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fresno state Health BENEFITS WORKSHEET BENEFITS ELIGIBLE

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CALIFORNIA STATE UNIVERSITY, FRESNO
Health BENEFITS WORKSHEET - NEW HIRE/BENEFITS ELIGIBLE
Employee’s Legal Name Fresno State ID:
Staff/Administrator Faculty
Mailing Address (street, city, state, zip) Update new address at MyFresnoState (Self-Service) or Payroll Services.
Home/Cell Phone
Hire Date/Eligibility Date
New Enrollment – appointment eligible for benefits.
Section 2: 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)
PORAC (PPO) This medical plan is restricted to Unit 8 employees with SUPA membership.
*
COPY OF PROOF OF ALTERNATE NON-CSU COVERAGE REQUIRED
I elect to enroll in FlexCash for: Health only ($128/mo) Dental only ($12/mo) Health & Dental ($140/mo)
DELTA DENTAL (PPO)
DELTA CARE USA (HMO) Specify provider name and facility:________________________________
Section 5: IMPORTANT INFORMATION FOR NEW ENROLLMENTS
RELATIONSHIP CODE
• NEW ENROLLMENTS: List all eligible dependents to be enrolled in health and/or dental plans (including yourself).
• ADDING DEPENDENTS or SPOUSE/DOMESTIC PARTNER: Attach appropriate documents
o Certificate of Live Birth and Social Security number are required for each eligible dependent
SSN
Medical Dental
DATE OF BIRTH
SELF
F M Add
Add
F M
F M Add
F M Add
F M Add
F M Add
Section 6: Enrollment - To enroll/decline, carefully review the information in this section and check the box:
S or DP
no yes
agency:
Section 1: Type of Transaction
Section 3: FlexCash Option (Cash payment in exchange for waiving CSU medical and/or CSU dental coverage)
Section 4: Dental Plan Options – Check plan selected
Basic
Vision
If spouse or domestic partner is employed or retired from CSU system, State civil service,
CalPERS Public Agency/School or CALSTRS are you a dependent on their health plans?
o Marriage Certificate or Declaration of Domestic Partnership CIRCLE
Email
Gender LEGAL - NAME (FIRST, M.I., LAST)
Use Work ZIP Code for Health Eligibility?
No Yes, ZIP :
Date: (mm/dd/yyyy)
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:
Rev 5/2018
Comments:
*
Relationship Codes:
S - Spouse DP - Domestic Partner NC - Natural Child SC - Step Child AC - Adopted Child DPC - Domestic Partner Child PCR - Parent Child Relationship
This document must be received by Human Resources, Joyal Admin., Room 211, (559) 278-2032 within 60 days of Hire/Benefit Eligibility.
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 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.
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
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fresno state Health BENEFITS WORKSHEET BENEFITS ELIGIBLE

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Completed 21 April 2020

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