Updated 08/14/20
Health Insurance Enrollment, Change & Cancellation Form
1.) EMPLOYEE INFORMATION
Employee Name:
_______________________________________________________________________
Last Name First Name M.I.
Employee Number:
___________________________________
Employee Group:
Salaried (AEA/OE3 & MCEG)
ATU
AFSCME
IBEW
2.) HEALTH INSURANCE COVERAGE OPTIONS (please read notes section):
MEDICAL PLAN OPTION: Anthem Select - HMO
Anthem Traditional - HMO
Check this box if you Blue Shield Access + - HMO
Blue Shield Trio HMO
*
wish to use SacRT’s zip code Health Net Smartcare HMO **
to access services Kaiser - HMO
PERS Choice PERS Select PERS Care
United Healthcare HMO
Western Health Advantage HMO
Waive
*Only in: El Dorado, Nevada, Placer, Sacramento, Yolo counties
**Not in: El Dorado, Nevada, Placer, Sacramento, Yolo counties
New Enrollment
Change Coverage Level
Coverage Level: Employee Only
Employee + One
Employee + Family
Note: If you choose a plan that costs more than the BS Access+ Sacramento
Plan, YOU WILL PAY the difference in the amount paid by SacRT for the
Sacramento Blue Shield Access+ Plan and the cost of the selected plan.
Note: If you choose the Blue Shield Access+ plan or a plan that is less than the
BS Access+ Sacramento Plan, YOU WILL PAY 10% of that plan’s premium and
SacRT will pay 90%.
3.) CASH-IN-LIEU PROGRAM:
I wish to enroll in the Cash-in-Lieu Program and have alternative health care coverage:
Note: You must provide proof of alternative insurance coverage with this enrollment form to enroll in this Program. The proof of other
medical coverage should provide reasonable evidence that the employee and all members of the employee’s expected tax family enrolled in any
SacRT benefit plan have or will have minimum essential coverage (other than individual coverage).
If you are enrolling, changing or canceling dental and/or vision coverage, complete this form and the CalPERS
(HBD-12) Form, Sections C and D only
4.) DENTAL PLAN OPTION: Delta Dental (PPO)
DeltaCare USA (HMO)
Waive
New Enrollment
Change Coverage Level
Coverage Level: Employee Only
Employee + One
Employee + Family
5.) VISION PLAN OPTION: Basic SacRT Paid (No cost)
Plus Buy-Up ($10.69 per month)
Premier Buy-Up ($13.77 per month)
Waive
New Enrollment
Change Coverage Level
Coverage Level: Employee Only
Employee + One
Employee + Family
I understand that unless I experience a qualified family status change as described under Section 2, I will not be able to enroll in
coverage (if waived), make changes or cancel my elections until the next Open Enrollment period.
I understand that as a participant in the medical plan, I will have my portion of the monthly premium contribution deducted from
my paycheck twice a month according to the level of coverage I elected. I also understand that my portion of the monthly premium
may increase each plan year due to annual healthcare contract changes/increases in premium. As a part of the CalPERS program,
SacRT is obligated to follow all PEMHCA provisions, including the requirement that SacRT continue my medical coverage for one
additional month beyond my termination month. I understand that my portion of the additional month's payment will be deducted
from my final paycheck. I understand that if I wish to waive the additional month's coverage and payment, I may terminate my
benefits effective as of the end of my termination month; however, if I do so, I will be treated as having voluntarily terminated my
benefits and will not be eligible for COBRA coverage.
Employee Signature Date
click to sign
signature
click to edit
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