Fillable CSU Chico Benefit Enrollment Worksheet

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CSU Chico Benefit Enrollment Worksheet

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BENE-Benefit-Worksheet.pdf | Rev. 04/03/2018
Office
Use only:
Supporting Documents
Welcome email
Address checked
COBRA/HIPAA
Keyed in PIMS
Audit PIMS
PERS ID entered
Audit CalPERS DOH
ACA Codes
CALIFORNIA STATE
UNIVERSITY, CHICO
HUMAN RESOURCES SERVICE CENTER
BENEFITS
400 W. 1ST STREET
KENDALL HALL ROOM 118
CHICO, CA 95929-0010
530-898-5436
FAX: 530-898-4817
Benefit Enrollment/
Change Worksheet
You have the option to voluntarily decline benefits offered by the CSU. If you do not select medical coverage (or FlexCash) within 60 days
from your date of hire, then you are agreeing, by default, to decline the offer of medical coverage.
A - Personal Information
Employee Legal Name:
First and Last Name
Employee ID #:
Mailing Address: Daytime Phone #:
Marital Status:
Single Married Domestic Partner (DP)
If mailing is P.O. Box provide physical address:
B - Type of Transaction - Select only one
New Enrollment
Are you currently enrolled in a CalPERS health plan? No Yes
If yes, please list Employer:
I voluntarily decline enrollment into the CalPERS Health Program for myself and my dependents. Proceed to section G
Add Spouse/Dependent(s) -
Reason for change:
Delete Spouse/Dependent(s) -
Reason for change:
Cancel Plan Coverage -
Reason for change:
Annual Open Enrollment -
Specify changes requested:
Return from unpaid leave -
Date of return
Proceed to section G (Previous benefit plans will be reinstated)
C - Health Plan Selection - Check plan you want to enroll in:
D - Dental Plan Selection - Check plan you want to enroll in:
Delta Dental (PPO): DeltaCare USA (HMO):
Specify provider (HMO only):
E - FlexCash Plan
In lieu of health and/or dental
coverage, I elect to enroll in
FlexCash Health or Dental.
PLEASE COMPLETE BOX H
ON REVERSE
PPO Plans:
HMO Plan:
I wish to cancel FlexCash
coverage.
PERS Care PERS Select California PERS Choice
Blue Shield Access + California
Note: Additional plans (based on your residence's zip code) may be available if residing out of area. If
selecting an out of area plan, please list name here:
F - List each person to be enrolled, added and/or deleted from plan(s) - See page 2 for required documents:
Family
Relationship
Legal Name
First and Last name
DOB
mm/dd/yy
Social Security Number*
Gender
M/F
Health
Add Delete
Dental
Add Delete
Vision
Add Delete
1 SELFxxxx
2
3
4
G - Employee Certification - Please read and sign below:
l I voluntarily decline, elect to enroll in, change, and/or cancel the benefit plan(s) as indicated above.
l
l
I certify that all dependents enrolled above are eligible family members and are not enrolled in another CalPERS health plan or CSU dental plan.
I understand that I may only make plan changes or add/delete eligible dependents during the annual open enrollment period or after submitting
supporting documentation of a qualifying life event.
l I understand that the effective date of benefits depends on many factors; including my first day of employment, the date I submit enrollment
documents, my pay plan and the pay period.
l I understand that I am responsible for paying benefit deductions that may be owed due to enrollment or changes in benefits coverage.
Employee's Signature: Date Signed:
Print Form
Reset Form
Enrollment Type Required Copies of Supporting Documentation & Information*
Active employee - new
enrollment
N/A
If adding dependents see required documents below
Enroll or adding a spouse
Marriage Certificate, https://www.cdph.ca.gov/Programs/CHSI/Pages/Marriage-License-Information.aspx
Enroll or adding a registered
domestic partner
Declaration of Domestic Partnership from the California Secretary of State's Office
www.sos.ca.gov/registries/domestic-partners-registry/
Enroll or adding/deleting a
dependent
Qualifying reason for add/delete
Birth Certificate, https://www.cdph.ca.gov/Programs/CHSI/Pages/Birth,-Death,-Fetal-Death,-Still-Birth--Marriage-Certificates.aspx
Enroll or adding a dependent
who is in a parent-child
relationship
Employer and/or CalPERS reserves the right to request any supporting documentation
Affidavit of Parent-Child Relationship (HBD-40)
https://www.calpers.ca.gov/docs/forms-publications/affidavit-parent-child-form.pdf
Deleting a spouse due to
divorce
Divorce Decree (Only available from the Superior Court in the county where the divorce was filed)
Deleting a registered
domestic partner due to
termination of partnership
Termination of Domestic Partnership submitted to the California Secretary of State's Office
https://www.sos.ca.gov/registries/domestic-partners-registry/forms-fees/
Enroll Disabled child over
age 26
Member Questionnaire for the CalPERS Disabled Dependent Benefit form (HBD-98)
https://www.calpers.ca.gov/docs/forms-publications/questionnaire-disabled-dependent-form.pdf
Medical Report for the CalPERS Disabled Dependent Benefit form (HBD-34)
https://www.calpers.ca.gov/docs/forms-publications/medical-report-dependent-form.pdf
Birth Certificate, https://www.cdph.ca.gov/Programs/CHSI/Pages/Birth,-Death,-Fetal-Death,-Still-Birth--Marriage-Certificates.aspx
Enrolling self or dependents
due to loss of other
coverage
Birth Certificate, https://www.cdph.ca.gov/Programs/CHSI/Pages/Birth,-Death,-Fetal-Death,-Still-Birth--Marriage-Certificates.aspx
Marriage Certificate, https://www.cdph.ca.gov/Programs/CHSI/Pages/Marriage-License-Information.aspx
Declaration of Domestic Partnership (domestic partner) https://www.sos.ca.gov/dpregistry/
Need proof of coverage loss (all)
Death of employee, retiree,
or family member
Need written notification of date of death
*SOCIAL SECURITY NUMBERS REQUIRED FOR ALL SUBSCRIBERS AND DEPENDENTS:
With the passage of the Health Care Reform Act in March 2010, CalPERS is required to report the Social Security members of all
subscribers and their dependents. Dependents include the spouse or domestic partner and/or children. We do not need to view
or have copies of Social Security cards, but are required to have the Social Security number information on file for all health/
dental/vision enrolled dependents.
More detailed information can be found in the Benefits Enrollment Instructions,
at www.calpers.ca.gov or by calling CalPERS at 888 CalPERS (or 888-225-7377).
H - FlexCash Selection - Check plan selected:
In lieu of health and/or dental coverage, I wish to enroll in:
FlexCash Health ($128/mo) FlexCash Dental ($12/mo)
If other coverage is through your spouse or domestic partner please provide their Social Security Number:
I certify that I am covered by another qualifying group health plan that conforms to the Affordable Care Act's (ACA's) minimum value
standards. I certify that I will maintain coverage in a qualifying group health plan on an ongoing basis and I agree to notify my campus
Benefits Officer within 60 days if I lose coverage under the medical and/or dental insurance plan(s). I understand that an individual health
insurance policy (for example, Covered California or another insurance marketplace) and coverage under Tricare, Medicare and Medi-Cal are
not qualifying group health plan coverage for purposes of the FlexCash Benefit Program.
I must provide proof of alternate non-CSU group coverage with the benefits worksheet.
Date
Employee's Signature:
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CSU Chico Benefit Enrollment Worksheet

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Completed 10 April 2020

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