State Health Benefits Guide

Transcription

1 State Health Benefits Guide CALIFORNIA PUBLIC EMPLOYEES RETIREMENT SYSTEM a August 2015

2 Table of Contents Contents This guide contains the following topics: Topic Page Introduction 1 Contact Information 2 Summary of Health Benefit Forms & Publications 6 Health Benefits Officer Roles and Responsibilities 7 CalPERS Communication 9 Health Plan Options 11 Health Eligibility Requirements 14 Health Enrollment 22 Direct Payment Authorization 31 Consolidated Omnibus Budget Reconciliation Act (COBRA) 33 Employee Separations 35 Health Benefits into Retirement 39 Separation and Retirement Dates 41 Post Retirement Health Vesting 43 Survivor Benefits 47 Retiree Dental and Vision Coverage 50 Resources 52

3 Introduction Introduction The Guide is designed to assist you, as the employer, in conducting business on behalf of the CalPERS Health Benefits Program which is subject to the Public Employees Medical & Hospital Care Act (PEMHCA). You have a fiduciary responsibility to manage the program by ensuring that only eligible employees and their dependents are covered. This guide aims to increase your knowledge of the health benefits business rules to ensure compliance with federal and state laws and provide you information to assist employees in making informed and educated decisions. Note: This Guide is administrative in nature. In the event of unintentional conflict between the guide and PEMHCA or the Regulations, PEMCHA and the Regulation will prevail. 1

4 Contact Information CalPERS CalPERS General Please contact the CalPERS Customer Contact Center at 888 CalPERS (or ) for assistance relating to: Health Enrollment Health Eligibility Member Enrollment Appeals System Access & Processing Note: Information is also available online at the CalPERS website CalPERS General Resource Information To request Circular Letters, forms, and/or publications, you can: Go online to the CalPERS website Circular Letters are mailed and archived online to view and download; all Forms and Publications are available for download or online order Contact CalPERS Central Receiving at (800) Employers may us to request bulk forms and publications Contact Information Health Plans Health Plan Inquiries Select the following individual health plan links for the items listed below, questions or requests: Health Plan Toll Free Telephone Numbers Evidence of Coverage Booklets Identification Cards Benefits, Deductibles, Limitation & Exclusions Verification of Provider Participation Change in Primary Care Provider Service Area Boundaries Individual Conversion Policy Direct Payment Authorization or Consolidated Omnibus Budget Reconciliation Act (COBRA) 2

5 Contact Information Health Plans, Continued Anthem Blue Cross PPO and HMO Website: Blue Shield of California Website: Health Net Website: Kaiser Permanente Website: Sharp Health Plan Website: United Healthcare Website: CVS Caremark Website: 3

6 Contact Information Dental Plans Introduction California Department of Human Resources (CalHR) administers the State s Dental Program, the California State University (CSU) Chancellor s office administers the CSU Dental program, and California Association of Highway Patrolmen (CAHP) administers the CAHP dental plan. CalPERS maintains enrollment information and premium deductions for State and CSU retirees only. Delta Dental Premier & Delta Preferred Option (State) Website: Delta Dental Basic & Enhanced (CSU) Website: DeltaCare USA (State & CSU) Website (State Retirees): Website (CSU Retirees): 4

7 Contact Information Dental Plans, Continued Safeguard Enhanced Website: Note: Safeguard is now considered a MetLife company, but the name of the dental plan will remain the same. Western Dental Website: Premier Access Website: CAHP Dental Trust (Anthem Blue Cross) Website: 5

8 Summary of Health Benefit Forms & Publications CalPERS Form Name Health Benefit Plan Enrollment Form Declaration of Health Coverage Health Benefit Plan Enrollment Form for Retirees/Survivors Medical Report for the CalPERS Disabled Dependent Benefit Member Questionnaire for the CalPERS Disabled Dependent Affidavit of Parent-Child Relationship COBRA Election Form Direct Payment Authorization Form Health Plan s Evidence of Coverage CalPERS Publication Health Program Guide Health Benefit Summary CalPERS Medicare Enrollment Guide Description For active employees, to enroll, change, or cancel enrollment in a CalPERS health plan. To document an active employee s decision to elect or decline health coverage. Used as proof that coverage was offered. For retirees or survivors, to enroll, change, or cancel enrollment in a CalPERS health plan. For enrollment or continuation of a disabled child over age 26. This form provides medical information to CalPERS and is to be completed by an attending physician. For enrollment or continuation of a disabled child over age 26. This form provides medical information to CalPERS and is to be completed by the member. To establish eligibility for dependents of a parent-child relationship. To continue coverage under COBRA provisions and authorize direct payment for enrollment in a group continuation plan. To apply for continuation of enrollment while employee is on off-pay status. A detailed guide describing the benefits of a specific health plan. Also provides the employee with a certificate of coverage. This publication is mailed to new members by the health plan and is also available online through the specific health plan website. Description Provides an overview of the CalPERS Health Program. A comprehensive summary of all CalPERS health plans. A practical guide to understanding how CalPERS and Medicare work together. 6

9 Health Benefits Officer Roles and Responsibilities Introduction Your agency is required to designate a Health Benefits Officer (HBO) and one or more assistant HBOs to be an authorized point of contact for employees health benefits issues. Only qualified and trained HBOs or assistant HBOs are authorized to sign required enrollment forms on behalf of your agency. Active employees must go through you for all eligibility and enrollment issues. An HBO is also considered a Personnel Specialist who processes health transactions and provides health eligibility and enrollment information to employees. Roles and Responsibilities The HBO has the following roles and responsibilities: Education: Educate all newly eligible and existing employees with relevant information regarding eligibility and enrollment Inform employees that a review of eligibility can occur at any time Inform employees of their obligation to advise you if dependents lose eligibility (i.e. divorce) Stay up-to-date on communications from us regarding changes in law or policies Be familiar with the California Public Employees Retirement Law (PERL), State Employees Dental Care Act and PEMHCA provisions - California Government Codes (G.C.) 20160, 20164, 22750, and California Code of Regulations (CCR) Have knowledge of available resources 7

10 Health Benefits Officer Roles and Responsibilities, Continued Roles and Responsibilities (continued) Eligibility determination and enrollment processing: Obtain required supporting documentation as proof of eligibility prior to enrollment Ensure only eligible employees and family members are enrolled in order to comply with all provisions of Confirm enrollment forms are complete, free of errors and signed by you and the employee Retain enrollment forms and supporting documentation in employee s official personnel file Approve enrollments for employees and/or their dependents Process health transactions timely and accurately Maintenance and monitoring: Verify that employees are enrolled in the correct health plan based on their residential or work zip code Maintain complete and accurate demographic records for all employees including: - Current addresses and phone numbers - Social Security numbers for all employees and their eligible family members Monitor ongoing eligibility and enrollment opportunities for employees and their eligible family members. - Including tenure and time base, direct pay and COBRA requirements Maintain your contact information in my CalPERS Note: It is against the law to continue enrollment of any ineligible family member. If this occurs the employee may be liable for all costs incurred during the ineligibility period. 8

11 CalPERS Communication Introduction We communicate with you through several communication channels including: The CalPERS Website Circular Letters CalPERS Employer Bulletins my CalPERS Employer News CalPERS Website The CalPERS website has become an important source of information for you regarding the CalPERS Health Program, such as eligibility rules, covered services, available health plans and premium rates. Note: For additional information about the CalPERS Health Program go to the CalPERS website. Circular Letters Circular Letters are issued to keep you informed of changes in policies and procedures. These letters provide important documentation for reference to administer CalPERS benefit programs. Note: The Circular Letter Search page located on the CalPERS website can help you find specific topics of interest. CalPERS Employer Bulletin Sign up and get the latest employer news and information tailored specifically for you sent right to your inbox. CalPERS Employer Bulletins come in plain text format easy for viewing and retrieval. Note: Stay informed by signing up for the CalPERS Employer Bulletin quickly and easily on the CalPERS website. 9

12 CalPERS Communication, Continued my CalPERS Important messages for you are displayed on the my CalPERS Home Page and on the CalPERS website. Note: To access trending updates, as well as more information and resources, view my CalPERS Technical Requirements on the CalPERS website. Employer News CalPERS Employer News is published quarterly. This publication provides important information and a calendar of upcoming events for employers doing business with us. The Employer News is available on the CalPERS website for downloading. If you sign up for the CalPERS Employer Bulletin you will receive an notification when the latest issue is available online. Note: To access more information and resources, search for Employer News on the CalPERS website Forms & Publications page. 10

13 Health Plan Options Health Plan Availability Employees are eligible to enroll in a health plan using either their residential or work ZIP Code. A P.O. Box may be used for mailing purposes but cannot be used to establish eligibility. If a residential ZIP Code is used, all enrolled family members must reside in the health plan s service area. - When an enrolled dependent resides separately from your employee, the enrolled dependent s residential ZIP Code must also be included in the health plan s service area. - Your employee or enrolled dependent should always contact the health plan to ensure the dependent is assigned to a provider or clinic within the respective health plan s service area. Example: Your employee lives in Northern California and is enrolled in Kaiser, and their dependent lives in Southern California. They can each seek services as long as both residential ZIP Codes qualify for enrollment. If a work ZIP Code is used, all enrolled family members must receive all covered services (except emergency and urgent care) within the health plan s service area, even if they do not reside in that service area. Working retirees may use the ZIP Code of their current employer for basic health plan eligibility. - If enrolled in a Medicare Advantage plan, the member s residential address must be used. 11

14 Health Plan Options, Continued CalPERS Health Maintenance Option (HMO) Basic Health Plans Depending on where your employee resides or works, one or more Basic health plan types and plan choices may be available. HMO features include: A range of health benefits including preventive health services A monthly fee (premium) with no calendar year deductible A set co-payment for the care provided A primary care physician (PCP) who coordinates the patient s care including referrals to specialists Note: The California Department of Managed Health Care regulates all HMOs in California. Title 28 Section (H)(i) of the California Code of Regulations, defines health plan requirements for the geographic area in which the health plan provides coverage under an HMO. HMO Basic Health Plans CalPERS Basic HMO Plans include: Anthem Blue Cross Blue Shield of California Health Net of California Kaiser Permanente Sharp Health Plan UnitedHealthCare California Correctional Peace Officers Association (CCPOA) - Must belong to the association and be a dues paying member Note: HMOs are available only in designated California service areas with the exception of Kaiser which is available in parts of other states but the benefits may vary. 12

15 Health Plan Options, Continued CalPERS Preferred Provider Organization (PPO) Basic Health Plans Preferred Provider Organization (PPO) PPO features include: Access to a network of health care providers known as preferred providers Choice of specialists without a referral Option to obtain services from non-preferred providers Note: A calendar year deductible applies to PPO plans. PPO Basic Health Plans PPO Plans include: PERSCare PERS Choice PERS Select California Association of Highway Patrolmen (CAHP)* Peace Officers Research Association of California (PORAC)* * Must belong to the association and be a dues paying member. Note: All of our PPO plans are administered by Anthem Blue Cross and available throughout California. PERSCare, PERSChoice and PORAC are also available out-of-state. CalPERS Exclusive Provider Organization (EPO) Basic Health Plans Blue Shield EPO serves Colusa, Mendocino and Sierra Counties only, and Anthem Blue Cross EPO serves Monterey County only. Exclusive Provider Organization (EPO): Offers the same covered services as an HMO Services must be obtained from the statewide EPO network of preferred providers Note: Evidence of Coverage Booklets can be viewed and/or printed from the applicable health plan website. 13

16 Health Eligibility Requirements Eligible Employees Eligible employees may enroll themselves or themselves and all eligible family members. Eligibility is based on tenure and time base of a qualifying appointment. Employees are eligible if they satisfy the following: Have a permanent appointment or a limited term appointment with a duration of more than six months and, Work at least half-time - California State University (CSU): Some professors and other bargaining units working less than half-time may be eligible for health benefits. (G.C (a)(4)) Note: The Affordable Care Act may impact eligibility requirements for CalPERS employers. Refer to Circular Letter (Attachment: Employer Designation Model Template) and the IRS website for additional information on the issued final regulations titled, Shared Responsibility for Employers Regarding Health Coverage. Ineligible Employees Certain employees are not eligible for CalPERS health benefits. Ineligible employees include: Those working less than half time (excluding some professors and other bargaining units working less than half-time) Those whose appointment lasts less than six months Those whose job classification is Limited-Term Intermittent (seasonal or temporary) Those classified as Permanent-Intermittent who do not meet the hour requirements within the control period 14

17 Health Eligibility Requirements, Continued Eligible Family Members Eligible employees may enroll themselves only or themselves and all eligible family members. Below is a list of eligible dependents. The terms family member and dependent are used interchangeably. Eligible family members include: Spouse Registered domestic partner Children (natural, adopted, domestic partner s, or step) up to age 26 Children, up to age 26, if the employee or annuitant has assumed a parent-child relationship and is considered the primary care parent Certified disabled dependent children age 26 and older Note: Eligible children can be enrolled regardless of their marital, student or employment status. Domestic Partners Your employee may add their registered domestic partner to their health plan within 60 days of registration of the domestic partnership. The coverage will become effective the first day of the month following the date you receive the Health Benefit Plan Enrollment form. Eligibility requirements are as follows: Same-sex domestic partnerships between persons who are both at least 18 years of age Opposite sex domestic partnerships where one person is over the age of 62 and the other is at least 18 years old - A domestic partnership validly formed in another jurisdiction that is substantially equivalent to a registered domestic partnership in California may also be recognized - The Secretary of State must register the domestic partnership Note: For additional information regarding same-sex marriage pertaining to CalPERS eligibility and enrollment, refer to the Circular Letter Search page located on the CalPERS website. 15

18 Health Eligibility Requirements, Continued Children The employee s natural-born, adopted, domestic partner s and stepchildren who are under age 26 may be added as outlined below: Newborn children should be added within 60 days of birth. Coverage is effective from the date of birth Newly adopted children should be added within 60 days of physical custody. Coverage is effective from the date physical custody is obtained Stepchildren or a domestic partner s children under age 26 can be added within 60 days after the date of your marriage or registration of your domestic partnership The coverage will become effective the first day of the month following the date you receive the Health Benefit Plan Enrollment form. 16

19 Health Eligibility Requirements, Continued Certified Disabled Child A child age 26 and over who is incapable of self-support because of a mental or physical condition may be eligible for enrollment. The disability must have existed prior to reaching age 26 and continuously since age 26, as certified by a licensed physician. Employees are required to complete and submit the Member Questionnaire for the CalPERS Disabled Dependent Health Benefit form and the physician must complete and submit a Medical Report for the Disabled Dependent Benefit for CalPERS approval. The initial certification of the Disabled Dependent must occur during one of the following two eligibility periods (whichever applies): Within 60 days before and ending 60 days after the child s 26 th birthday (member and dependent currently enrolled), or Within 60 days of a newly eligible employee s initial enrollment in the CalPERS Health Program Upon certification of eligibility, the dependent s coverage must be continuous and without lapse. The employee will be required to submit an updated questionnaire and medical report for re-certification periodically, upon request. Note: If the disabled child has a Social Security- approved disability, the employee must provide CalPERS with a copy of his or her Medicare card. This enrollment is subject to CalPERS approval. 17

20 Health Eligibility Requirements, Continued Parent-Child Relationship A child other than an adopted, step, or recognized natural child up to age 26 may be added to your health plan if both of the following criteria are met: You have assumed a parent-child relationship You are considered the primary care parent Evidence of this relationship may include assuming responsibilities - Providing shelter - Clothing - Food - Child care or education for the child Upon enrollment, and annually thereafter the employee must: Sign the affidavit, under penalty of perjury, that the information they are providing is true and correct Acknowledge that it is unlawful to make false representation or to present false information You have the right to request any and all supporting documentation to substantiate the eligibility determination such as: Court records School records Tax returns Additional proof that a parent-child relationship exists Note: Proposed changes to these regulations are currently under review. Changes will be communicated via a Circular Letter and all reference material will be updated accordingly. 18

21 Health Eligibility Requirements, Continued Ineligible Family Members The following are considered ineligible family members: Former spouse/former domestic partner - Former spouses/domestic partners cannot be enrolled as a dependent on the employee s state health coverage under any circumstance - If an employee is court-ordered to provide coverage, it is the employee s obligation to provide that coverage, not CalPERS Children age 26 or older Disabled dependents age 26 or older who were never enrolled or were deleted from coverage Foster children Spouse of adult children Parents Grandparents It is against the law to continue enrollment of an ineligible family member. If this occurs the member may be liable for all costs incurred during the ineligibility period. 19

22 Health Eligibility Requirements, Continued Permanent Intermittent (PI) Employment and Control Periods State PI employment is irregular or recurring, hourly employment that is less than full time each year. A PI employee may be eligible to enroll if they have earned a minimum of 480 paid hours at the end of a control period. Control Periods January 1 June 30 Effective August 1 July 1 December 31 Effective February 1 An employee: Cannot become eligible in the middle of a control period even if the minimum hours are met. Must be credited with at least 480 paid hours at the end of each control period or at least 960 hours in two consecutive periods to qualify to continue coverage. PI Deferred Enrollment PI employees, who are off pay status during the 60-day eligibility period after the end of the control period, may request a deferred enrollment within 60 days after the return to pay status within the same control period. Delayed enrollments will result in coverage of less than six months. A delayed enrollment does not extend the eligibility period, as the paid hours must be counted again at the end of each Control Period. During a qualifying Control Period (after the 480/960 hour requirement has been met), an enrolled employee s coverage will be automatically suspended if there is insufficient earnings, unless the employee elects direct pay. This direct pay option may be offered during the qualifying Control Period only, and must end as of January 31st or July 31st, respectively. 20

23 Health Eligibility Requirements, Continued PI Deferred Enrollment (continued) For PI employees who do not have the required 480 hours accumulated at the end of the current Control Period, the regular (or direct pay) coverage must be canceled with an effective date of February 1, or August 1 whichever is appropriate. Following the cancellation of coverage, the PI employee is then eligible for the COBRA continuation coverage (See COBRA section). PI Continued Enrollment An enrolled employee may continue coverage into a position with tenure of less than 6 months as long as the time base is half time or more, and there is no break in service in excess of a full pay period or more. The coverage will continue indefinitely when subsequent appointments of less than 6 months apply, as long as the time base does not fall below half time, and there are no breaks of a full pay period or more. An employee who takes coverage into a PI position may continue it through a full control period; at which time the paid hours worked must be counted to determine continued eligibility. Example: The employee changes from a permanent full time to PI position on March 15. The hours worked during the subsequent Control Period (July 1- December 31) must be counted to determine if the employee is eligible for continued coverage. All eligibility is lost if the regular or PI employee is appointed into a limited term intermittent position. In such cases, the coverage must be canceled. Legal Reference Family Member (G.C ) Domestic Partners (G.C and 22843) Parent-Child Relationship (CCR (o)) Permanent Intermittent (G.C ) 21

24 Health Enrollment New Enrollment New employees have 60 calendar days from the date of their initial appointment to enroll themselves and eligible family members in a health plan. PI employees have 60 days from the end of the qualifying control period to enroll. The effective date of the enrollment is the first of the month following the date you receive the Health Benefit Plan Enrollment form. CalPERS Health Open Enrollment As the employer, you are responsible for educating employees on CalPERS Health Open Enrollment. Each year, prior to Open Enrollment, a Circular Letter is sent to you with information regarding: Health Program Highlights which provides important details regarding health plans and premium rates for the new year Various communications released to employees, available online tools and employer resources Your additional responsibilities The CalPERS Health Open Enrollment period is traditionally held annually each fall and allows eligible employees to: Enroll Change health plans Add/delete eligible dependents Cancel coverage All transactions become effective January 1 following the Open Enrollment period. Note: Learn more about Open Enrollment by viewing FAQs - Open Enrollment on the CalPERS website. 22

25 Health Enrollment, Continued Additional Enrollment Opportunities The Health Insurance Portability and Accountability Act (HIPAA) was enacted in 1996 by Congress to improve portability and continuity of health insurance coverage. HIPAA offers two provisions, Special Enrollment and Late Enrollment, for employees and their eligible family members to enroll in a CalPERS health plan outside of the initial enrollment period and the Open Enrollment period. HIPAA requires that the Declaration of Health Coverage form be completed whether the employee elects to enroll or decline health coverage. Provides proof that the employee was given the opportunity to enroll or decline coverage for self and eligible family members. Must be completed upon initial health eligibility and for most enrollment requests. 23

26 Health Enrollment, Continued Special Enrollment Special Enrollment opportunities include: Loss of other non-calpers coverage Marriage/domestic partnership Birth/adoption Court-ordered coverage Special Enrollment is applied as follows: Enrollment must be requested within 60 calendar days of the event Effective date is the first day of the month following the date the enrollment form and supporting document(s) is received by you. Exception for birth/adoption effective dates (CCR (d)(h)) The effective date of enrollment of a newborn or adopted child of an employee or annuitant enrolled for self and one or more family member is the date of birth or the date physical custody is obtained. The effective date of enrollment of a newborn or adopted child of an employee or annuitant enrolled for self only is the first day of the month following the date of birth or the date physical custody is obtained. Note: Inquiries regarding the time between the date of birth or the date physical custody is obtained and the effective date of the CalPERS coverage should be referred to the health plan. Late Enrollment Late Enrollment allows an employee to request enrollment if they declined or cancelled enrollment for themselves or their dependents, and the Special Enrollment exceptions do not apply. Late Enrollment is applied as follows: A 90-day waiting period is required The effective date of enrollment will be the first of the month following the 90-day waiting period after you receive the Health Benefit Plan Enrollment form and applicable supporting documentation. 24

27 Health Enrollment, Continued Mandatory Transactions Mandatory transactions are additions or deletions to a health enrollment due to requirement by law. Mandatory transactions include events such as: Divorce or termination of domestic partnership Death of a family member Dependent who is age 26 or older For most transactions, the effective date is the 1st day of the month following the event date. Retroactive reimbursement of health premiums will not exceed six months prior to the date the mandatory event is reported (CCR ). Permissive Transactions Permissive transactions are additions or deletions to a health enrollment at the voluntary request of the enrolled member. Permissive transactions include events such as: Child reaches age 18 Family member enters military Family member obtains other group coverage For most transactions, the effective date is the 1st of the month after you receive the enrollment form(s) and applicable supporting documentation. Retroactive Transactions Retroactive transactions occur when the eligibility status for a member or dependent changes due to death, marital status, changes in employment and other circumstances, and the change is not reported in a timely manner. These transactions often result in a difference between the premiums paid and the premiums that should have been paid if the transaction had been reported timely. Retroactive Reimbursement Reimbursement to members and employers is limited to the amount of excess health premiums paid for a period of up to six months prior to the date on which the action is processed and recorded, pursuant to the member s request for retroactive cancellation or deletion of the ineligible family member. 25

28 Health Enrollment, Continued Prohibited Enrollments The following types of enrollments are not permitted: Enrolling in two CalPERS health plans Dual CalPERS coverage occurs when a member is enrolled in a CalPERS health plan as both a member (subscriber) and a dependent or as a dependent on two enrollments. Split Enrollment of dependents When two active or retired members are married to each other or in a domestic partnership and enroll in a CalPERS health plan in their own right, one parent must carry all dependents on one health plan. Parents cannot split enrollment of dependents When dual CalPERS coverage or a split enrollment is discovered, the enrollment that caused the dual coverage or split enrollment must be retroactively canceled. The employee may be responsible for all costs incurred from the date the dual coverage or split enrollment began. Changing Health Plans Health plans may be changed at the following times: During the CalPERS Open Enrollment period Within 60 days of the following events: Change in residence or change in employment Upon retirement Enrollment in Medicare by a member or their dependent This only applies after the member retirees 26

29 Health Enrollment, Continued Life Changes The employee is responsible for ensuring that their health enrollment information is accurate. Information that must be reported in a timely manner includes: Marriage/domestic partnership Divorce/termination of domestic partnership Former spouse or registered domestic partner is no longer eligible to receive health benefits under the employee s coverage Death of an employee The employer, surviving spouse, registered domestic partner or a family member must notify CalPERS to report the death After we process the death report, the health coverage for the employee and all enrolled dependents will automatically cancel. Death of a family member Employee must notify you Change of residential address An employee must contact you when they move to ensure the correct ZIP Code is used to establish eligibility in a health plan. Medicare eligibility Once a member or their dependent becomes eligible for Medicare due to age or a disability, they should notify CalPERS immediately to receive further guidance. Failure to maintain current and accurate health enrollment information can result in liability to reimburse health premiums or health care services during the entire ineligibility period. 27

30 Health Enrollment, Continued Required Health Enrollment Documents The following tables below lists the necessary forms and supporting documentation required for the various types of enrollments or changes to enrollment. For a complete list, refer to Required Health Enrollment Documents. Social Security numbers are required for all dependents upon initial enrollment or upon change of enrollment. Enrollment Type CalPERS Forms Copies of Supporting Documentation Active employee new enrollment Adding a registered domestic partner Adding a spouse Adding/ deleting a dependent child Adding a dependent who is in a parent-child relationship Deleting a spouse due to divorce Health Benefit Plan Enrollment* Declaration of Health Coverage Health Benefit Plan Enrollment Declaration of Health Coverage Health Benefit Plan Enrollment Declaration of Health Coverage Health Benefit Plan Enrollment Declaration of Health Coverage Affidavit of Parent-Child Relationship Health Benefit Plan Enrollment Declaration of Health Coverage Health Benefit Plan Enrollment Declaration of Health Coverage N/A Declaration of Domestic Partnership from the California Secretary of State s Office Marriage Certificate Birth Certificate Reason for add/delete As the employer, you reserve the right to request any supporting documentation Divorce Decree 28

31 Health Enrollment, Continued Required Health Enrollment Documents (continued) Enrollment Type CalPERS Forms Copies of Supporting Documentation Deleting a domestic partner due to termination of partnership Enrolling self or dependents due to loss of other health coverage Disabled child over age 26 certification Death of employee, retiree, or family member Change plans due to address change Health Benefit Plan Enrollment Declaration of Health Coverage Health Benefit Plan Enrollment Declaration of Health Coverage Member Questionnaire for the CalPERS Disabled Dependent Medical Report for the CalPERS Disabled Dependent Health Benefit Plan Enrollment Declaration of Health Coverage Health Benefit Plan Enrollment Declaration of Health Coverage Termination of Domestic Partnership submitted to the California Secretary of State s Office Proof of loss of coverage Marriage Certificate (Spouse) Declaration of Domestic Partnership (domestic partner) Birth Certificate (child) N/A Death Certificate Include both old & new addresses 29

32 Health Enrollment, Continued Required Health Enrollment Documents (continued) Enrollment Type CalPERS Forms Copies of Supporting Documentation Off-Pay Status Direct Payment N/A continue coverage Authorization Off-Pay Status Health Benefit N/A cancel coverage COBRA Plan Enrollment Group Continuation Coverage (COBRA Election) N/A *Used to enroll, change and cancel health plan enrollment Note: To view CalPERS Health Program Forms, search for health forms on the CalPERS website Forms & Publications page. These forms are revised periodically. Legal References Retroactive Transactions: CCR (f)(2)(C) and (c)(1) 30

33 Direct Payment Authorization When an employee may be eligible An employee may be eligible to elect to continue their health coverage in the following situations: Leave of absence without pay On temporary disability leave and do not use leave credits for supplementation Pending approval of disability retirement or service retirement Pending approval of Non-Industrial or State Disability Insurance benefits Suspended from their job or they institute legal proceedings appealing a dismissal from their job State Permanent Intermittent employee eligible for health benefits but in a non-pay status Upon the death of an employee while in State service, the law requires the State employer (except CSU) to continue to pay contributions for all enrolled dependents health coverage for 120 days. When an employee elects to enroll When an employee elects to enroll in direct pay: A Direct Payment Authorization form must be completed and signed by you and the employee The employee must pay 100 percent of the premium directly to the health plan by the established due dates The employee may elect to delete dependents before starting Direct Pay and must submit a Health Benefit Plan Enrollment form to you The employee may add newly acquired dependents while on Direct Pay Additional information may be obtained in the following Circular Letter: Addresses Off Pay Status: Health Enrollment Procedures 31

34 Direct Payment Authorization, Continued When an employee elects to enroll (continued) The employee must contact you if they wish to discontinue their direct pay There is no limitation on how long they can be enrolled unless it is due to a layoff - A new Direct Payment Authorization form would need to be completed if the employee extends their leave past the original direct pay end date provided on the original form. - An employee who is laid off may use direct pay up to one year. When an employee does not elect to enroll in direct pay, a Health Benefit Plan Enrollment form must be completed and signed by you and the employee to cancel coverage. Employee returns to work Upon the employee s return to work, you must: Update the employee s status in my CalPERS Schedule health deductions to resume the 1st of the month following the employee s return if they elect to re-enroll. - Payment must be made for the month in which the employee returns to work. 32

35 Consolidated Omnibus Budget Reconciliation Act (COBRA) Background COBRA is a federal entitlement program for continuation of identical coverage when an employee or eligible family member loses health coverage due to a COBRA qualifying event. COBRA As the employer, you are responsible for: Providing COBRA information to the employee and/or their eligible family members Informing the employee that up to 102 percent of the health premium is to be paid by them, directly to the health plan for the coverage period Collecting completed Group Continuation Coverage (COBRA Election) form within 60 days of the qualifying event if they elect to continue coverage. COBRA Qualifying Events The following table lists COBRA qualifying events and their coverage period: Qualifying Events Separation from employment Reduction in work hours (including layoff) Military leave Divorce or domestic partnership termination Legal separation Child that ceases to be dependent Death of an employee or annuitant (unless dependent qualifies for continued coverage as a survivor) Coverage Period 18 months 18 months 24 months 36 months 36 months 36 months 36 months 33

36 Consolidated Omnibus Budget Reconciliation Act (COBRA), Continued California COBRA (Cal-COBRA) Under certain conditions, California law permits an extension of COBRA continuation coverage known as Cal-COBRA: If the employee exhausts federal COBRA coverage and had less than 36 months of coverage, COBRA coverage may extend the benefit up to a total of 36 months, but cannot exceed 36 months. Employee must have been continuously enrolled and paid premiums for the original 18 months of coverage Employee must request an extension through the health plan Employee must pay premiums directly to the health plan Health premiums may not exceed 110 percent Legal References 1985 Consolidated Omnibus Budget Reconciliation Act (COBRA). A.B. 1401, 2002, Thomson Individual Conversion Policy, CCR and CCR

37 Employee Separations Reporting Employers must always update the appointment status of their employees in PIMS. Accurate reporting of employee separations will ensure correct billing on a monthly basis. Transactions that update the member s enrollment status will update the health plan. During these status changes, timely and accurate information will ensure a smooth transition for your employee and their dependents. Your responsibility in each type of separation is listed below. Employee Separation (NOT Retiring) Effective Date Termination of the health insurance coverage as an active employee is the first of the second month following the date of separation. Since this is prepaid health coverage and payroll deductions are taken the month preceding the coverage month, the employee is entitled to coverage for the month following the dismissal or resignation date (CCR ). Consolidated Omnibus Budget Reconciliation Act (COBRA) Provide employee with COBRA election forms. See the COBRA section of this guide for more information. Cancelling Coverage If the employee does NOT want the coverage for the month following their separation, the employee must sign a Health Benefit Plan Enrollment form electing to voluntarily cancel their coverage. If the employee cancels coverage, they will NOT be eligible for group continuation benefits (COBRA). 35

38 Employee Separations, Continued Temporary Leave of Absence Continuing or Cancelling Coverage while on Leave of Absence An employee who is not on regular pay status for a full pay period or more may elect to either cancel their health benefits coverage or continue coverage by paying the premium directly to the health plan (Direct Payment). See the Direct Payment Authorization section of this guide for more information. Death of Employee Reporting Employers must report the death of their employees in my CalPERS or contact the CalPERS Customer Contact Center at 888-CalPERS (or ). Effective Date The effective date of the termination of the health insurance coverage is the first of the month following the date of death. Provide dependents, if any, with COBRA election forms. COBRA, if elected, will begin after the 120 days of the employer paid Direct Pay is exhausted. Please see the COBRA section of this guide for more information. Special provision for Survivors of Police and Firefighters If the employee died as a result of injury or disease out of, and in the course of his or her official duties, G.C may apply. Contact 888-CalPERS (or ) for more information. 36

39 Employee Separations, Continued Separation for Service Retirement Reporting Employees must apply for Service Retirement from their respective retirement systems Employees must file an Application for Service Retirement. If at all possible, the employee should submit this document to CalPERS no earlier than 90-days prior to their retirement date. Employers must update the appointment status for their employees in PIMS For CalPERS members, employers also submit a: - Report of Separation and Advance Payroll Information form - Your agency will receive the form when CalPERS acknowledges receipt of the Application for Service Retirement from the member. Please refer to the Health Benefits into Retirement section of this guide for more details on continuation of health coverage in retirement. Effective Date Termination of the health insurance coverage as an active employee is the first of the second month following the date of separation. Direct Payment While it is not necessary to submit a Direct Payment Authorization form when an application for service retirement is being processed, it may be done if a delay in receiving retirement benefits is anticipated. Please refer to the Direct Payment Authorization section of this guide for more information. 37

40 Employee Separations, Continued Separation for Disability Retirement Reporting Employees must apply for Disability Retirement from their respective retirement systems - Members must file an Application for Disability Retirement - Employers must update the appointment status for their employees in my CalPERS and submit the Report of Separation and Advance Payroll Information form Effective Date Termination of the health insurance coverage as an active employee is the first of the second month following the date of separation. Continuing Coverage (Direct Pay) Applications for Disability Retirement can take a long time to process (months), resulting in a delay of retirement benefits. It is strongly recommended that employees submit a Direct Payment Authorization form when a Disability Retirement is pending. Otherwise, the member will be not covered until the retirement account is established. If the member requires health services during this time they will be denied. Please refer to the Direct Payment Authorization section of this guide for more information. Legal References Survivors of a Firefighter or Peace Officer - G.C Retroactive Reimbursement - CCR (f)(2)(C) - CCR (c)(1) 38

41 Health Benefits into Retirement Retiree Eligibility An employee must meet all of the following requirements to be eligible to enroll or continue enrollment in our health plan as a retiree: Separate and retire within 120 days Receive a monthly retirement allowance Be eligible for Health Benefits at separation If an employee separates, with no intent to retire, health coverage will be terminated the first of the second month following the date of separation. Note: Once an employee retires, CalPERS becomes the Health Benefits Officer. Retirees should be directed to the CalPERS Customer Contact Center at 888 CalPERS (or ) with any questions. Medicare Medicare is a federal health insurance program that covers individuals age 65 and older, or individuals under age 65 with certain disabilities. The Social Security Administration (SSA) is the federal agency responsible for Medicare eligibility determination, enrollment, and premiums. The Centers for Medicare & Medicaid Services (CMS) regulates the Medicare program. 39

42 Health Benefits into Retirement, Continued Medicare Enrollment Four months prior to the active or retired member s 65th birth month, they will receive notification from CalPERS that includes a Certification of Medicare Status form to complete. The notification informs the member of the requirements they will have to meet to continue their health coverage after age 65. When a member is actively employed past age 65 and their health coverage is based on this employment, they will remain enrolled in a basic health plan. An active member or an active member s spouse who is working past the age of 65 may defer Medicare enrollment through SSA if they are covered under an active employer group health plan. 40

43 Separation and Retirement Dates When Health Premiums are paid When an active state employee permanently separates to retire, the premiums are paid as follows: Separation date is between the 1st 10th of the month - Retiree health coverage begins the first of the month following the retirement date Separation date is between the 11th 31st of the month - Retiree health coverage begins the first day of the second month following retirement date Separation and Retirement Dates To determine the effective date of a new retiree enrollment, please refer to the table below. If separation and retirement dates are within 30 days of each other and the employee is enrolled in a health plan at the time of separation then health coverage will continue into retirement without a break. Note If the employee does not want to continue health benefits into retirement, they must cancel health coverage through you. 41

44 Separation and Retirement Dates, Continued Separation and Retirement Dates (continued) If separation and retirement dates are between 31 and 120 days of each other and the employee is enrolled in a CalPERS health plan at the time of separation then health coverage will not automatically continue. The employee may request to re-enroll with us as follows: Note When the health coverage lapses they may be eligible for Direct Pay. more than 120 days apart regardless of whether they are enrolled in a CalPERS health plan at the time of separation Within 60 days of the retirement date During Open Enrollment Due to the 90-day HIPAA Late Enrollment cannot be reinstated. They are no longer eligible for CalPERS health benefits. There are some exceptions to the rule. 42

45 Post - Retirement Health Vesting Employer Contribution The amount of credited State service required to receive a percentage of the employer contribution toward the cost of the monthly health premium during retirement. State service is defined as service rendered as an employee or officer of the State, the university, a school employer or a contracting agency for compensation (G.C ). The monthly employer contribution or State s Share is specified by California Government Code (G.C.) The employer contribution is adjusted annually The amount the State contributes toward a retiree s health coverage depends on State Health Vesting requirements. Some bargaining units are subject to dependent health vesting where the State provides new employees a reduced health benefits contribution toward dependent vesting. - Refer to CalHR for additional detailed information Note: If the health plan premium is more than the State s share, the retiree will be responsible to pay any amount above that. Health Vesting The amount of credited State service required to receive a percentage of the employer contribution toward the cost of the monthly health premium during retirement. State service is defined as service rendered as an employee or officer of the state, the university, a school employer, or a contracting agency for compensation. (G.C ) Fully vested: A State member has enough years of State service to receive 100 percent of the State contribution towards the health plan s premium upon retirement. Partially vested: A State member s service years are enough to cover at least 50 percent of the state contribution. - State health vesting criteria does not allow for an employer contribution less than 50 percent. Not vested: A State member does not have enough years of State service to receive a state contribution. - A retiree may be enrolled in a CalPERS health plan, even if they are not vested. However, they would be responsible for paying 100 percent of the health plan premium. 43