Premium Benefit shall be the aggregate amounts of the Premium Benefit the retired member or Disabled member is entitled to receive during the previous six months.

C. In order to receive a Premium Benefit payment pursuant to subsection (B), a retired member or Disabled member shall submit to the ASRS the Reimbursement of Medical and/or Dental Cost (Six-Month Reimbursement Program) form after the last day of the last month for which the retired member or Disabled member is seeking reimbursement.

D. The Reimbursement of Medical and/or Dental Cost (Six-Month Reimbursement Program) form that a retired member or Disabled member submits pursuant to subsection (C) shall include the following information:

1. The retired member's or Disabled member's Social Security number or U.S. Tax Identification number;

2. The retired member's or Disabled member's full name;

3. The retired member's or Disabled member's mailing address and phone number;

4. The retired member's or Disabled member's date of birth;

5. The retired member's or Disabled member's status with the ASRS;

6. The retired member's or Disabled member's status with the retired member's or Disabled member's Employer;

7. The following Coverage information for the Coverage policy holder:

a. First and last names;

b. Social Security number or U.S. Tax Identification number;

c. Date of birth;

d. Effective date of Coverage;

8. The following information for each dependent enrolled in, or to be enrolled in, Coverage:

a. First and last name;

b. Social Security number or U.S. Tax Identification number;

c. Date of birth;

d. Effective date of Coverage;

9. Six-month reimbursement totals identified by:

a. The month and year the premium is due for Coverage;

b. The total medical plan premium per month;

c. The total dental plan premium per month;

d. The employee's out-of-pocket payroll deduction for a medical premium per month;

e. The employee's out-of-pocket payroll deduction for a dental premium per month;

f. The employee's total out-of-pocket payroll deduction for medical and dental premiums per month;

10. The Employer's name;

11. The Employer's phone number;

12. The Employer's email address;

13. The name of the Employer's representative; and

14. The dated signature of the Employer's representative.

Notes

Ariz. Admin. Code § R2-8-206

New Section made by final rulemaking at 10 A.A.R. 1962, effective May 4, 2004 (Supp. 04-2). Section expired under A.R.S. § 41-1056(E) at 16 A.A.R. 1765, effective July 14, 2010 (Supp. 10-3). Adopted by final rulemaking at 23 A.A.R. 1414, effective 7/3/2017. Amended by final expedited rulemaking at 27 A.A.R. 479, effective 3/5/2021.