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Oe-benefits-worksheet-2018 BENEFITS ENROLLMENT WORKSHEET

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2018 OPEN ENROLLMENT BENEFITS WORKSHEET
This document must be received by HR, Lindero Hall , by 4:00 p.m. on Friday, October 5, 2018
SECTION 1. Employee Information
Employee’s Legal Name
CSUCI ID
Home/Cell Phone
Mailing Address (street, city, state, zip)
Email
SECTION 2: Type of Transaction – Check all that apply
Change MEDICAL plan from: ___________________________________ Select new plan in SECTION 3
Change DENTAL plan from: ____________________________________ Select new plan in SECTION 3
Change: Add/ Delete Dependent(s)
SECTION 4: List dependent(s) to add/delete
Change: Enroll in FLEXCASH
Cancel Medical plan:__________ Dental plan:
Enroll in FlexCash Medical($128) FlexCash Dental($12)
ATTACH copy of proof of alternate NON-CSU coverage
Cancel FlexCash Medical ($128) FlexCash Dental ($12)
Enroll in Medical plan Dental plan
Select Medical and/or Dental plan(s) from Section 3 (below).
New Enrollment – Eligible for benefits but not currently enrolled in any plan. Select Plan(s) in SECTION 3
SECTION 3: Medical Plan Options – Check plan selected
Anthem Blue Cross
Select* (HMO)
Anthem Blue Cross
Traditional* (HMO)
BlueShield Access+
Advantage*(HMO)
Health Net
SmartCare* (HMO)
Kaiser* (HMO)
United HealthCare
Alliance* (HMO)
PERSChoice(PPO)
PERS Select(PPO) PERS Care(PPO)
Health Net Salud Y Mas
PORAC (PPO) restricted to Unit 8
employees with SUPA membership
Dental Plan Options– Check plan selected
Delta Dental (PPO) Delta Care USA (HMO) Specify provider name and facility: _______________________________
SECTION 4: Important Information for New Enrollments
•
ADDING DEPENDENTS or SPOUSE/DOMESTIC PARTNER, ATTACH COPIES OF APPROPRIATE DOCUMENTS:
•
Children- birth certificate
•
Spouse/Domestic Partner- Government Issued Marriage Certif
icate or Declaration of Domestic Partnership
•
Parent Child Relationship- An Affidavit of Parent/Child Relationship is required
•
CHANGES: List all currently enrolled dependents for all plans (including yourself) then select “Add” or “Delete” or “No Change”
Relationship Codes:
S – Spouse DP - Domestic
Partner NC - Natural Child SC - Step Child AC - Adopted Child DPC - Domestic Partner
PCR - Parent Child Relationship Child
RELATIONSHIP
CODE
Gender
LEGAL - NAME (FIRST, M.I., LAST)
SSN
Medical
Dental
DATE OF BIRTH
SELECT ACTION
SELF
F
M
F
M
F
M
F
M
F
M
F
M
SECTION 5: Enrollment - To enroll/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.
Employee Signature:
Date:
(mm/dd/yyyy)
Add Delete No Change
Add Delete No Change
Add Delete No Change
Add Delete No Change
Add Delete No Change
Add Delete No Change
CalPERS 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 the system being unable to perform its functions regarding your status.
Please do not include information that is not requested.
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).
Privacy Information
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 d
eduction 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 Human Resources 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 Human Resources
office may result in adverse consequences.
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Completed 16 February 2020

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