Fillable Get File GroupId 4202574 Filename 2017 2520dec.-2520of 2520healthcoverage Declaration Of Health Coverage: HBD 12A (California Maritime Academy)

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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
Office
r 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
health
insurance 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 no
dependents
and you have other health coverage,
or
b) Declining enrollment or canceling your health insurance coverage for yourself and
eligible
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 than
having
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 Notice
The 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 Ocer at
400 Q Street, Sacramento, CA 95811 or call us
at 888 CalPERS (or 888-225-7377).
May 2016
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Get File GroupId 4202574 Filename 2017 2520dec.-2520of 2520healthcoverage Declaration Of Health Coverage: HBD 12A (California Maritime Academy)

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Completed 16 July 2020

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