BENEFITS ENROLLMENT WORKSHEET
ACA Enrollment
Questions? Call Human Resources: (707) 654-1021 Email: breece@csum.edu
Employee Information
Employee Name
Marital Status
Social Security Number
(Home) Street Address
City
State, Zip
Contact Phone Number
Transferring from another CSU/State Agency?
No YesAgency:
Type of Action
Enroll in Plan
Health
FlexCash Health
Cancel Plan
Health
FlexCash Health
Add/Delete Dependent
Health
Change Plan
Health
Permitting Event:
Event Date:
Plan Option: We MUST receive your enrollment by the 3
rd
of the month for your FlexCash to be effective the 1
st
of the next month.
Medical Plan Selection (list of plans on the back of sheet)
Health Plan:
FlexCash Enrollment:
Health ($128/month) Health Plan: Group #:
*If selecting FlexCash, a copy of your health insurance card is required
Dependent Information
Please make sure you have included the following copies, if applicable:
Spouse:
Marriage Certificate
Divorce Decree
Domestic Partner:
Declaration of Domestic Partnership
Dissolution of Domestic Partnership
Dependent Child:
Birth Certificate
Adoption Certificate
Affidavit of Parent/Child Relationship
Dependent Enrollment Selections
First Name
Last Name
Social Security
Birthdate
Relationship
Health
Add
Del
I hereby elect to enroll in the above health and dental plans, and understand that my effective date for these plans is based on the
date the official documents are received by Human Resources. If currently enrolled in another CalPERS health plan, I must choose
between plans.
Signature: ____________________________________________ Date: ______________________________________
click to sign
signature
click to edit
BENEFITS ENROLLMENT WORKSHEET
ACA Enrollment
Questions? Call Human Resources: (707) 654-1021 Email: breece@csum.edu
Medical Plans:
Anthem Select HMO
Health Net Salud Y Mas HMO
PERS Choice PPO
Anthem Traditional HMO
Health Net SmartCare HMO
PERS Select CA PPO
Blue Shield Access + HMO
Kaiser CA HMO
PERSCare PPO
Kaiser Out of State
United HealthCare HMO
PORAC PPO
CalPERS guidelines for enrolling family members are as follows:
Your spouse or domestic partner can be added to your
health plan if done within 60 days after the date of your marriage or
registration of your domestic partnership. A copy of
your marriage certificate or Declaration of Domestic Partnership and your spouse's or domestic partner's Social Security
number are required. Former spouses and former domestic partners are not eligible.
Children are eligible for health coverage up to age 26. They are eligible even if they are married, do not live with you,
or are not students. Eligible children are defined as natural, adopted, step or domestic partner’s children under age
26. If your dependent is married, you may not enroll their spouse or children (unless the child is an economic
dependent of the employee). A birth certificate or adoption papers and Social Security number are required.
A child over age 26, and is incapable of self-support due to a mental or physical condition that existed prior to age 26,
may be included when you first enroll. A Questionnaire for the CalPERS Disabled Dependent Benefit Form (HBD-98)
and Medical Report for the CalPERS Disabled Dependent Benefit Form (HBD-34) must be approved by CalPERS prior to
enrollment and must be updated upon request.
Another person's child under age 26 may be eligible for coverage if you have been granted custody or joint custody by a
court or the child resides with you. Birth Certificate, Social Security Number and Affidavit of Eligibility of Economically-
Dependent Children Form (HBD-35) must be filed prior to enrollment and must be updated upon request.
You can add the following family members either at the time of enrollment or at a later date:
A spouse or registered domestic partner
Children age 18 or older not living in your home
Eligible children who are not in your custody
Dependents in the military, when they return to civilian life
Split Enrollments:
Members who are married or in a registered domestic partnership who both work, or works, for
agencies in the CalPERS
Health Program can enroll separately. If you and your spouse or domestic partner enrolls
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 or registers a domestic
partnership with 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 or domestic partnership registration. 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.