Section 2: Type of Transaction – Check all that apply
Change MEDICAL plan from ____________________ to ___________________ Select new plan in SECTION 3
Change DENTAL plan from ____________________ to ____________________ Select new plan in SECTION 4.
Change: Add / Delete Dependent(s)
Complete SECTION 3 & 4:Select current Medical/Dental plan for adding/deleting dependent(s).
SECTION 5: List dependent(s) to add/delete
Change: Enroll in FLEXCASH Change: Cancel FLEXCASH
Cancel
Enroll in
ATTACH FlexCash form & copy of proof of alternate NON-CSU coverage .
Cancel FlexCash Medical ($128) FlexCash Dental($12)
Enroll in Medical plan Dental plan
OFFICE USE: Pending-- Copy of Marriage Certificate or Declaration of Domestic Partnership SSN(s) and/or copy of Birth Certificate(s)
Documents Received:
Staff/Administrator
Faculty
Mailing Address (street, city, state, zip) Update new address at MyFresnoState (Self-Service) or Payroll Services.
Email
Home/Cell Phone
CALIFORNIA STATE UNIVERSITY, FRESNO
New Enrollment – Eligible for benefits but not currently enrolled in any plan. Select Plan(s) in SECTION 3 & 4 (below). Section
Section 3: Medical Plan Options – Check plan selected
Anthem Blue Cross
Select* (HMO)
Anthem Blue Cross
Traditional* (HMO)
BlueShield Access+
Advantage*(HMO)
Health Net
SmartCare* (HMO)
Kaiser* (HMO)
United HealthCare
Alliance* (HMO)
PERSChoice(PPO)
PERS Select(PPO) PERS Care(PPO)
PORAC (PPO) This medical plan is restricted to Unit 8 employees with SUPA membership.
DELTA DENTAL (PPO)
DELTA CARE USA (HMO) Specify provider name and facility:_______________________________
Select Medical and/or Dental plan(s) from Section 3 & 4 (below).
AT TACH FlexCash Program form and appropriate dependent documents (e.g. birth
certificate, marriage certificate, domestic partnership)
RELATIONSHIP
CODE
SSN
Medical Dental
DATE OF BIRTH CIRCLE ACTION
SELF F M
Add
Delete
Continue
Add Delete
F M
F M Add Delete
F M
Add Delete
F M
Add Delete
F M Add Delete
S or DP
LEGAL - NAME (FIRST, M.I., LAST)
CIRCLE
Gender
• ADDING DEPENDENTS or SPOUSE/DOMESTIC PARTNER: ATTACH APPROPRIATE DOCUMENTS
• A Certificate of Live Birth and Social Security number are required for each eligible dependent.
•
Marriage Certificate or Declaration of Domestic Partnership and Social Security number is required.
• CHANGES: List all currently enrolled dependents for all plans (including yourself) then circle “Add” or “Delete” or “Continue" (currently enrolled).
Continue
Continue
Continue
Continue
Continue
Date: (mm/dd/yyyy)
Section 6: Enrollment - To enroll/decline, carefully review the information in this section and check the box:
I ELECT TO ENROLL/MAKE CHANGES TO a health benefits plan as indicated above and agree to authorize deductions from my salary to cover my share of
the cost of enrollment as it is now or as it may be in the future. I CERTIFY that the information provided herein is accurate and listed dependents are eligible
family members as defined in the Public Employees' Medical and Hospital Care Act.
I VOLUNTARILY enroll into the selected Health Plan. I AGREE to read the associated Evidence of Coverage (EOC) and any subsequent EOCs in the following
years to understand the benefits of the plan. The Subscriber and all eligible dependents agree to all the terms and conditions of the EOC and the Health Plan.
I UNDERSTAND that enrolling in certain health plans requires binding arbitration and that any dispute as to medical malpractice, that is as to whether any
medical services rendered under this contract were unnecessary or unauthorized or were improperly, negligently, or incompetently rendered, will be determined
by submission to arbitration as provided by California Law and not by a lawsuit or resort to court process except as California law provides for judicial review of
arbitration proceedings. The parties to this agreement, by entering into it, are giving up their constitutional right to have any such dispute decided in a court of law
before a jury and instead are accepting the use of arbitration.
I DECLINE ENROLLMENT into the CalPERS Health Program for myself and my dependents.
I UNDERSTAND that if I choose to enroll at a later date, I must wait at least 90
days after I request enrollment or until the next Open Enrollment (OE) period
before enrolling in the CalPERS Health Program. Furthermore, if I or my dependents involuntarily lose other health insurance coverage, I may request enrollment
into the Program within 60 days from the date of lost coverage. If I do not request enrollment within 60 days, I must wait at least 90 days or until the next OE
period before I can enroll. The effective date of coverage will be the first of the month following the 90 day waiting period or the OE effective date.
Employee Signature:
*
Relationship Codes:
S - Spouse DP - Domestic Partner NC - Natural Child SC - Step Child AC - Adopted Child DPC - Domestic Partner Child PCR - Parent Child Relationship
Section 5: IMPORTANT INFORMATION FOR NEW ENROLLMENTS AND CHANGES
2018 Open Enrollment Health Benefits Worksheet
This document must be received by HR, Joyal Administration Bldg, Room 211 by 5:00 p.m. on Friday, October 5, 2018
Medical plan:__________
FlexCash Medical ($128)
Dental plan:___________
FlexCash Dental ($12)
*If electing an HMO, are you requesting employer zip code for health plan eligibility? (HMO plans are based on your residence’s zip code)
No
Yes
Agency:
If spouse or domestic partner is employed or retired from CSU system, State civil service,
CalPERS Public Agency/School or CALSTRS are you a dependent
on their health plans?
Rev 9/2018
Section 1: Type of Transaction – Check all that apply
Employee’s Legal Name
FresnoState ID
Section 4: Dental Plan Options - Check plan selected
