CSU, Long Beach Benefits Enrollment Worksheet

CSU, Long Beach
Benefits Enrollment Worksheet
Complete and return this form to Benefits Services (Brotman Hall 353)
Campus ID:
Phone: (562) 985-2381
Fax: (562) 985-1821
Employee Information
Employee Name
Marital Status
Social Security Number
(Home) Street Address
City
State
Contact Phone Number
Contact Email
Zipcode
Transferring from another CSU/State Agency?
No Yes—Agency:
Type of Action
Enroll in Plan
Cancel Plan
Add/Delete Dependent
Change Plan
Health
Vision
Health
Vision
Health
Health
Dental
HCRA/DCRA
Dental
HCRA/DCRA
Dental
Dental
Vision
HCRA/DCRA
FlexCash Health
FlexCash Health
FlexCash Dental
FlexCash Dental
Open Enrollment
September 15, 2014
Permitting Event _____________________________________________
Event Date: ___________________________
Plan Option
Employees requiring additional plan information can find physical copies at Brotman Hall 353 or online at www.csulb.edu/benefits
Medical Plan Selection ___________________________________________________ (list of plans on the back of sheet)
Dental Plan Selection _____________________________________________________ (list of plans on the back of sheet)
FlexCash Enrollment: * We MUST receive your enrollment by the 3rd of the month for your FlexCash to be effective the 1st of the next month.*
Health ($128/month) Health Plan _______________________________ Group No: _______________________
Dental ($12/month) Dental Plan ________________________________ Group No: _______________________
Tax Advantage Premium Plan (TAPP): If enrolled in a medical plan, your monthly premium will be automatically paid from pre-tax
dollars through TAPP. Check the following box if you elect not to participate in TAPP. (Form 674)
Dependent Information
Please make sure you have included the following copies, if applicable:
Spouse:
Domestic Partner:
Marriage Certificate
Divorce Decree
Dependent Child:
Declaration of Domestic Partnership
Dissolution of Domestic Partnership
Birth Certificate
Adoption Certificate
Affidavit of Parent/Child Relationship
Dependent Enrollment Selections
First Name
Last Name
Social Security
Birthdate
Relationship
Health
Dental
Vision
Add Del Add Del Add Del
I hereby elect to enroll in the above health/dental plans, and understand that my effective date for these plans is based on the date
the official documents are received by Benefits Services. If currently enrolled in another CalPERS health plan, I must choose between
plans.
Signature: ___________________________________________________ Date: ________________________________
Benefits Services
Phone: (562) 985-2381
Email: [email protected]
Website: www.csulb.edu/benefits
Medical Plans:
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Anthem Select HMO
Anthem Traditional HMO
Blue Shield Access+ HMO
Blue Shield NetValue HMO
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Health Net Salud Y Mas HMO
Health Net Smartcare HMO
Kaiser CA HMO
PERSCare PPO
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PERS Choice PPO
PERS Select CA PPO
PORAC PPO
UnitedHealthCare HMO
Dental Plans:

Deltacare USA or Delta Dental
CalPERS guidelines for enrolling family members are as follows:
Your spouse or domestic partner can be added to your health plan if done within 60 days after the date of your marriage or
registration of your domestic partnership. A copy of your marriage certificate or Declaration of Domestic Partnership and
your spouse's or domestic partner's Social Security number are required. Former spouses and former domestic partners are
not eligible.
Children are eligible for health coverage up to age 26. They are eligible even if they are married, do not live with you, or are
not students. Eligible children are defined as natural, adopted, step or domestic partner’s children under age 26. If your
dependent is married you may not enroll their spouse or children (unless the child is an economic dependent of the
employee). A birth certificate or adoption papers and Social Security number are required.
A child over age 26, and is incapable of self-support due to a mental or physical condition that existed prior to age 26, may be
included when you first enroll. 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 request.
Another person's child under age 26 may be eligible for coverage if you have been granted custody or joint custody by a court
or the child resides with you. Birth Certificate, Social Security Number and Affidavit of Eligibility of Economically-Dependent
Children Form (HBD-35) must be filed prior to enrollment and must be updated upon request.
You can add the following family members either at the time of enrollment or at a later date:
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A spouse or registered domestic partner
Children age 18 or older not living in your home
Eligible children who are not in your custody
Dependents in the military, when they return to civilian life
Split Enrollments
Members who are married or in a registered domestic partnership who both work, or works, for agencies in the CalPERS
Health Program can enroll separately. If you and your spouse or domestic partner enrolls 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.
Voluntary Benefits are available to you as a CSU benefits-eligible employee. Premiums for voluntary benefit plans are fully
paid by the employee; CSU does not contribute. The following voluntary plans are available to you: Retirement Savings Plans,
Health/Dependent Care Reimbursement Account Plans, Pre-Paid Legal, Critical Illness Insurance, Auto and Home Insurance,
Life Insurance, Long Term Disability, Accidental Death & Dismemberment and Pre-Tax Parking
Benefits Services
Phone: (562) 985-2381
Email: [email protected]
Website: www.csulb.edu/benefits
Benefits Services
Accounts Receivable Signature Authorization Form
Complete and return this form to Benefits Services in Brotman Hall 353
I ____________________________________ understand that I am responsible for paying benefit
premiums/deductions owed by me for the enrollment or change in my benefits. I further understand that
retroactive benefit premium/deductions can occur when enrollment documentation is not processed in time for a
deduction to be established by the State Controller’s prior to the effective date of coverage. On occasion, benefit
premium/deductions can be delayed for more than one month resulting in a multi month accounts receivable.
My signature below authorizes Payroll Services to establish a retroactive payroll deduction in the amount owed to
be taken from my upcoming monthly payroll check to pay for retroactive benefits premiums/deductions. If this
amount exceeds $__________, I would prefer to discuss payment options with my Payroll Technician.
This authorization is effective immediately upon receipt by Benefits Services and will remain in effect until I
choose to cancel this authorization via written notification.
Employee Name (Printed)
Empl ID
Signature
Date
*The State Controller’s Office (SCO), as the pay agent for California State University (CSU), establishes, changes
and discontinues benefit premiums/deductions based on information received by Benefits Services and
authorized by the employee.
cc: Payroll Services
Office Use Only
Accepted by Authorized Campus Representative: ___________________________________
Date Received: ___________________________