INSTRUCTIONS / DEFINITIONS INTERLOCATION TRANSFER REQUEST - BENEFITS UCPC UFIN301A

Transcription

1 Purpose: The Form allows the University of California to submit available personnel information between locations to ensure that the transferring employee will have continuous benefit coverage without any interruption in service. Use: Upon notification of transfer and/or separation date, the transferring location completes and submits this form to the receiving location within 5 business days. The receiving location processes this form within 3 business days of receipt. Click here to access the list of ITCs. Instructions: 1. Based on existing information in the transferring system (PPS or UCPath), the transferring location completes Sections 1-6. Section 1, Key Information, is required for all transfers/breaks in service. Sections 2 4, Enrolled Benefits, Other Deductions and Information, are only required for breaks in service of less than 120 days Section 5, Benefits Eligibility Data, is required for PPS to PPS Transfers, only Section 6, Comments, may be used for any comments, regardless of the situation Section 7 is for internal use only by the receiving end (receiving location) of the transfer 2. The transferring location submits the Form to the receiving location via secure . Notes: It is not necessary to enter zeroes when there is no data. If fields are empty, it is assumed there is no data to report. Due to ACA requirements, full social security numbers are needed for dependents in Section 4. Form Buttons: There are three buttons at the top of the form. These buttons are only visible via the monitor. The buttons cannot be seen on a print preview or a printout of the form. The Clear Form Button will ask the employee if he/she is sure that he/she would like to clear all data entry on the form. If employee selects Yes, the form will be cleared of all data entered up until that point. The Validate Button will highlight all empty, required fields on the form. When all required fields have been completed, the button will display a message confirming that there are no longer any required fields to complete. The Undo Highlight Button will remove the highlight from the form, should the user not want the validate highlight to be visible, as they continue to complete the form. pg. i of v

2 Definitions Section 2: Enrolled Benefits Benefits Eligibility IINS; BELI Eff Dt MCB CUR $ IINS; Cur/Nxt ContBase Provide Medical Contribution Base for Current Year MCB NXT $ IINS; Cur/Nxt ContBase Provide Medical Contribution Base for Next Year OASDI/MED IGEN; FICA Elig Cd E= OASDI + Medicare, M = Medicare Only, N= Neither State Domestic Partners Declaration - Yes or No IINS; State Dom Part Dec Mark "Yes" if the employee has a registered domestic partner, Mark "No" if the employee does not have a domestic partner TIP IINS; INS RED Mark "Yes" if employee is enrolled in TIP, Mark "No" if employee has opted out of TIP Retirement System IRET; Retirement (blank) = No retirement plan N = Not eligible H = DCP Casual (Safe Harbor) B = UCRP (University of California Retirement Plan), no deduction U = UCRP (University of California Retirement Plan), deduction 1 = UCRP (University of California Retirement Plan), no deduction, FY limit P = PERS (Public Employees Retirement System) F = FCSRS (Federal Civil Service Retirement System) S = SCERA (Sacramento County Employees Retirement Association) O = OCERS (Orange County Employees Retirement Association W = UCRP (Tier 2013 University of California Retirement Plan), deduction 6 = UCRP (Tier 2013 University of California Retirement Plan), no deduction, FY limit A = UCRP (Tier 2013 University of California Retirement Plan), no deduction T = UCRP (Tier 2016 University of California Retirement Plan), deductions D = UCRP (Tier 2016 University of California Retirement Plan), no deductions 7 = UCRP (Tier 2016 University of California Retirement Plan), no deductions, FY limit 8 = DC Choice, no deductions, FY Limit C = DC Choice (Tier 2016) X = Eligible for 2016 Tier, pending election/default Vesting Start TBD This will be a manual entry until the field is created in PPS. pg. ii of v

3 Definitions (continued) Medical - Plan Name IINS; Medical-Description Enter the medical carrier code: KN=Kaiser North, KS= Kaiser South, CM=CORE, SP= Blue Shield Health Savings Plan, HB = Health Net Blue and Gold, SU= UC Care, WH= Western Health Advantage, P1= PSBP Medical/Health Net HMO, P2= PSBP Medical/Health Net PPO. NOTE: Codes can be found on IBN2 screen under Medical Medical Coverage Code IINS; Cov Enter coverage level code: U= Employee Only, UA=Employee + Adult, UAC= Family, Medical - Covered Through IINS; End Enter the coverage end date Dental - Plan Name IINS; Dental -Description Enter the dental plan carrier code: Delta Dental PPO= D1, DeltaCare USA (HMO)=D3, PSBP Health Net Dental HMO= P3, PSBP Principal Dental PPO= P4 NOTE: Codes can be found on IBN2 screen under Dental Dental - Coverage Code IINS; Cov Enter coverage level code: U = Employee Only, UA=Employee + Adult, UAC= Family, Dental - Covered Through IINS; End Enter the coverage end date Vision - Plan Name IINS; Vision -Description Enter the Vision carrier code: Vision Care= VI, PSBP Health net Vision Plan= P5 NOTE: Codes can be found on IBN2 screen under Vision Vision - Coverage Code IINS; Cov Enter coverage level code: U= Employee Only, UA=Employee + Adult, UAC= Family, Vision - Covered Through IINS; End Enter the coverage end date Legal Y/N IINS; Legal -Description Select Y if electing legal plan or N if not electing legal plan Legal - Coverage Code IINS; Cov Enter coverage level code: U= Employee Only, UA=Employee + Adult, UAC= Family, UC= Employee + Child(ren) Legal - Covered Through IINS; End Enter the coverage end date Supplemental Life - Plan Code IINS; Supplemental Life - Cov Supplemental Life - Annual Salary Supplemental Life - Effective IINS; Supplemental Life - Sal Base IINS; Supplemental Life - Eff Enter Supplemental Life coverage code: 1 X Annual= 1, 2X Annual= 2, 3X Annual= 3, 4 X Annual= 4, Flat Coverage/Supplemental Life 20K= F Enter the supplemental life annual salary base Enter the plan effective date pg. iii of v

4 Definitions (continued) Dependent Life - Plan Code IINS; Dep Life - Cov Enter Code for Dependent Life Plan: Y = Basic Plan, S = Expanded Plan (Spouse/DP only), B = Expanded Plan (Spouse/DP + Children), C = Expanded Plan (Child(ren) Only) Dependent Life - Effective IINS; Dep Life - Eff Enter the effective date for the Dependent Life Plan Supplemental Disability Plan Waiting Period Supplemental Disability Monthly Salary Supplemental Disability Effective Voluntary Disability Short- Term IINS; STD/Suppl Dis - Cov Enter Supplemental Disability Plan Waiting Period as a 3 digit code: 007 = 7 Days, 030 = 30 Days, 090 = 90 Days, 180 = 180 Days IINS; STD/Suppl Dis - Sal Enter the supplemental disability annual salary base Base IINS; STD/Suppl Dis EFF IINS;Short-Term Dis Enter the plan effective date Select the checkbox for Short-Term Disability Voluntary Disability Long- IINS;BSC/Long-Term Dis Select the checkbox for Long-Term Disability Term Voluntary Disability PPIBN10 Select the Effective for Short-Term Voluntary Disability Short-Term Effective Voluntary Disability PPIBN10 Select the Effective for Long-Term Voluntary Disability Long-Term Effective AD&D - Coverage Code IINS; AD&D - Cov Enter AD&D coverage code: Self=S, AD&D Employee=S, Family= F, Modified Family (employee and eligible Children)=M, AD&D+Spouse/DP= F AD&D - Principal Sum IINS; AD&D - Prin Sum Enter the AD&D coverage amount AD&D - Effective IINS; AD&D - Eff Enter the plan effective date DEPCARE FSA - Annual Amount IDED; DepCare User Define Balance DEPCARE FSA annual deduction amount DEPCARE FSA YTD Balance IDED; DepCare Year-to- Enter the DEPCARE FSA YTD Balance Health FSA - Annual Amount IDED; FSA User Define Balance Health FSA YTD Balance IDED; FSA Year-to- Enter the Health FSA YTD Balance Health HSA - Annual Amount IDED; HSA User Define Balance Health FSA annual deduction amount Health HSA annual deduction amount for employee contribution Health HSA - Monthly Amount IGTN: HSA Gross to Net Enter the monthly HSA deduction amount (G) Health HSA YTD Balance IDED; HSA Year-to- Enter the Health HSA YTD Balance Monthly UCRP Buyback Deduction Amount IGTN; GTN# and Description If the employee has UCRP Buyback Deductions, enter the monthly UCRP Buyback deduction amount pg. iv of v

5 Definitions (continued) Estimated Vacation Balance ILAH; Vacation Enter estimated vacation balance at time of transfer As of See Definition Enter as of date Estimated Sick Leave Balance ILAH; Sick Leave Enter estimated sick leave balance at time of transfer As of See Definition Enter as of date Section 3: Other Deductions Description of Deduction IGTN; GTN# and Description Add any deductions here that will not be covered by benefit deductions. Example: Cal Casualty Monthly Deduction Amount IGTN; GTN AMOUNT Enter the monthly deduction amount Section 4: Information IMEM; Dependent Name Information - Name IMEM; Birthdate Information - DOB IMEM; Relation Information - Relationship Enter the dependent's name Enter the dependent's date of birth Enter the dependent's relationship to the employee. Provide tax dependency data if available. Gender - M or F IMEM; Gender Select 'M' for "Male" or 'F' for "Female" IMEM; SSN Enter the full Social Security Number Information - SSN Information - MDVL IMEM; Medical-Dental- Vision-Legal Plan Cov Indicate which plans the dependent is enrolled in by placing an "X" in the applicable boxes Section 5: PPS Benefits Eligibility Data Assigned BELI PPEINS0 Enter the assigned BELI Derived BELI PPEINS0 Enter the derived BELI Effective PPEINS0 Enter the effective date Primary BELI Status Qualifier PPEINS0 Enter the primary status qualifier PPEINS0 Enter the Secondary BELI Status PPEINS0 Enter the secondary status qualifier Qualifier PPEINS0 Enter the pg. v of v