THE CALIFORNIA STATE UNIVERSITY Office of the Chancellor 401 Golden Shore Long Beach, California (562)

THE CALIFORNIA STATE UNIVERSITY Office of the Chancellor 401 Golden Shore Long Beach, California 90802-4210 (562) 951-4411 Date: March 5, 2004 Code: TECHNICAL LETTER To: From: Subject: Human Resources Directors Benefits Managers Payroll Managers Cathy Robinson, Assistant Vice Chancellor Human Resources Administration Eligibility Criteria for CSU Voluntary Benefit Plans The California State University (CSU) provides multiple voluntary benefit plans to eligible represented and unrepresented employees. To assist campuses in administration of voluntary benefit plans, Human Resources Administration has compiled and attached the Description of Benefit, Enrollment Periods, Eligibility Criteria, and Enrollment Forms and Codes for each of the following voluntary benefit plans: A. FlexCash B. Tax Advantage Premium Plan (TAPP) C. Health Care Reimbursement Account Plan (HCRA) Dependent Care Reimbursement Account Plan (DCRA) D. DPA Savings Plus Plan (401(k)/457) E. Tax Sheltered Annuity (TSA) 403(b) Plan F. Pre Tax Parking G. Voluntary Life Insurance H. Voluntary Automobile and Homeowner Insurance I. Voluntary Insurance Plans Please refer to the referenced attachments for detailed information. Campuses also may refer to benefit Administrative Guides and Technical Letters for additional information, as appropriate. Please contact Human Resources Administration at (562) 951-4411 if you have questions regarding this information. This Technical Letter is also available via Human Resources Administration s Web page at: http://www.calstate.edu/hradm/memos.shtml. CR/pc Attachments Distribution: CSU Presidents Vice Chancellor, Human Resources Associate Vice Presidents/Deans of Faculty Director, SOSS

ATTACHMENT A Page 1 of 7 FlexCash Enrollment Code: 381-001 Effective Date of Benefit: August 1, 1992 Plan Year Period: January 1 December 31 Pre-tax Benefit: No Enrollment Method: CSU FlexCash Form Description of Benefit FlexCash allows eligible CSU employees to waive medical and/or dental coverage in exchange for a taxable cash allowance. Participants must submit proof of verifiable non-csu medical and/or dental coverage. Current cash allowance is as follows: Medical coverage waived - $128 Dental coverage waived - $12 Newly hired eligible employees have sixty days in which to enroll in the benefit. After the sixty-day limit, enrollment is allowable only in the occurrence of a change in status (as defined), or during the annual benefits open enrollment period (dates announced in benefits technical letter). Enrollment Periods First 60 days of employment Annual open enrollment Within 60 days of an allowable change in status (see Appendix B in FlexCash Admin Guide) Change In Status Events Affect Plan Eligibility Change in status events are defined by the IRS regulations. Allowable change in status events include: Marriage, divorce, annulment or legal separation, or dissolution of domestic partnership; Death of spouse, domestic partner, or dependent (or loss of eligible dependent status); Birth, adoption or placement for adoption of a child, or change in dependency status of an Employee s child; Change in custody that affects the child s eligibility for coverage under this Plan or the plan of the child s parent; Termination or commencement of employment of employee, spouse or domestic partner, or dependent; Change from full-time to part-time employment (or vice versa) by either Employee or spouse or domestic partner, if the change affects the Employee s medical and/or dental coverage; Gain or loss of alternative non-csu coverage; A significant change in the alternative non-csu coverage; Entitlement to Medicare or Medicaid by an Employee, spouse or domestic partner, or dependent; or A change in worksite or residence resulting in eligibility or cessation of the Employee s coverage under any health maintenance organization offered through the plan; Starting or returning from an unpaid leave of absence by either Employee or spouse or domestic partner. Other circumstances approved by the Plan Administrator in a nondiscriminatory manner and consistent with Applicable Laws and Regulations. With the exception of the following, employees have sixty days in which to enroll, cancel or change due to a change in status event: Loss of alternative non-csu medical and/or dental coverage (no limit) Employment change to less than half-time (no limit)

ATTACHMENT A Page 2 of 7 Pre-paid The effective date of this benefit is the 1 st of the month following the pay period that the first deduction is taken. Staff and Non-AY Faculty example: 2. Enrollment form received and processed during August pay period 3. Additional cash added to employee s September 1 pay warrant Additional example: 2. Employee decides in October to enroll 3. Enrollment form received and processed during October pay period 4. Additional cash added to employee s November 1 pay warrant AY example: 2. Deduction taken 1 st pay period of AY calendar (September) 3. Additional cash added to employee s October 1 pay warrant Enrollment End Date Actives: The first day of the month employee is enrolled in a CSU paid health and/or dental plan, either as an employee or a dependent. The first day of the month CSU is required to provide coverage to employee s dependent child as required by a medical child support under section 609(a) of ERISA. The first day of the following month in which the time base falls below 0.5, or 0.4 for AB 211 employees. Separated Employees/Retirees: Last day of the month in which an active employee retires or separates from the campus. Specific Eligibility Criteria Eligibility for enrollment is contingent upon the employee being considered benefits eligible for CSU medical and dental benefits. Regular Eligibility Criteria Eligible: All represented and unrepresented employee groups Eligible: All active positions Eligible: An employee who is a dependent of a CSU retiree is eligible for FlexCash for health only; no FlexCash for dental Ineligible: Rehired annuitants, FERPS, hourly intermittent employees and employees appointed in any classification excluded from benefits (refer to TL HR/Benefits 2004-09, Attachment F). Ineligible: Employees on unpaid leaves of absence, including FMLA Ineligible: Employees covered as a dependent of another active CSU employee Sum of FTE for all active positions must be > = 0.5 Employee is on a Pre-Retirement Reduction in Time Base (PIMS field, Item 962 = 7552) and was benefits eligible previously (eligible faculty employees only refer to TL HR/Benefits 2003-11). Appointment Duration at least one position must qualify Permanent/probationary appointments (no appointment expiration date). Employee on a Pre-retirement Reduction in Time Base who was benefits eligible previously. Temporary appointment of at least 6 months and 1 day from appointment effective date to appointment expiration date.

ATTACHMENT A Page 3 of 7 Temporary appointment less than 6 months and 1 day continuous with no break in service between this appointment and previous benefits-eligible appointment. A transaction such as a temporary promotion, reclassification, or reassignment for less than 6 months and 1 day given to a benefits eligible permanent/probationary employee. Mid appointment increases to FTE and the original effective date of the appointment (not the effective date of the increase in FTE) and appointment expiration date is at least 6 months and 1 day (TL HR/Benefits 2003-06). Summer quarter classes where the intent is to appoint the employee to a qualifying permanent position in the fall quarter. Classes are 2389, 2390, 2402, 2395, 2367, 2394, 2368, and 2357. This is a campus manual process. Once an employee is benefits eligible, benefits continue in subsequent consecutive appointments as long as FTE > = 0.5 regardless of length of appointment. Sum FTE for all CSU positions meeting the criteria under Employee Group. The appointment with the longest appointment expiration date is used to determine eligibility based on duration. AB 211 Eligibility Criteria (Effective Date Of Benefit: July 1, 2003) Eligible: Part-time lecturers and coaches in class codes 0357, 0360, 0361, 0364, 0365, 0557, 0560, 0564, 2308, 2358, 2375, 2378, 2381, and 2384 who do not meet the regular eligibility criteria. Ineligible: Employees on unpaid leaves of absence, including FMLA. Sum of FTE for all qualifying positions in the CSU must be >= 0.4 (and up to 1.0) Appointment Duration - at least one position must qualify Minimum of one semester or two consecutive quarters. Mid appointment increases to FTE and the original effective date of the appointment (not the effective date of the increase in FTE) and appointment expiration date is at the end of one semester, two consecutive quarters or the Academic Year (TL HR/Benefits 2003-06). Once an employee is benefits eligible, benefits continue in subsequent consecutive appointments as long as FTE > = 0.4 regardless of length of appointment. Sum FTE for all CSU positions meeting the criteria under Employee Group. The appointment with the longest appointment expiration date is used to determine eligibility based on duration. Grandfathered Eligibility Criteria Eligible: Part-time lecturers and coaches in class codes 2308, 2358, 2375, 2378, 2381, or 2384 who do not meet the regular eligibility criteria. Ineligible: Employees on unpaid leaves of absence, including FMLA. Sum of FTE for all qualifying positions in the CSU must be >= 0.4 but <= 0.49 Appointment Duration at least one position must qualify Temporary appointment of at least six months and one day from appointment effective date to appointment expiration date.

ATTACHMENT A Page 4 of 7 Mid appointment increases to FTE and the original effective date of the appointment (not the effective date of the increase in FTE) and appointment expiration date is at least 6 months and 1 day (TL HR/Benefits 2003-06). Once an employee is benefits eligible, benefits continue in subsequent consecutive appointments as long as FTE is >= 0.4 but <= 0.49 regardless of length of appointment. Sum FTE for all CSU positions meeting the criteria under Employee Group. The appointment with the longest appointment expiration date is used to determine eligibility based on duration. Enrollment Form and Codes The FlexCash enrollment form and the corresponding codes appear on the following pages.

The California State University FLEXCASH PROGRAM ENROLLMENT AUTHORIZATION TECHNICAL LETTER ATTACHMENT A Page 5 of 7 Please type or use ballpoint pen, print clearly. Return completed form to campus Benefits Officer. SEE PRIVACY NOTICE ON REVERSE OF EMPLOYEE COPY 2. SOCIAL SECURITY NO. 3. MARITAL STATUS 1. TYPE OF ENROLLMENT (Check appropriate box) ANNUAL/OPEN ENROLLMENT 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 381-001 Monthly Total $ 6. Statement of Other Medical and/or Dental Coverage This section must be completed if you choose cash instead of your own CSU medical and/or dental insurance plans. In Item C enter the total monthly cash option amount (sum of the amounts entered in items A and B). I certify that I am covered by another non-csu medical and/or dental plan(s). I certify that I will maintain coverage in this medical and/or dental insurance plan(s) 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). 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 have reviewed the FlexCash Brochure describing the CSU s optional FlexCash Plan, including the legal definitions and change in benefit election limitations authorized 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 form are irrevocable during this plan year unless I experience an allowable family status change event as defined in these regulations or other permitting events as described in the FlexCash brochure. I understand that my FlexCash enrollment in lieu of medical and/or dental coverage will continue from year to year until I complete a new FlexCash Enrollment Authorization form to change or cancel FlexCash enrollment. 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. Date Received: 19. 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)

ATTACHMENT A Page 6 of 7 NEW ENROLLMENTS PERMITTING EVENT CODE PERMITTING EVENT DATE TIME EFFECTIVE LIMIT DATE Description of the event Box 10 Box 9 Box 7 New employee 01 Appointment date 60 days Standard New enrollment during open enrollment 03 Open enrollment start date Open enrollment period only As determined by open enrollment schedule Enrollment due to gain of alternative non-csu 05a Date of Event 60 days Standard medical and/or dental coverage Enrollment due to starting or returning from an 07 Date of return to active work 60 days Standard unpaid leave of absence by either employee or spouse or registered domestic partner (also includes military, NDI and sabbatical paid leaves.) Enrollment due to new marriage, registration of 17 Date of Event 60 days Standard domestic partnership, or birth or adoption of a child Enrollment due to termination or commencement 37 Date of Event 60 days Standard of spouse s or domestic partner s employment; or change to/from full-time employment of employee or spouse or domestic partner, if change affects medical and/or dental coverage. Enrollment due to significant change in alternative non-csu coverage 55 Date of Event 60 days Standard CHANGE OF ENROLLMENT Change during open enrollment 03 Open enrollment start date Open enrollment period only Change due to gain of alternative non-csu medical and/or dental coverage Change due to loss of alternative non-csu medical and/or dental coverage Change due to starting or returning from an unpaid leave of absence by either employee or spouse or registered domestic partner (also include military and sabbatical paid leaves.) Change due to new marriage, registration of domestic partnership, or birth or adoption of a child. Change due to divorce or dissolution of domestic partnership (mandatory deletion from medical and dental plans); or death of spouse or registered domestic partner, or dependent (or loss of eligible dependent status). Change due to significant change in alternative non-csu coverage As determined by open enrollment schedule 05a Date of Event 60 days Standard 05b Date of Event No limit Mandatory 07 Date of return to active work 60 days Standard 17 Date of Event 60 days Standard 27 Date of Event 60 days Standard 55 Date of Event 60 days Standard

ATTACHMENT A Page 7 of 7 CANCELLATIONS PERMITTING EVENT CODE PERMITTING EVENT DATE TIME EFFECTIVE LIMIT DATE Description of the event Box 10 Box 9 Box 7 Cancel during open enrollment 03 Open enrollment start date Open enrollment period only As determined by open enrollment schedule Cancel due to loss of alternative non-csu 5a Date of Event No limit Mandatory coverage Cancel due to starting or returning from an 07 Date of return to active work 60 days Standard unpaid leave of absence by either employee or spouse or registered domestic partner (also include military and sabbatical paid leaves.) Cancel due to new marriage, registration of 17 Date of Event 60 days Standard domestic partnership, or birth or adoption of a child. Cancel due to divorce, or dissolution of 27 Date of Event 60 days Standard domestic partnership (would also require mandatory deletion from medical and dental if enrolled), or death of spouse or registered domestic partner, or dependent (or loss of eligible dependent status). Cancel due to termination or commencement of 37 Date of Event 60 days Standard spouse s or domestic partner s employment; or change to/from fulltime employment of employee or spouse or domestic partner, if change affects medical and/or dental coverage. Cancel due to employment change to less than half-time (no employee signature required). 38 Date status changes No limit First day of 2 nd month following permitting event Administrative deletion of ineligible employee 42 Date of initial enrollment No limit Mandatory (no employee signature required). For those who were never eligible. Cancel due to significant change in alternative non-csu coverage 55 Date of Event 60 days Standard OPEN ENROLLMENT PERIOD EVENT CODE New enrollment, cancellation, or change of FlexCash option 03 Open enrollment date start Open enrollment period only As determined by open enrollment schedule EXCEPTIONS Exceptions 44 Apply dates to match the situation. Requires approval of President, Chancellor, or his/her designee EXPLANATION OF EFFECTIVE DATE TERMS USED Standard Effective Date If a properly completed FlexCash Enrollment Authorization form is received in the State Controller s Office by the 10 th of the month, the effective date of enrollment, change of enrollment, or cancellation is the first of the month following. Mandatory Effective Date Enrollment ceases on the first of the month following the permitting event date. State Controller s Office policy limits retroactive processing to 36 months (3 years).

ATTACHMENT B Page 1 of 3 Tax Advantage Premium Plan (TAPP) Enrollment Code: 376-XXX (X code tied to CalPERS health plan) Effective Date of Benefit: January 1, 1990 Pre-tax Benefit: Yes Enrollment Method: Automatic Description of Benefit The Tax Advantage Premium Plan is also known as the CSU Premium Conversion Plan. TAPP allows eligible employees to pay contributions toward CSU-sponsored health plans on a pre-tax basis. Under TAPP, health plan premiums are exempt from Federal and State income taxes and from FICA (Social Security) taxes. TAPP has no other impact on salary based benefits, including the employee s CalPERS contributions. Employees eligible to enroll in a CSU health plan are automatically eligible for TAPP enrollment, and enrollment is coordinated between both benefit programs. When an employee enrolls in a health plan, enrollment in TAPP is automatic, unless the employee chooses to opt out of TAPP. If the employee opts out, the employee s portion of the health premium is taken AFTER taxes. To opt out of TAPP, the campus benefits representative completes the 674 form specifying employee decision that health benefits be non-tapp. The SCO codes the enrollment and forwards copy of the HBD-12 to CalPERS for processing. If 376 precedes the org code of the health plan, it is an indication that the employee is enrolled in TAPP. Data for employees not enrolled in TAPP will only reflect the three digits of the health plan s org code. An employee can choose to enroll and/or opt out during the first 60 days of enrolling in a health plan, within sixty days of a change in status event (as defined), or during any subsequent open enrollment period. Enrollment Periods First 60 days of employment that an employee chooses to enroll in a health plan Annual open enrollment Within 60 days of an allowable change in status Change In Status Events Affect Plan Eligibility Change in status events are defined by the IRS regulations. Allowable change in status events include: Marriage, divorce, annulment or legal separation, domestic partnership or dissolution of domestic partnership; Death of spouse, domestic partner, or dependent (or loss of eligible dependent status); Birth, adoption or placement for adoption of a child, or change in dependency status of an Employee s child; Change in custody that affects the child s eligibility for coverage under this Plan or the plan of the child s parent; Termination or commencement of employment of employee, spouse or domestic partner, or dependent; Change from full-time to part-time employment (or vice versa) by either Employee or spouse or domestic partner, if the change affects the Employee s medical and/or dental coverage; Gain or loss of alternative non-csu coverage; A significant change in the alternative non-csu coverage; Entitlement to Medicare or Medicaid by an Employee, spouse or domestic partner, or dependent; or A change in worksite or residence resulting in eligibility or cessation of the Employee s coverage under any health maintenance organization offered through the plan; Starting or returning from an unpaid leave of absence by either Employee or spouse or domestic partner; or Other circumstances approved by the Plan Administrator in a nondiscriminatory manner and consistent with Applicable Laws and Regulations.

ATTACHMENT B Page 2 of 3 Pre-paid The effective date of this benefit is the 1 st of the month following the pay period that the first deduction is taken. Staff and Non-AY Faculty example: 2. Deduction taken August pay period 3. Coverage starts September pay period AY example: 2. Deduction taken 1st pay period of AY calendar (September) 3. Coverage starts October pay period Coverage End Date One month after final deduction Regular Eligibility Criteria Eligible: All represented and unrepresented employees. Eligible: All active positions. Ineligible: rehired annuitants, FERPS, hourly intermittents and employees in the classifications listed in TL HR/Benefits 2004-09, Attachment F. Ineligible: Employee on a Family Medical Leave. The employee s portion of health benefit premiums is paid by an accounts receivable (AR) set up by the campus; therefore TAPP is not applied. Employer s portion of health premiums is processed manually through the SCO via form 674). Ineligible: Employees on unpaid leaves of absence, causing health premiums to be interrupted. Ineligible: Employees who are on direct payment to continue health premiums. Sum of FTE for all active positions in the CSU must be >= 0.5; or, Employee is on a Pre-retirement Reduction in Time Base (PIMS field, Item 962 = 7552) and was benefits eligible previously (eligible faculty employees only refer to TL HR/Benefits 2003-11). Appointment Duration at least one position must qualify Permanent/probationary appointments (no appointment expiration date). Employee on a Pre-retirement Reduction in Time Base who was benefits eligible previously. Temporary appointment of at least 6 months and 1 day from appointment effective date to appointment expiration date. Temporary appointment less than 6 months and 1 day continuous with no break in service between this appointment and previous benefits-eligible appointment. A transaction such as a temporary promotion, reclassification, or reassignment for less than 6 months and 1 day given to a benefits eligible permanent/probationary employee. Mid appointment increases to FTE and the original effective date of the appointment (not the effective date of the increase in FTE) and appointment expiration date is at least 6 months and 1 day (TL HR/Benefits 2003-06). Summer quarter classes where the intent is to appoint the employee to a qualifying permanent position in the fall quarter. Classes are 2389, 2390, 2402, 2395, 2367, 2394, 2368, and 2357. This is a campus manual process. Sum FTE for all CSU positions meeting the criteria under Employee Group. The appointment with the longest appointment expiration date is used to determine eligibility based on duration.

ATTACHMENT B Page 3 of 3 AB 211 Eligibility Criteria Eligible: Part-time lecturers and coaches in class codes 0357, 0360, 0361, 0364, 0365, 0557, 0560, 0564, 2308, 2358, 2375, 2378, 2381, and 2384 who do not meet the regular eligibility criteria. Ineligible: Employee on a Family Medical Leave. The employee s portion of health benefit premiums is paid by an accounts receivable (AR) set up by the campus; therefore TAPP is not applied. Employer s portion of health premiums is processed manually through the SCO via form 674). Sum of FTE for all qualifying positions in the CSU must be >= 0.4 (and up to 1.0) Appointment Duration at least one position must qualify Minimum of one semester or two consecutive quarters. Mid appointment increases to FTE and the original effective date of the appointment (not the effective date of the increase in FTE) and appointment expiration date is at the end of one semester, two consecutive quarters or the Academic Year (TL HR/Benefits 2003-06). Sum FTE for all CSU positions meeting the criteria under Employee Group. The appointment with the longest appointment expiration date is used to determine eligibility based on duration. Grandfathered Eligibility Criteria Eligible: Part-time lecturers and coaches in class codes 2308, 2358, 2375, 2378, 2381, or 2384 who do not meet the regular eligibility criteria. Ineligible: Employee on a Family Medical Leave. The employee s portion of health benefit premiums is paid by an accounts receivable (AR) set up by the campus; therefore TAPP is not applied. Employer s portion of health premiums is processed manually through the SCO via form 674). Sum of FTE for all qualifying positions in the CSU must be >= 0.4 but <= 0.49 Appointment Duration at least one position must qualify Temporary appointment of at least six months and one day from appointment effective date to appointment expiration date. Mid appointment increases to FTE and the original effective date of the appointment (not the effective date of the increase in FTE) and appointment expiration date is at least 6 months and 1 day (TL HR/Benefits 2003-06). Once an employee is benefits eligible, benefits continue in subsequent consecutive appointments as long as FTE is >= 0.4 but <= 0.49 regardless of length of appointment. Sum FTE for all CSU positions meeting the criteria under Employee Group. The appointment with the longest appointment expiration date is used to determine eligibility based on duration.

ATTACHMENT C Page 1 of 10 Health Care Reimbursement Account Plan (HCRA) Enrollment Code: 378-017 (Code changes annually) Administrative Fee Deduction Code: 375-001 Effective Date of Benefit: June 1, 2001 Plan Year Period: January 1 December 31 Pre-tax Benefit: Yes Enrollment Method: HCRA/DCRA Enrollment Form Description of Benefit The Health Care Reimbursement Account Plan (HCRA) allows eligible CSU employees to pay for eligible out-ofpocket medical expenses with pre-tax payroll deductions pursuant to Internal Revenue Service (IRS) code 125. The payroll deductions are taken in equally monthly installments based on an annual amount chosen by the employee. Yearly contributions to this plan can be a minimum of $240 up to a maximum of $5,000, which equates to a minimum monthly payroll deduction of $20 up to a maximum of $416.66. Participation in this plan automatically prompts the State Controller s Office to apply an administrative fee for each contribution through deduction code 375-001. Currently, the administrative fee for this plan is $2.00 per month. Once enrolled in the plan, the employee s participation is locked for the 12-month plan period unless the employee separates from the campus or has a qualifying change in status event. Newly hired eligible employees have sixty days in which to enroll in the benefit. After the sixty-day limit, enrollment is allowable only in the occurrence of a change in status (as defined), or during the annual benefits open enrollment period (dates announced in benefits technical letter). Enrollment Periods First 60 days of employment Annual open enrollment (required to continue or start enrollment from plan year to plan year) Within 60 days of an allowable change in status (see Appendix C in HCRA/DCRA Administrative Guide) Change In Status Events Affect Plan Eligibility Change in status events are defined by the IRS regulations and allow eligible participants to stop, start, cancel or enroll in the plan outside of the standard initial enrollment and/or annual open enrollment period. Allowable change in status events include: Change in Legal Marital Status Marriage, divorce, death of Spouse, legal separation or annulment; Change in Number of Dependents The birth, death, adoption, loss or gain of domestic partner or loss or gain of legal custody or placement for adoption of a child; Termination/Commencement of Employment The beginning or the end of employment of the Employee, Spouse or Dependent that impacts the Employee s, Spouse s, or Dependent s eligibility; Dependent Eligibility Events that cause a Dependent to satisfy or cease to satisfy eligibility requirements for coverage on account of attainment of age, student status, or any similar circumstances; The events listed above qualify as a change in status event only if the change causes a gain or loss of eligibility for coverage under the CSU or other plan. Other change in status events include: Entitlement to Medicare or Medicaid Employee, Spouse or Dependent gains or loses eligibility for Medicare or Medicaid; or Judgment, decree, court order, or Qualified Medical Child Support Order (QMCSO). Pre-paid The effective date of this benefit is the 1 st of the month following the pay period that the first deduction is taken. Staff and Non-AY Faculty example: 2. Enrollment form received and processed during August pay period 3. Deduction appears on September 1 pay warrant

ATTACHMENT C Page 2 of 10 Additional example: 2. Employee decides in October to enroll 3. Enrollment form received and processed during October pay period 4. Deduction appears on employee s November 1 pay warrant AY example: 2. Deduction taken 1 st pay period of AY calendar (September) 3. Deduction appears on employee s October 1 pay warrant Enrollment End Date Actives: The first day of the month following the pay period that the employee has a qualifying change in status event that is processed by the SCO by the tenth of the month. The last day of the month of the plan year (December 31) if the participant chooses not to re-enroll. The last day of month following the pay period of the last deduction, i.e., unpaid leave of absence if employee chooses not to direct pay while on leave. For example, if the employee separates on February 20 and the HCRA deduction appears on the final warrant, enrollment in the plan ends March 31. Separated Employees/Retirees: Last day of the month following the pay period of the last deduction in which an active employee retires or separates from the campus. Specific Eligibility Criteria Enrollment in HCRA is specifically tied to classification. Exclusions are listed by classification code as noted below. Regular Eligibility Criteria Eligible: All represented and unrepresented employee groups Eligible: All active positions Eligible: Employees concurrently appointed in an eligible and ineligible classification with a time base Eligible: Employees on an unpaid leave of absence, including FMLA IF employee chooses direct payment. While on unpaid status, direct payments will be made on an AFTER-tax basis. Ineligible: Rehired annuitants, FERPS, hourly intermittent employees and employees appointed in any classification excluded from benefits (refer to TL HR/Benefits 2004-09, Attachment F) including the following: Student classifications (0100, 1870, 1871, 1872, 1874, 1875, 1876), Graduate Assistants (2355), Instructional Faculty, Designated Discipline - Extra Quarter Assignment (2367), Instructional Faculty, Extra Quarter Assignment QSYRO (2368), Instructional Faculty, Executive Committee, Academic Senate (2394), Trade rate employees, Special pay classifications (2322, 2322, 2356, 2357, 2363, 2365, 2974, 4660), Employees appointed without a time base, in any classification (e.g., intermittent, indeterminate), and/or Any person who performs service for the CSU solely as an independent contractor Position must have a time base, but there is no minimum time base requirement. Appointment Duration does not apply to HCRA

ATTACHMENT C Page 3 of 10 The appointment with the eligible classification is used to determine eligibility for HCRA. AB 211 Eligibility Criteria Eligible: Part-time lecturers and coaches in class codes 0357, 0360, 0361, 0364, 0365, 0557, 0560, 0564, 2308, 2358, 2375, 2378, 2381, and 2384. Eligible: Employees on an unpaid leave of absence, including FMLA IF employee chooses direct payment. While on unpaid status, direct payments will be made on an AFTER-tax basis. Position must have a time base, however, there is no minimum time base requirement. Appointment Duration does not apply to HCRA eligibility The appointment with the eligible classification is used to determine eligibility for HCRA. Grandfathered Eligibility Criteria Eligible: Part-time lecturers and coaches in class codes 2308, 2358, 2375, 2378, 2381, or 2384 who do not meet the regular eligibility criteria. Eligible: Employees on an unpaid leave of absence, including FMLA IF employee chooses direct payment. While on unpaid status, direct payments will be made on an AFTER-tax basis. Position must have a time base, however, there is no minimum time base requirement Appointment Duration does not apply to HCRA eligibility The appointment with the eligible classification is used to determine eligibility for HCRA. Enrollment Form and Codes The HCRA enrollment form and the corresponding change in status codes appear after the Dependent Care Reimbursement Account Plan (DCRA) benefits eligibility section.

ATTACHMENT C Page 4 of 10 Dependent Care Reimbursement Account Plan (DCRA) Deduction Code: 380-017 (Code changes annually) Administrative Fee Deduction Code: 375-001 Effective Date of Benefit: July 1, 1988 Plan Year Period: January 1 December 31 Pre-tax Benefit: Yes Enrollment Method: HCRA/DCRA Enrollment Form Description of Benefit The Dependent Care Reimbursement Account Plan (DCRA) allows eligible CSU employees to pay for eligible outof-pocket household, child and/or Dependent care expenses with pre-tax payroll deductions pursuant to Internal Revenue Service (IRS) Code 125. The payroll deductions are taken in equal monthly installments based on an annual amount chosen by the employee. Yearly contributions to this plan can be a minimum of $240 up to a maximum of $5,000, which equates to a minimum monthly payroll deduction of $20 up to a maximum of $416.66. The maximum amount of $5,000 is reduced to $2,500 if the employee is married and files an income tax return separately from the Spouse. Participation in this plan automatically prompts the State Controller s Office to apply an administrative fee for each contribution through deduction code 375-001. Currently, the administrative fee for this plan is $2.00 per month. Once enrolled in the plan, the employee s participation is locked for the 12-month plan period unless the employee separates from the campus or has a qualifying change in status event. Newly hired eligible employees have sixty days in which to enroll in the benefit. After the sixty-day limit, enrollment is allowable only in the occurrence of a change in status (as defined), or during the annual benefits open enrollment period (dates announced in benefits technical letter). Enrollment Periods First 60 days of employment Annual open enrollment (required to continue or start enrollment from plan year to plan year) Within 60 days of an allowable change in status (see Appendix C in HCRA/DCRA Administrative Guide) Change In Status Events Affect Plan Eligibility Change in status events are defined by the IRS regulations and allow eligible participants to stop, start, cancel or enroll in the plan outside of the standard initial enrollment and/or annual open enrollment period. Allowable change in status events include: Change in Legal Marital Status Marriage, divorce, death of Spouse, legal separation or annulment; Change in Number of Dependents The birth, death, adoption, loss or gain of domestic partner or loss or gain of legal custody or placement for adoption of a child; Change In Work Hours Change in work schedule including a decrease or increase in hours, full-time/parttime switch, start/stop or unpaid leave of absence or a strike or lockout of employee, Spouse or Dependent. Termination/Commencement of Employment The beginning or the end of employment of the Employee, Spouse or Dependent that impacts the Employee s, Spouse s, or Dependent s eligibility; or Dependent Eligibility Events that cause a Dependent to satisfy or cease to satisfy eligibility requirements for coverage on account of attainment of age, student status, or any similar circumstances. The events listed above qualify as a change in status event only if the change causes a gain or loss of eligibility for coverage under the CSU or other plan. Other change in status events include: Dependent Care Provider Cost/Coverage Change Significant change in cost and/or coverage of Dependent care provided as long as provider is not a relative. Judgment, decree, court order, or Qualified Medical Child Support Order (QMCSO).

ATTACHMENT C Page 5 of 10 Pre-paid The effective date of this benefit is the 1 st of the month following the pay period that the first deduction is taken. Staff and Non-AY Faculty example: 2. Enrollment form received and processed during August pay period 3. Deduction appears on September 1 pay warrant Additional example: 2. Employee decides in October to enroll 3. Enrollment form received and processed during October pay period 4. Deduction appears on employee s November 1 pay warrant AY example: 2. Deduction taken 1 st pay period of AY calendar (September) 3. Deduction appears on employee s October 1 pay warrant Enrollment End Date Actives: The first day of the month following the pay period that the employee has a qualifying change in status event that is processed by the SCO by the tenth of the month. The last day of the month of the plan year (December 31) if the participant chooses not to re-enroll. The last day of month following the pay period of the last deduction, i.e., unpaid leave of absence. Separated Employees/Retirees: Last day of the month following the pay period of the last deduction in which an active employee retires or separates from the campus. Specific Eligibility Criteria Enrollment in DCRA is specifically tied to classification. Exclusions are listed by classification code and are noted below: Regular Eligibility Criteria Eligible: All represented and non-represented employee groups Eligible: All active positions Eligible: Employees concurrently appointed in an eligible and ineligible classification and time base. Ineligible: Employees on an unpaid leave of absence, including FMLA. Direct Payment is not an option for DCRA participants. Ineligible: Rehired annuitants, FERPS, hourly intermittent employees and employees appointed in any classification excluded from benefits (refer to TL HR/Benefits 2004-09, Attachment F) including the following: Student classifications (0100, 1870, 1871, 1872, 1874, 1875, 1876), Graduate Assistants (2355), Instructional Faculty, Designated Discipline - Extra Quarter Assignment (2367), Instructional Faculty, Extra Quarter Assignment QSYRO (2368), Instructional Faculty, Executive Committee, Academic Senate (2394), Trade rate employees, Special pay classifications (2322, 2322, 2356, 2357, 2363, 2365, 2974, 4660), Employees appointed without a time base, in any classification (e.g., intermittent, indeterminate), and/or Any person who performs service for the CSU solely as an independent contractor

ATTACHMENT C Page 6 of 10 Position must have a time base, however there is no minimum time base requirement. Appointment Duration does not apply to DCRA The appointment with the eligible classification is used to determine eligibility for DCRA. AB 211 Eligibility Criteria Eligible: Part-time lecturers and coaches in class codes 0357, 0360, 0361, 0364, 0365, 0557, 0560, 0564, 2308, 2358, 2375, 2378, 2381, and 2384. Ineligible: Employees on unpaid leaves of absence, including FMLA. Direct payment is not an option for DCRA participants. Position must have a time base, however, there is no minimum time base requirement. Appointment Duration does not apply to DCRA eligibility The appointment with the eligible classification is used to determine eligibility for DCRA. Grandfathered Eligibility Criteria Eligible: Part-time lecturers and coaches in class codes 2308, 2358, 2375, 2378, 2381, or 2384 who do not meet the regular eligibility criteria. Ineligible: Employees on an unpaid leave of absence, including FMLA. Direct payment is not an option for DCRA participants. Position must have a time base, however, there is no minimum time base requirement Appointment Duration does not apply to DCRA eligibility The appointment with the eligible classification is used to determine eligibility for DCRA. Enrollment Form and Codes The DCRA enrollment form and the corresponding change in status codes appear on the following pages.

ATTACHMENT C Page 7 of 10 The California State University DEPENDENT CARE/HEALTH CARE REIMBURSEMENT ACCOUNT PLANS R ENROLLMENT AUTHORIZATION Please type or print clearly with ballpoint pen. 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 OPEN ENROLLMENT NEWLY ELIGIBLE ENROLLMENT CHANGE DUE TO PERMITTING EVENT CANCELLATION 4. NAME (first) (initial) (last) Married Single 5. REIMBURSEMENT PLAN ELECTIONS: To establish a Health Care and/or Dependent Care Reimbursement Account, enter the amount you want to have deducted EACH month from your pay warrant: The minimum monthly deduction amount for each account is $20.00, up to a maximum of $416.66, as allowed by the Plan. Benefit Deduction Item (Pre-Tax) Health Care Reimbursement Account (HCRA) Dependent Care Reimbursement Account (DCRA) 8. Coverage Statement 6. DED/ORG Code 7. Monthly Deduction Amount 378- A. $. 380- B. $. SCO Use Only I UNDERSTAND THAT MY ENROLLMENT INTO THE HEALTH CARE AND/OR DEPENDENT CARE REIMBURSEMENT ACCOUNT PLAN(S) IS FOR THE CURRENT PLAN YEAR ONLY. IF I WISH TO CONTINUE ENROLLMENT FOR THE NEXT PLAN YEAR, I MUST RE-ENROLL ANNUALLY DURING OPEN ENROLLMENT. I hereby agree to have my monthly pay reduced by the amount(s) specified above. I understand that IRS regulations require that my monthly deductions authorized by this form are irrevocable during this plan year, unless I experience an allowable status change event, as defined in these regulations and described in the Health Care and/or Dependent Care Reimbursement Account brochure(s). This reduction in pay is effective with the December pay period (unless this is a mid-year enrollment), and will continue for each succeeding pay period until the end of the Plan Year. My agreement to have my pay reduced is made on the condition that the CSU contribute the amounts to the Reimbursement Account(s) that I have specified on this document. I also agree to pay the $2.00 monthly administrative fee through payroll deduction on a post-tax basis. The $2.00 administrative fee is charged per Plan. I understand that requests for reimbursement must be for eligible services/supplies incurred between the effective dates of my participation in the Plan(s) through the end of the Plan Year. Each Plan Year begins on January 1 and ends December 31. All reimbursement requests for the current Plan Year must be postmarked by June 30 of the following Plan Year in order to be reimbursed. I further understand that any unclaimed amount remaining in my Health Care or Dependent Care Reimbursement Account(s) after that date will be forfeited. I have read the above statements and agree to the terms and conditions of the Health Care and/or the Dependent Care Reimbursement Account Plan(s) as outlined on this form. Employee s Signature: Date Signed: FOR CAMPUS USE ONLY 9. Effective Date of Action 10. Employee CBID 11. Permitting Event Date 12. Permitting Event Code Mo Day -1- Year Mo Day Year 13. Remarks: 14. Agency Code 15. Unit Code 16. Campus Name 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 Health Care and/or Dependent Care Reimbursement Plan(s). Signature: 18. Date Received: 19. Telephone Number: DISTRIBUTION: ORIGINAL - State Controller s Office COPY Campus COPY W/PRIVACY NOTICE Employee

ATTACHMENT C Page 8 of 10 This chart describes the election changes permitted during a period of coverage. Events may fall into more than one election category. Exceptions are permissible only to the extent that such change or revocation is on account of and consistent with these Change in Status Events. The following events qualify as a change in status event only if they result in a gain or loss of eligibility under the CSU or another plan: Please note that Change in Cost and Coverage (DCRA only), Entitlement or loss of entitlement to Medicare or Medicaid (HCRA only), Judgment, decree, court order, or Qualified Medical Child Support Order (QMCSO) are not subject to the gain or loss of eligibility requirement. TYPES OF ALLOWABLE CHANGES Event DCRA HCRA Change in Legal Marital Status Marriage Divorce, legal separation, annulment Enroll as newly eligible or cancel, increase, decrease contributions Enroll as newly eligible or cancel, increase, decrease contributions Enroll as newly eligible or cancel, increase, decrease contributions Enroll as newly eligible or cancel, increase, decrease contributions Spouse s death Enroll as newly eligible or cancel, increase, decrease contributions Change in Number of Dependents Increase in number of employee s eligible tax Dependents (e.g., by birth, legal custody, adoption, domestic partner, or placement for adoption) Enroll as newly eligible or increase contributions Enroll as newly eligible or cancel, increase, decrease contributions Enroll as newly eligible or increase contributions Decrease in number of employee s eligible tax Dependents (e.g., by death, loss of legal custody, loss of domestic partner as a tax Dependent or because child becomes self supporting) Cancel or decrease contributions Cancel or decrease contributions Termination/Commencement of Employment A. Employee Employee begins employment Enroll as newly eligible Enroll as newly eligible Employee terminates employment Employee is rehired less than 30 days after termination of employment Employee is rehired more than 30 days after termination of employment Change in employee s employment status that causes a significant change in cost or coverage Other change in employee s employment status that causes employee to lose eligibility for coverage under plan Cancel contributions (contributions will cancel automatically) Reinstate prior election unless intervening status change event Enroll as newly eligible See Change in Cost or Change in Coverage rules Cancel contributions Cancel contributions (contributions will cancel automatically) or Increase contributions on an after-tax basis (for administrative fee only) to pay for HCRA COBRA coverage (see Section 8 of Administrative Guide for additional information) Reinstate prior election unless intervening status change event Enroll as newly eligible None Cancel contributions or Increase contributions on an after-tax basis (for administrative fee only) to pay for HCRA COBRA coverage (see Section 8 of Administrative Guide for additional information)

ATTACHMENT C Page 9 of 10 Event DCRA HCRA Other change in employee s employment status that causes employee to gain eligibility for coverage under plan B. Spouse or Dependent Spouse or Dependent terminates employment Spouse or Dependent commences employment Other change in Spouse s or Dependent s employment status that causes Spouse or Dependent to cease to be eligible for coverage under his/her plan Other change in employment status that causes Spouse or Dependent to gain eligibility for coverage under his/her plan Change in Work Hours A. Employee Employee commences unpaid leave (including FMLA) Employee returns less than 30 days after beginning of unpaid leave Enroll as newly eligible Enroll as newly eligible or cancel, increase, decrease contributions (i.e., in order to enroll or increase, Spouse must attend school full-time or become an eligible tax Dependent) Enroll as newly eligible or cancel, increase, decrease contributions Enroll as newly eligible or increase contributions Cancel or decrease contributions Cancel contributions Prior election will automatically resume Enroll as newly eligible Enroll as newly eligible or increase contributions Cancel or decrease contributions Enroll as newly eligible or increase contributions Cancel or decrease contributions Cancel contributions Increase contributions on an after-tax basis (See Section 8 for additional information) Prior election will automatically resume Employee returns more than 30 days after beginning of unpaid leave Prior election will automatically resume or Make election to same extent permitted as new hires Prior election will automatically resume or Make election to same extent permitted as new hires Employee commences paid leave Cancel or decrease contributions No change Employee returns from paid leave B. Spouse or Dependent Spouse or Dependent commences unpaid leave Spouse or Dependent returns from unpaid leave Dependent ceases to satisfy CSU s plan eligibility requirements on account of age, student status, or any similar circumstance (i.e., no longer a tax Dependent) Enroll as newly eligible or increase contributions No change Enroll as newly eligible or cancel, increase, decrease contributions Enroll as newly eligible or increase contributions Enroll as newly eligible or cancel, increase, Cancel or decrease contributions decrease contributions Change in Dependent Eligibility Cancel coverage or decrease contributions Cancel coverage or decrease contributions only if Dependent no longer is an eligible tax Dependent. (Also see Change in Number of Eligible Tax Dependents) Dependent satisfies CSU s plan eligibility requirement on account of age, student status, or any similar circumstance (i.e., new tax Dependent) Enroll as newly eligible or increase contributions (also see Change in Number of Eligible Tax Dependents) Enroll as newly eligible or increase contributions only if Dependent becomes an eligible tax Dependent. (also see Change in Number of Eligible Tax Dependents)