OPEN ENROLLMENT BENEFITS WORKSHEET

This document MUST be received by Human Resources, DURING OPEN ENROLLMENT September 14th - October 9th, 2015.

Employee’s Legal Name:

CSUN ID:

Staff Administrator Faculty TA

Department:

Office Ext: Home/Cell Phone: Preferred E-Mail:

Marital Status: Married Single Copy of Marriage Certificate Domestic Partnership (DP) Copy of DP Certificate DP iputed ility fo

Spouse/Domestic Partner: Requires Copy of Marriage Certificate or Certificate of Domestic Partnership for same-sex. Is spouse or domestic partner employed or retired from the CSU system, State civil service or a CalPERS Public Agency? NO YES If yes, list agency: ____________________________________________________________________

Section 1: Type of Transaction – OPEN ENROLLMENT

New Enrollment (Complete sections that apply)

Cancellation of Plan(s) (Complete sections that apply)

Change of Plan(s) (Complete sections that apply) Change – Add Eligible Dependent(s) (Documentation required) Dental / Flexcash / HCRA / DCRA forms required for transactions

Change – Delete Dependent(s) (Documentation required) * SELECT plan(s) in Section 2 - 6 that apply to begin your benefit request below: ALL Changes / Enrollments EFFECTIVE January 1, 2016.

Section 2: Medical Plan Options – Check plan selected. You must also complete CalPERS Health Benefit Plan Enrollment Form (PERS-HBD-12 [Rev. 6/13])

PERS Care (PPO) PERS Choice (PPO) PERS Select (PPO) PORAC (PPO) This medical plan is restricted to Unit 8 employees with SUPA.

Blue Shield Access + (HMO) Blue Shield Net Value (HMO) Kaiser Permanente Anthem HMO Select Anthem HMO Traditional

UnitedHealthcare Health Net Salud Y Mas Health Net Smartcare

Section 3: Dental Plan Options – Check plan selected. You must also complete CSU Dental Plan Enrollment Authorization Form (CSU 692 [Rev. 3/2013])

DELTA Dental (PPO) Delta Care USA (HMO) Specify provider name and facility:_______________________________________________

Section 4: Vision Service Plan (VSP)

VSP

Section 5: FlexCash Option (Cash payment in exchange for waiving CSU medical and/or CSU dental coverage)

Copy of Proof of Alternate non-CSU Coverage. You must also complete the Flexcash Enrollment Form

I elect to enroll in FlexCash for: Health only ($128/mo) Dental only ($12/mo.) Health & Dental ($140/mo.)

Section 6: Flexible Spending Account HCRA / DCRA You must also complete the HCRA / DCRA Enrollment Form

HCRA (Monthly Deduction) $________________ DCRA (Monthly Deduction) $_____________________

SECTION 7: IMPORTANT INFORMATION FOR NEW ENROLLMENTS AND CHANGES: New Enrollments: List all eligible dependents to be enrolled in health and/or dental plans (including yourself).

Changes/Cancellations: List all currently enrolled dependents for all plans (including yourself) then check “Add” or “Delete.”

RELATIONSHIP Check Gender LEGAL - NAME (FIRST, M.I., LAST) DOB SSN Medical Dental Vision Add Delete N/A

SELF F M

F M

F M F M F M

F M

Please check each statement & sign below.

I understand that my effective date is based on the date this document is signed & received by Human Resources (HR). I have read the reverse side of this form outlining the CalPERS guidelines for enrolling in a health plan. ADDING DEPENDENTS: I understand that a Certificate of Live Birth is required for each dependents except spouse/domestic partner when I sign the original enrollment documents. ADDING NEWBORN: A Hospital Record of Birth or Certificate of Live Birth is required for enrollment. I will provide the Social Security # to HR in compliance with the health plan requirements for adding a dependent within 90 days from date of birth.

Employee’s Signature: Date: _______________________

HR OFFICE USE: Copy of Marriage Certificate or Domestic Partnership Hospital Record of Birth (Newborn only) Birth Certificate (s)

Date Received in HR _________ Conf. Letter Sent________CBID_________RETCode_________ 9/5/2013

CalPERS guidelines for enrolling family members are as follows:

*New employees: You have 60 calendar days from the date of your initial appointment to enroll yourself or yourself and all eligible family members in a health plan.

Spouse: You may add your spouse to your health plan within 60 days of your marriage. You are required to provide a copy of the marriage certificate and the spouse’s Social Security Number and Medicare card (if applicable). You may complete an affidavit of marriage if you are unable to provide a copy of the marriage certificate. Registered Domestic Partner: You may add your registered domestic partner to your health plan within 60 days of registration of the domestic partnership. You must register your domestic partnership through the California Secretary of State’s Office. CalPERS requires that you submit a copy of the registered Declaration of Domestic Partnership, the domestic partner’s Social Security Number, and a copy of their Medicare card (if applicable). Same sex domestic partnerships between persons who are both at least age 18 and certain opposite sex domestic partnerships (one partner must be 62 years of age or older and the other partner at least 18 years of age) are eligible to register with the Secretary of State. Children: Natural-born (within 60 days of birth), adopted (within 60 days of physical custody), domestic partner’s, and stepchildren (within 60 days after the date of your marriage or registration of domestic partnership) who are under age 26 may be added to your health plan. CalPERS requires that you submit a copy of the child’s birth certificate or adoption papers and their social security number(s). Disabled Children Over Age 26: A child over age 26 who is incapable of self-support because of a mental or physical condition that existed prior to age 26 and continuously since age 26 may be included at your initial enrollment. This enrollment is subject to CalPERS approval. Prior to enrollment of a disabled child over the age of 26, you must submit a Member Questionnaire for the CalPERS Disabled Dependent Benefit form, and your doctor must complete and submit a Medical Report for the CalPERS Disabled Dependent form for CalPERS approval. You must update these forms periodically upon request. If the disabled child has a Social Security-approved disability, you must provide CalPERS with a copy of his or her Medicare card. CalPERS also requires that you provide the child’s social security number. Parent-Child Relationship: Other children may be eligible if they are under age 26 and a parent-child relationship exists when the employee has: (1) assumed a parental role or (2) is considered the primary care “parent.” You have 60 days from the date you assumed a primary custodial parental role to request enrollment. You must submit an Affidavit of Parent-Child Relationship at the time of enrollment for each child and annually thereafter up to age 26. The Associate Director of HR Services must approve or disapprove each affidavit. Enrollment cannot occur unless the Associate Director of HR Services first approve the affidavit. Split Enrollments: Members who are married or in a registered domestic partnership who both work, or worked, for agencies in the CalPERS Health Program can enroll separately. If you and your spouse or domestic partner enroll separately, you must enroll all eligible family members, regardless of the relationship, under only one of you. Dependents cannot be split between parents. For example, if a CalPERS member with children marries or registers a domestic partnership with another CalPERS member with children and each member has their own enrollment in the CalPERS Health Program, all children must be enrolled under one parent. The effective date of coverage will be the first of the month following the date of marriage or domestic partnership registration. If split enrollments are discovered, they will be retroactively corrected. You will be responsible for all costs incurred from the date the split enrollment began. Dual Coverage: You cannot be enrolled in a CalPERS health plan as a member and a dependent or as a dependent on two enrollments. This is called dual coverage and it is against the law. When dual coverage is discovered the coverage will be retroactively canceled. You may have to pay for all costs incurred from the date the dual coverage began.

This information was taken from the CalPERS Health Program Guide. More detailed information can be found at www.calpers.ca.gov or by calling CalPERS at 888 CalPERS (or 888-225-7377).

List additional eligible dependents to be enrolled in/deleted from Health and/or Dental and/or Vision plans.

RELATIONSHIP

Check Gender

LEGAL - NAME (FIRST, M.I., LAST)

DOB

SSN

Medical

Dental

Vision

Add

Delete

N/A

F M

F M

F M F M F M

F M