California State University, Fresno – Human Resources 2017 Open Enrollment Benefits Worksheet

This document must be received by HR, Joyal Administration Bldg, Room 211 by 5:00 p.m. on Friday, October 6, 2017.

SECTION 1. Employee’s Information

Employee’s Legal Name(First, M, Last) Fresno State ID:

Staff/Administrator Bargaining Unit _______ Faculty

Marital Status

Single Married Domestic Partnership

Gender

Male Female

If ADDING Spouse or Domestic Partner -Is spouse or domestic partner employed by CSU, State civil service or a CalPERS Public Agency?

NO YES -- Employer:

Address (Number & Street, City, State & Zip) If address has changed, please update your address using myFresnoState (Employee Self-Service).

Department Office Ext. Home/Cell Phone E-Mail

SECTION 2. Type of Transaction – Check as many as apply:

Change MEDICAL plan from ____________________ to ___________________ Select new plan in SECTION 3.

Change DENTAL plan from ____________________ to ____________________ Select new plan in SECTION 3.

Change: Add / Delete Dependent(s)

SECTION 3: Select current Medical/Dental plan for adding/deleting dependent(s) SECTION 4: List dependent(s) to add/delete * Review back of worksheet for eligibility and required document(s).*

Change: Enroll in FLEXCASH Change: Cancel FLEXCASH

Cancel Medical plan:_________ Dental plan:_______

Enroll in FlexCash Medical($128) FlexCash Dental($12)

ATTACH FlexCash form & copy of proof of alternate NON-CSU coverage and appropriate documents (e.g. birth certificate, marriage certificate, domestic partnership).

Cancel FlexCash Medical ($128) FlexCash Dental($12)

ATTACH FlexCash Cancellation form and appropriate documents (e.g. birth certificate, marriage certificate, domestic partnership)

Enroll in Medical plan Dental plan Select Medical and/or Dental plan(s) from Section 3 (below).

New Enrollment – Eligible for benefits but not currently enrolled in any plan. Select Plan(s) in SECTION 3 (below).

SECTION 3. Medical Plan Options

Anthem Blue Cross Select*(HMO) Anthem Blue Cross Traditional*(HMO) BlueShield Access + *(HMO)

Health Net SmartCare* (HMO) Kaiser *(HMO) United Healthcare Alliance*(HMO)

PERSChoice (PPO) PERS Care (PPO) PERS Select (PPO) PORAC (PPO) - This medical plan is restricted to SUPA members

*Zip Code Election: If you are not eligible to enroll in an HMO plan based on your residence’s zip code and you wish to enroll in an HMO based on California

State University, Fresno’s zip code, an additional form must be completed. PLEASE CONTACT HUMAN RESOURCES (559) 278-2032.

Dental Plan Options

DELTA DENTAL (PPO) DELTA CARE USA (HMO) If no provider is listed, Delta Care will assign provider. Specify provider name & facility:______________________________

SECTION 4. IMPORTANT ENROLLMENT INFORMATION FOR DEPENDENTS – See reverse side for eligibility. NEW ENROLLMENTS: List all eligible dependents (including yourself) to be enrolled in health and/or dental plan.

CHANGES: List all currently enrolled dependents (including yourself) for all plans with “N/A” action. Then list any new dependents to beadded or deleted. Check reverse side of this form for required documentation for adding a dependent.

Relationship CIRCLEGender LEGAL- NAME (FIRST, M.I., LAST) SOCIAL SECURITY# Medical Dental DATE OF BIRTH ACTION:

SELF F M

Add Delete Change NA

F M

F M

F M

F M

F M

F M

Please check each statement & sign below.

I understand that my changes noted above will become effective January 1, 2018. I understand my request to change health/dental plan will be processed electronically based on this 2017 Open Enrollment Worksheet. I understand that in order to add dependent(s), a SSN(s) and copy of Birth Certificate(s) for each dependent is required.

Employee’s Signature: Date: ______________________________ 9/16

OFFICE USE: Pending-- Copy of Marriage Certificate or Declaration of Domestic Partnership SSN(s) and/or copy of Birth Certificate(s)

Documents Received:

During the open enrollment period, eligible employees may enroll as “new”, change plans, or add/delete eligible dependents to their health/dental plans. Open Enrollment requests will be accepted beginning September 11, 2017 – October 6, 2017 by 5:00 p.m. at Joyal Administration, Room 211. Based on the CalPERS and State Controller’s deadlines and processing time, no exceptions can be made.

CALPERS GUIDELINES & DEPENDENT INFORMATION All health plans require a Social Security number and a copy of Birth Certificate for each dependent.

*Eligible Dependent(s) - Additional required documentation for adding dependents are noted below:

Spouse (opposite-sex and same-sex) and Domestic Partners (same-sex over the age of 18 or opposite sex-partners if over the age of 62). Requires a copy of Marriage Certificate or Domestic Partnership. Former spouses orformer domestic partners are not eligible.

Natural children, stepchildren or adopted children under the age of 26 regardless of whether or not they are

living with you or marriage status. Social Security number(s) in addition to a copy of birth certificate, adoption papersor other supporting documents are required.

Disabled Child over age 26, who is incapable of self support due to a mental or physical condition that existed priorto age 26, may be eligible to enroll in your health plans. A Questionnaire for the CalPERS Disabled DependentBenefit Form (HBD-98) and Medical Report for the CalPERS Disabled Dependent Benefit Form (HBD-34) mustbe approved by CalPERS prior to enrollment and must be updated upon CalPERS request. Please contact HumanResources for additional information (559) 278-2032.

Other: Another person's child under the age of 26 in a Parent-Child Relationship. [Contact Human Resources foradditional paperwork - Affidavit of Parent-Child Relationship (HBD-40) and documentation must be provided for eachdependent upon request for enrollment and if approved, re-certification with documentation is required each year tocontinue dependent(s) on-going enrollment.]

Split Enrollments: Members who are married and who both work or worked (retirees), for agencies in the CalPERS Health Program can enroll separately. If you and your spouse enroll separately, you must enroll all eligible family members, regardless of the relationship, under only one of you. Dependents cannot be split between parents. For example, if a CalPERS member with children marries another CalPERS member with children and each member has their own enrollment in the CalPERS Health Program, all children must be enrolled under one parent. The effective date of coverage will be the first of the month following the date of marriage. If split enrollments are discovered, they will be retroactively corrected. You will be responsible for all costs incurred from the date the split enrollment began.

Dual Coverage: You cannot be enrolled in a CalPERS health plan as a member and a dependent or as a dependent on two enrollments. This is called dual coverage and it is against the law. When dual coverage is discovered the coverage will be retroactively canceled. You may have to pay for all costs incurred from the date the dual coverage began.

Family Status Changes Outside of Open Enrollment Although CalPERS administers our health plans, all changes MUST be coordinated through Human Resources. It is the employee's responsibility to notify Human Resources within 60 days when there are any changes in their family status in order to add/delete eligible dependent(s). Additions and deletions of eligible dependents are effective the first of the month following the permitting event or receipt of Benefits Worksheet and documentation.

Family Status Changes include:

Marriage and Domestic Partnership (Requires Copy of Marriage Certificate or Declaration DomesticPartnership);

Birth of a child, Adoption, or Acquisition of a dependent child (Parent-Child Relationship- Contact HR);

Eligible dependent moves out;

Divorce, Legal Separation and Death (documentation required)

If eligible dependent(s) are not added or deleted within 60 days of a Family Status Change, dependent(s) may be added during Open Enrollment (Mid-September through Early-October) and will become effective the following plan year on January 1st.

Rev 12/15                                                                Original: Employee’s Personnel File         Copy: Employee

 

C Member Account Management Division

P.O. Box 942715

Sacramento, CA 94229 -2715

(888) CalPERS (or 888-225-7377)

TTY (877) 249-7442 FAX (800) 959-6545

 

Declaration of Health Coverage: HBD-12A (INSTRUCTIONS ON REVERSE)

 

PART B: If you are currently enrolled in the Health Benefits Program and you acquire new dependents

or if a court orders health coverage for your dependents, you can add your new dependents. See your

Health Benefits Officer or visit your personnel office for applicable time limits.  PART C: If you are not currently enrolled in the Health Benefits Program and you acquire new

dependents as a result of marriage, birth, adoption, or placement for adoption, or if a court orders health

coverage for your dependents, you can enroll yourself and dependents. See your Health Benefits Officer

or visit your personnel office for applicable time limits.   Special rules apply to retirement and death. Please read the back of this form carefully.

   

Member’s Signature   Date Signed Health Benefits Officer’s Signature

  EMPLOYEE INFORMATION

SOCIAL SECURITY NUMBER  

- -

  NAME (FIRST) (MIDDLE) (LAST)

PART A

I elect to enroll myself and all eligible dependents.

PART B-1

I elect to enroll myself. My eligible dependents have other health insurance coverage.

 PART B-2

I elect to enroll myself and all eligible dependents. I also have eligible dependents who have other health insurance coverage.

 

PART C-1

I decline enrollment for myself and

my eligible dependents because we have other health insurance coverage.

 PART C-2

I decline enrollment for myself and/or my eligible family members for reasons other than having health insurance coverage.

If you or your dependents lose health insurance

coverage, you can enroll in the CalPERS Health Benefits

Program. You must request enrollment within 60 days

from the date you lose coverage.

If you do not request enrollment within 60 days, you or

your dependents must wait at least 90 days or until the

next Open Enrollment Period before you can enroll in

the Program. Your effective date of coverage will be

the first of the month following the 90-day waiting

period or the Open Enrollment effective date.

You can request enrollment for yourself and/or your

dependents at any time. You must wait at least 90 days

after you request enrollment or until the next Open

Enrollment Period before you can enroll in the Program.

Your effective date of coverage will be the first of the

month following the 90 day waiting period or the Open

Enrollment effective date.

INSTRUCTIONS – DECLARATION OF HEALTH COVERAGE (HBD-12A)

Please contact your Health Benefits Officer if you have any questions regarding the HBD‐12A.

Employee Information

Complete with the appropriate employee information.

Part A: Mark this box if you are:

a) Enrolling in the Health Benefits Program and have no dependents, or

b) Enrolling yourself and ALL eligible dependents in the Health Benefits Program.

Part B-1:

Part B-2:

Mark this box if you are:

a) Enrolling yourself only, your dependents have other health insurance coverage, or

b) Canceling your dependents’ coverage because they have other health insurance

coverage

Mark this box if you are:

a ) Enrolling yourself and SOME of your dependents, your other dependents have healthinsurance coverage, or

b) Canceling coverage for some of your dependents because they have other health

insurance coverage.

Part C-1:

Part C-2:

Mark this box if you are:

a) Declining enrollment or canceling your health insurance coverage, you have nodependents and you have other health coverage, or

b) Declining enrollment or canceling your health insurance coverage for yourself andeligible dependents and you have other health insurance coverage.

Mark this box if you are:

a) Declining enrollment or canceling your health insurance for reasons other thanhaving health insurance coverage and you have no dependents, or

b) Declining enrollment or canceling your health insurance coverage for yourself and

eligible dependents for reasons other than having health insurance coverage.

IMPORTANT: It is your responsibility to notify your personnel office when there are any changes in your family situation. Changes include marriage, acquisition of a dependent child, divorce, legal separation, and death. Failure to notify your personnel office may result in adverse consequences.

Special rules to consider for retirement and death:

Retirees: you are eligible to enroll in a CalPERS health plan if you meet all of the criteria below:

Your retirement date is within 120 days of separation from employment You are eligible for health benefits upon separation You receive a monthly retirement allowance You retire from the State, California State University (CSU), or an agency that currently contracts with

CalPERS for health benefits

Survivor Death Benefit: your dependents may enroll in a CalPERS health plan as a survivor as long as they:

Are eligible for enrollment as a dependent on the date of death of a CalPERS retiree Receive a monthly survivor check Continue to qualify as an eligible family member

Dependents who are enrolled at the time of the employee or annuitant’s death and meet the eligibility requirements can continue the health enrollment as a survivor. Dependents who are not enrolled and meet the eligibility requirements may enroll in a health plan within 60 days of the employee or annuitant’s death, or during Open Enrollment.

The effective date of enrollment is the first day of the month following the date CalPERS receives the request. Exceptions may apply for certain contracting agency survivors who do not receive a monthly survivor check. Your survivor will need to contact your former employer for additional information.

Privacy NoticeThe privacy of personal information is of the utmost importance to CalPERS. The following information is provided to you in compliance with the Information Practices Act of 1977 and the Federal Privacy Act of 1974.

Information Purpose

The information requested is collected pursuant to the Government Code (sections 20000 et seq.) and will be used for administration of Board duties under the Retirement Law, the Social Security Act, and the Public Employees’ Medical and Hospital Care Act, as the case may be. Submission of the requested information is mandatory. Failure to comply may result in CalPERS being unable to perform its functions regarding your status.

Please do not include information that is not requested.

Social Security Numbers

Social Security numbers are collected on a mandatory and voluntary basis. If this is CalPERS’ first request for disclosure of your Social Security number, then disclosure is mandatory. If your Social Security number has already been provided, disclosure is voluntary. Due to the use of Social Security numbers by other agencies for identification purposes, we may be unable to verify eligibility for benefits without the number.

Social Security numbers are used for the following purposes: 1. Enrollee identification 2. Payroll deduction/state contributions 3. Billing of contracting agencies for employee/

employer contributions 4. Reports to CalPERS and other state agencies 5. Coordination of benefits among carriers 6. Resolving member appeals, complaints,

or grievances with health plan carriers

Information Disclosure

Portions of this information may be transferred to other state agencies (such as your employer), physicians, and insurance carriers, but only in strict accordance with current statutes regarding confidentiality.

Your Rights

You have the right to review your membership files maintained by the System. For questions about this notice, our Privacy Policy, or your rights, please write to the CalPERS Privacy Officer at 400 Q Street, Sacramento, CA 95811 or call us at 888 CalPERS (or 888-225-7377).

May 2016