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Health Benefits Plan Enrollment for Active Employees (HBD-12) (Chaffey College)

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Health Benefits Plan Enrollment for Active Employees (HBD-12) Instructions
Contact your agency's personnel office if you have questions about your health enrollment. To enroll or decline enrollment
in the CalPERS Health Program or to make changes to your health plan, you must submit an HBD-12 form to your Health
Benefits Officer (HBO). If you have more than five dependents, please complete another HBD-12 form. Your agency's
personnel office will retain your original HBD-12 form and supporting documentation or affidavits in your employee file and
will provide a copy to you.
SECTION A: Applicant Information
Enter your basic information as indicated. If you are using your work zip code for health eligibility, please include your work
zip code in part 8.
SECTIONS B & C: Type of Action and Type of Permitting Event
Select the the type of action and your permitting event. Below is a list of permitting events and required documentation. The
required documents in the table below are not inclusive; you may need to submit additional documentation upon your
HBO's request.
Permitting Event Required Documentation
New Employee
• Health Benefits Plan Enrollment Form (HBD-12)
New Contracting Agency
• Health Benefits Plan Enrollment Form (HBD-12)
Marriage or Domestic Partnership
• Marriage Certificate or
• Declaration of Domestic Partnership from the
Secretary of State's Office
Delete Dependent Due to Death
• Death Certificate
Divorce or Domestic Partnership Termination
• Divorce Decree or
• Termination of Domestic partnership submitted to
the Secretary of State's Office
Move
• New address - Please provide your new address to
your agency's personnel office
Birth/Adoption
• Birth Certificate/Adoption Paperwork
Open Enrollment
• Health Benefits Plan Enrollment Form (HBD-12)
SECTION D: Subscriber and Dependent Information
List yourself and other dependents and the actions you are requesting (add or delete). Use the relationship codes to
identify the type of dependents.
SECTION E: Enrollment
To enroll in a CalPERS health plan, you must review the information and check the box in part 16. To decline enrollment in
a CalPERS health plan, you must review the information and check the box in part 17. Sign and date the form in parts 18
and 19.
SECTIONS F & G: CalPERS Privacy Notices
Please review these important privacy notices.
SECTION H: Employer Use Only
Your agency's personnel office will complete this section.
More Information
You can obtain health benefits publications, required forms, and other information about your CalPERS health benefits
through our website at www.calpers.ca.gov or by calling CalPERS at 888 CalPERS (or 888-225-7377).
HBD-12 Instructions (Rev 01/2018) Page 1 of 1
Health Account Management Division
P.O. BOX 942715
Sacramento, CA 94229-2715
Health Benefits Plan Enrollment
888 CalPERS (or 888-225-7377) | TTY (877) 249-7442
FAX (800) 959-6545
for Active Employees (HBD-12)
www.calpers.ca.gov
3. 5.
6.
7.
Gender:
8.
NoYes
Use Work ZIP Code for Health Eligibility:
9.
2.
SECTION B: Type of Action
Decline CoverageCancel All CoverageChange Health PlanAdd/Delete DependentsEnroll in a Health Plan
10.
11.
12.
SECTION D: Subscriber and Dependent Information
Action
CalPERS ID or Social
Security Number
Date of
Birth
(mm/dd/yyyy)
GenderName (First, M.I., Last)
1.
15.
Date: (mm/dd/yyyy)
17.
18.
SECTION E: Enrollment
To enroll, carefully review the information in this section and check the box:
16.
To decline, carefully review the information in this section and check the box:
I ELECT TO ENROLL in (or 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.
S - Spouse DP - Domestic Partner NC - Natural Child SC - Step Child AC - Adopted Child DPC - Domestic Partner Child PCR - Parent Child Relationship
*
1
Relationship Codes:
Male
Female
Male
Female
Male
Female
Male
Female
Male
Female
Male
Female
Male Female
13.
14.
Delete
Add
Delete
Add
Delete
Add
Delete
Add
Delete
Add
Delete
Add
New Employee
Marriage or Domestic Partnership Date (mm/dd/yyyy):
Divorce or Domestic Partnership Termination
Move
Birth/
Adoption
Open
Enrollment
Delete Dependent Due to Death
SECTION C: Type of Permitting Event
New Contracting
Agency
19.
SELF
(List yourself and all of your dependents to be enrolled on your health plan)
Primary Care
Physician
Relationship
Code *
1
Employee Name: (First)
(M.I.)
(Last)
SECTION A: Applicant Information
Residence Address: (Street)
(City)
Mailing Address (If different): (Street)
(City)
If yes, enter zip code here: (ZIP)
Name of Health Plan: (If changing health plans, list new plan name)
Permitting Event Date: (mm/dd/yyyy)
Primary Phone:
Alternate:
Employee Signature:
(ZIP)
(County)
(ZIP)
(County)
(State)
(State)
E-mail Address:
Date of Birth:
(mm/dd/yyyy)
CalPERS ID or Social Security Number:
4.
Hire Date: (mm/dd/yyyy)
Other:
HBD-12 (Rev 01/2018)
Page 1 of 2
Submission of the requested information is mandatory. The information requested is collected pursuant to the California Government Code (sections
20000 et seq.) and is used for administration of the CalPERS Board's duties under the Public Employees' Retirement Law, the Social Security Act, and
the Public Employees' Medical and Hospital Care Act, as the case may be. Portions of this information may be transferred to other governmental
agencies (such as your employer), physicians and insurance carriers but only in strict compliance with current statutes regarding confidentiality. Failure
to supply the information may result in CalPERS being unable to perform its functions regarding your status.
You have the right to review your CalPERS membership files. For questions concerning your rights under the Information Practices Act of 1977, please
contact the CalPERS Customer Contact Center at 1-888-CalPERS (or 1-888-225-7377).
Section 7(b) of the Privacy Act of 1974 (Public Law 93-579) requires that any federal, State, or local governmental agency requesting an individual to
disclose a Social Security account number to inform the individual whether that disclosure is mandatory or voluntary, by which statutory or other
authority such number is solicited, and what uses will be made of it. Section 111 of Public Law 101-173 requires group health plans to collect and
provide member Social Security numbers for the coordination of federal and State benefits. Furthermore, the CalPERS health program requires each
enrollee's Social Security number for identification purposes and to verify eligibility for benefits.
The CalPERS health program uses Social Security numbers for the following purposes:
1. Enrollee identification for eligibility processing and eligibility verification
2. Payroll deduction and State contribution for State employees.
3. Billing of contracting agencies for employee and employer contributions.
4. Reports to CalPERS and other state agencies.
5. Coordination of benefits among health plans.
6. Resolution of member complaints, grievances and appeals with health plans.
IMPORTANT: It is your responsibility to notify your personnel office when there are any changes in your family situation. Changes include domestic
partnership termination, establishment of a parent-child relationship, acquisition of a dependent child, change of address, marriage, divorce, legal
separation, and death. Failure to notify your personnel office may result in adverse consequences.
SECTION H: For Employer Use
OtherCalSTRSCalPERS
Retirement
System:
21.20.
Please retain original signed form and all supporting documentation or affidavits in employee file. DO NOT send to CalPERS.
I hereby certify under the penalty of perjury that I am a duly appointed, qualified and acting Health Benefits Officer (HBO) of the above named agency, and the
payment by the agency as provided by Section 22870-22905 of the Government Code is hereby approved. Final determination of eligibility for the enrollment
action specified will be made by the Board of Administration, Public Employees' Retirement System, in accordance with the Public Employees' Medical and
Hospital Care Act and the regulations implementing the Act.
27.26.
Payroll
Office:
25.24.23.
22.
31.
30.29.
28
State Controller's
Office
Non Central
Public Agency
Billing
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 the
system being unable to perform its functions
regarding your status.
Please do not include information that is not
requested.
SECTION F: CalPERS Privacy Notice
SSN
Social Security numbers are collected on a
mandatory and voluntary basis. If this is CalPERS
first request for disclosure of your SSN, then
disclosure is mandatory. If your SSN 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 the CalPERS system and other
state agencies
5. Coordination of benefits among carriers
6. Resolve 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 the CalPERS Privacy Officer
at 400 Q Street, Sacramento, CA 95811 or call
our Customer Contact Center at 888-CalPERS
(888-225-7377).
33.
32.
SECTION G: Privacy Information
Agency Name:
Date of Hire:
(mm/dd/yyyy)
CalPERS Employer ID:
Division ID:
Employee Bargaining Unit/Employee Group:
Date Received by Employer:
Effective Date:
(mm/dd/yyyy)
Health Benefits Officer: (Print name)
Date: (mm/dd/yyyy)
Phone Number:
Remarks:
Signature:
HBD-12 (Rev 01/2018) Page 2 of 2
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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Health Benefits Plan Enrollment for Active Employees (HBD-12) (Chaffey College)

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Completed 3 September 2020

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