Married Single NEWLY ELIGIBLE ENROLLMENT CHANGE DUE TO PERMITTING EVENT CANCELLATION

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Hilda Simon
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1 THE CALIFORNIA STATE UNIVERSITY FLEXCASH PROGRAM ENROLLMENT AUTHORIZATION Please type or use ball point pen, print clearly. Return completed form to campus Benefits Officer. SEE PRIVACY NOTICE ON REVERSE OF EMPLOYEE COPY 1. TYPE OF ENROLLMENT (Check appropriate box) 2. SOCIAL SECURITY NO. 3. MARITAL STATUS ANNUAL/OPEN ENROLLMENT NEWLY Married Single NEWLY ELIGIBLE ENROLLMENT CHANGE DUE TO PERMITTING EVENT CANCELLATION 4. NAME (first) (initial) (last) 5. PLAN ELECTIONS Refer to the FlexCash Brochure for cash option election information. Cash Option Type Monthly Payment Instructions for Completing Cash Option Elections A. Cash in lieu of medical insurance $ If you are electing the cash option in lieu of medical insurance, enter the monthly cash amount in item A, otherwise enter none. B. Cash in lieu of dental insurance $ If you are electing the cash option in lieu of dental insurance, enter the monthly cash amount in item B, otherwise enter none. C. Plan Code Monthly Total $ In Item C enter the total monthly cash option amount (sum of the amounts entered in items A and B). 6. ATTESTATION OF OTHER QUALIFYING GROUP HEALTH COVERAGE This section must be completed if you choose cash instead of your own CSU medical and/or dental insurance plans. I certify that I am covered by another qualifying group health plan that conforms to the Affordable Care Act s (ACA s) minimum value standards (see next page). I certify that I will maintain coverage in a quali fyin g gro up health plan on an ongoing basis and I agree to notify my campus Benefits Officer within 60 days if I lose coverage under the medical and/or dental insurance plan(s). I understand than an individual health insurance policy (for example, from Covered California or another insurance marketplace) and coverage under Tricare, Medicare and Medi-Cal are not qualifying group health plan coverage for purposes of the FlexCash Benefit Program. Alternative Coverage A. Medical insurance carrier s name Policy Number B. Dental insurance carrier s name Policy Number Complete this section ONLY if your other non-csu medical and/or dental insurance coverage is through your spouse s (or domestic partner s*) plan(s). Spouse s (or domestic partner s*) SSN: I understand that my FlexCash election in lieu of Health Coverage will continue from year to year until I take action to change or cancel my enrollment. I understand that my benefit elections are regulated under Section 125 of the Internal Revenue Service (IRS) Code. I understand that regulations under the IRS Code require that my benefit choices authorized by this election are irrevocable until the next scheduled open enrollment unless I have a valid Change in Status Field as defined in IRS Code Section 125 or other permitting events. I have read and agree to the terms and conditions of the FlexCash Program as outlined on this form and in the FlexCash Brochure. Employee s Signature: Date Signed: FOR CAMPUS USE ONLY 7. Effective Date of Action 8. Employee CBID 9. Permitting Event Date 10. Permitting Event Code Mo Day -1- Year Mo Day Year 11. Health Form Attached? (HBD12) 12. Dental Form Attached? (STD 692) 13. Agency Code 14. Unit Code 15. Campus Name Yes No Yes No 16. Remarks: 17. Authorized Campus Signature I hereby certify under penalty of perjury as follows: That I am the duly appointed, qualified and acting officer of the herein named agency and that I am authorized to make this certification; that the employee named herein is eligible for enrollment in the CSU FlexCash Program. Signature: 18. ADDRESS OF AUTHORIZED CAMPUS BENEFITS OFFICER SIGNER: 19. Date Received: 20. Telephone Number: *Employees who obtain alternative non-csu coverage through a domestic partner are not required to submit proof of registration through the Secretary of State process to enroll in the FlexCash Program. DISTRIBUTION: ORIGINAL - State Controller s Office COPY Campus COPY- Employee (with privacy notice) Revised October 2015

2 The Affordable Care Act (ACA) establishes a minimum value standard of a benefits of health plan. For a qualifying group health plan to meet the ACA s minimum value standards, the plan must cover at least 60 percent of the total allowed costs of benefits provided under the plan. Employees may refer to their plan s Summary of Benefits and Coverage document to determine if their coverage meets the law s minimum value standards. For more information on qualifying group coverage refer to the FlexCash brochure located on CSU s website at flexible/tapp.page.shtml. PRIVACY NOTICE The Information Practice Act of 1977 (Civil Code Section ) and the Federal Privacy Act (Public Law ) require that this notice be provided when collecting personal information from individuals. Information requested on this form is used by the State Controller s Office and the program administrator for the purposes of identification and account processing. It is mandatory to furnish all information requested on this form except for marital status, which may be furnished on a voluntary basis. Failure to provide the mandatory information may result in the enrollment elections not being processed or being processed incorrectly. The State Controller s Office requires the employee s social security number and name for identification purposes. Legal references authorizing maintenance of this information include Government Code Sections 1151 and 1153, Sections 6011 and 6051 of the Internal Revenue Code, and Regulation 4, Section , Code of Federal Regulations, under Section 218, Title II of the Social Security Act. Copies of the FlexCash Enrollment Authorization are maintained in confidential files of the State Controller s Office for five years. Employees have the right of access to copies of their Enrollment Authorization forms upon request. The official responsible for the maintenance of the forms is: Chief of Personnel/Payroll Services Division, State Controller s Office, Post Office Box 94250, Sacramento, California

3 California State University, Fresno Human Resources 2016 Open Enrollment Benefits Worksheet This document must be received by HR, Joyal Administration Bldg, Room 211 by 5:00 p.m. on Friday, October 7, SECTION 1. Employee s Information Employee s Legal Name Fresno State ID: Marital Status Single Married Domestic Partnership Gender Male Female Staff/Administrator Bargaining Unit Faculty If ADDING Spouse or Domestic Partner -Is spouse or domestic partner employed by CSU, State civil service or a CalPERS Public Agency? NO YES -- Employer: Address (Number & Street, City, State & Zip) If address has changed, please update your address using myfresnostate (Employee Self-Service). Department Office Ext. Home/Cell Phone SECTION 2. Type of Transaction Check as many as apply: Change MEDICAL plan from to Select new plan in SECTION 3. Change DENTAL plan from to Select new plan in SECTION 3. Change: Add Dependent(s) - List dependent(s) in SECTION 4. * Review back of worksheet for eligibility and required document(s).* Change: Delete Dependent(s) - List dependent(s) in SECTION 4. Change: Enroll in FLEXCASH Change: Cancel FLEXCASH Cancel Medical plan: Dental plan: Enroll in FlexCash Medical($128) FlexCash Dental($12) ATTACH FlexCash form & copy of proof of alternate NON-CSU coverage and appropriate documents (e.g. birth certificate, marriage certificate, domestic partnership). Cancel FlexCash Medical ($128) FlexCash Dental($12) ATTACH FlexCash Cancellation form and appropriate documents (e.g. birth certificate, marriage certificate, domestic partnership) 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 (below). SECTION 3. Medical Plan Options Select new plan Anthem Blue Cross Select*(HMO) Anthem Blue Cross Traditional*(HMO) BlueShield Access + *(HMO) Health Net SmartCare* (HMO) Kaiser *(HMO) United Healthcare Alliance*(HMO) PERSChoice (PPO) PERS Care (PPO) PERS Select (PPO) PORAC (PPO) - This medical plan is restricted to SUPA members *Zip Code Election: If you are not eligible to enroll in an HMO plan based on your residence s zip code and you wish to enroll in an HMO based on California State University, Fresno s zip code, an additional form must be completed. PLEASE CONTACT HUMAN RESOURCES (559) Dental Plan Options Select new plan DELTA DENTAL (PPO) DELTA CARE USA (HMO) If no provider is listed, Delta Care will assign provider. Specify provider name & facility: SECTION 4. IMPORTANT ENROLLMENT INFORMATION FOR DEPENDENTS See reverse side for eligibility. NEW ENROLLMENTS: List all eligible dependents (including yourself) to be enrolled in health and/or dental plan. CHANGES: List all currently enrolled dependents (including yourself) for all plans with N/A action. Then list any new dependents to be added or deleted. Check reverse side of this form for required documentation for adding a dependent. Relationship CIRCLE Gender LEGAL- NAME (FIRST, M.I., LAST) SOCIAL SECURITY# Medical Dental DATE OF BIRTH CIRCLE ACTION SELF F M Add Delete Change NA F M Add Delete Change NA F M Add Delete Change NA F M Add Delete Change NA F M Add Delete Change NA F M Add Delete Change NA F M Add Delete Change NA Please check each statement & sign below. I understand that my changes noted above will become effective January 1, I understand my request to change health/dental plan will be processed electronically based on this 2016 Open Enrollment Worksheet. I understand that in order to add dependent(s), a SSN(s) and copy of Birth Certificate(s) for each dependent is required. Employee s Signature: Date: 9/16 OFFICE USE: Pending-- Copy of Marriage Certificate or Declaration of Domestic Partnership SSN(s) and/or copy of Birth Certificate(s) Documents Received:

4 During the open enrollment period, eligible employees may enroll as new, change plans, or add/delete eligible dependents to their health/dental plans. Open Enrollment requests will be accepted beginning September 12, 2016 October 7, 2016 by 5:00 p.m. at Joyal Administration, Room 211. Based on the CalPERS and State Controller s deadlines and processing time, no exceptions can be made. CALPERS GUIDELINES & DEPENDENT INFORMATION All health plans require a Social Security number and a copy of Birth Certificate for each dependent. *Eligible Dependent(s) - Additional required documentation for adding dependents are noted below: Spouse (opposite-sex and same-sex) and Domestic Partners (same-sex over the age of 18 or opposite sexpartners if over the age of 62). Requires a copy of Marriage Certificate or Domestic Partnership. Former spouses or former domestic partners are not eligible. Natural children, stepchildren or adopted children under the age of 26 regardless of whether or not they are living with you or marriage status. Social Security number(s) in addition to a copy of birth certificate, adoption papers or other supporting documents are required. Disabled Child over age 26, who is incapable of self support due to a mental or physical condition that existed prior to age 26, may be eligible to enroll in your health plans. A Questionnaire for the CalPERS Disabled Dependent Benefit Form (HBD-98) and Medical Report for the CalPERS Disabled Dependent Benefit Form (HBD-34) must be approved by CalPERS prior to enrollment and must be updated upon CalPERS request. Please contact Human Resources for additional information (559) Other: Another person's child under the age of 26 in a Parent-Child Relationship. [Contact Human Resources for additional paperwork - Affidavit of Parent-Child Relationship (HBD-40) and documentation must be provided for each dependent upon request for enrollment and if approved, re-certification with documentation is required each year to continue dependent(s) on-going enrollment.] Split Enrollments: Members who are married and who both work or worked (retirees), for agencies in the CalPERS Health Program can enroll separately. If you and your spouse 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 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. 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. Family Status Changes Outside of Open Enrollment Although CalPERS administers our health plans, all changes MUST be coordinated through Human Resources. It is the employee's responsibility to notify Human Resources within 60 days when there are any changes in their family status in order to add/delete eligible dependent(s). Additions and deletions of eligible dependents are effective the first of the month following the permitting event or receipt of Benefits Worksheet and documentation. Family Status Changes include: Marriage and Domestic Partnership (Requires Copy of Marriage Certificate or Declaration Domestic Partnership); Birth of a child, Adoption, or Acquisition of a dependent child (Parent-Child Relationship- Contact HR); Eligible dependent moves out; Divorce, Legal Separation and Death (documentation required) If eligible dependent(s) are not added or deleted within 60 days of a Family Status Change, dependent(s) may be added during Open Enrollment (Mid-September through Early-October) and will become effective the following plan year on January 1 st.

5 C Member Account Management Division P.O. Box Sacramento, CA (888) CalPERS (or ) TTY (877) FAX (800) Currently enrolled as a dependant on a Fresno State Health plan under employee Peoplesoft ID: Declaration of Health Coverage: HBD-12A (INSTRUCTIONS ON REVERSE) EMPLOYEE INFORMATION SOCIAL SECURITY NUMBER NAME (FIRST) (MIDDLE) (LAST) - - PART A I elect to enroll myself and all eligible dependents. PART B-1 I elect to enroll myself. My eligible dependents have other health PART B-2 I elect to enroll myself and all eligible dependents. I also have eligible dependents who have other health PART C-1 I decline enrollment for myself and my eligible dependents because we have other health PART C-2 I decline enrollment for myself and/or my eligible family members for reasons other than having health If you or your dependents lose health insurance coverage, you can enroll in the CalPERS Health Benefits Program. You must request enrollment within 60 days from the date you lose coverage. If you do not request enrollment within 60 days, you or your dependents must wait at least 90 days or until the next Open Enrollment Period before you can enroll in the Program. Your effective date of coverage will be the first of the month following the 90-day waiting period or the Open Enrollment effective date. You can request enrollment for yourself and/or your dependents at any time. You must wait at least 90 days after you request enrollment or until the next Open Enrollment Period before you can enroll in the Program. Your effective date of coverage will be the first of the month following the 90 day waiting period or the Open Enrollment effective date. PART B: If you are currently enrolled in the Health Benefits Program and you acquire new dependents or if a court orders health coverage for your dependents, you can add your new dependents. See your Health Benefits Officer or visit your personnel office for applicable time limits. PART C: If you are not currently enrolled in the Health Benefits Program and you acquire new dependents as a result of marriage, birth, adoption, or placement for adoption, or if a court orders health coverage for your dependents, you can enroll yourself and dependents. See your Health Benefits Officer or visit your personnel office for applicable time limits. Special rules apply to retirement and death. Please read the back of this form carefully. Member s Signature Date Signed Health Benefits Officer s Signature Rev 12/15 Original: Employee s Personnel File Copy: Employee

6 INSTRUCTIONS DECLARATION OF HEALTH COVERAGE (HBD-12A) Please contact your Health Benefits Officer if you have any questions regarding the HBD 12A. Employee Complete with the appropriate employee information. Information Part A: a) Enrolling in the Health Benefits Program and have no dependents, or b) Enrolling yourself and ALL eligible dependents in the Health Benefits Program. Part B-1: Part B-2: Part C-1: Part C-2: a) Enrolling yourself only, your dependents have other health insurance coverage, or b) Canceling your dependents coverage because they have other health insurance coverage a) Enrolling yourself and SOME of your dependents, your other dependents have health insurance coverage, or b) Canceling coverage for some of your dependents because they have other health a) Declining enrollment or canceling your health insurance coverage, you have no dependents and you have other health coverage, or b) Declining enrollment or canceling your health insurance coverage for yourself and eligible dependents and you have other health a) Declining enrollment or canceling your health insurance for reasons other than having health insurance coverage and you have no dependents, or b) Declining enrollment or canceling your health insurance coverage for yourself and eligible dependents for reasons other than having health IMPORTANT: It is your responsibility to notify your personnel office when there are any changes in your family situation. Changes include marriage, acquisition of a dependent child, divorce, legal separation, and death. Failure to notify your personnel office may result in adverse consequences. Special rules to consider for retirement and death: Retirees: you are eligible to enroll in a CalPERS health plan if you meet all of the criteria below: Your retirement date is within 120 days of separation from employment You are eligible for health benefits upon separation You receive a monthly retirement allowance You retire from the State, California State University (CSU), or an agency that currently contracts with CalPERS for health benefits Survivor Death Benefit: your dependents may enroll in a CalPERS health plan as a survivor as long as they: Are eligible for enrollment as a dependent on the date of death of a CalPERS retiree Receive a monthly survivor check Continue to qualify as an eligible family member Dependents who are enrolled at the time of the employee or annuitant s death and meet the eligibility requirements can continue the health enrollment as a survivor. Dependents who are not enrolled and meet the eligibility requirements may enroll in a health plan within 60 days of the employee or annuitant s death, or during Open Enrollment. The effective date of enrollment is the first day of the month following the date CalPERS receives the request. Exceptions may apply for certain contracting agency survivors who do not receive a monthly survivor check. Your survivor will need to contact your former employer for additional information.

7 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 Information Purpose The information requested is collected pursuant to the Government Code (sections 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 CalPERS being unable to perform its functions regarding your status. Please do not include information that is not requested. Social Security Numbers Social Security numbers are collected on a mandatory and voluntary basis. If this is CalPERS first request for disclosure of your Social Security number, then disclosure is mandatory. If your Social Security number 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 CalPERS and other state agencies 5. Coordination of benefits among carriers 6. Resolving 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 to the CalPERS Privacy Officer at 400 Q Street, Sacramento, CA or call us at 888 CalPERS (or ). May 2016

Conditional Cash In Lieu of County Sponsored Health Insurance

Conditional Cash In Lieu of County Sponsored Health Insurance Human Resources Use Only Effective Date: Date of Hire: Amount: Certified by: Medi-Cal Tricare Schools Employer Plan CHIP Medicare Part A Full-Time