Form HBD-12 "Health Benefits Plan Enrollment for Active Employees" - California

What Is Form HBD-12?

This is a legal form that was released by the California Public Employees' Retirement System - a government authority operating within California. Check the official instructions before completing and submitting the form.

Form Details:

  • Released on June 1, 2020;
  • The latest edition provided by the California Public Employees' Retirement System;
  • Easy to use and ready to print;
  • Quick to customize;
  • Compatible with most PDF-viewing applications;
  • Fill out the form in our online filing application.

Download a fillable version of Form HBD-12 by clicking the link below or browse more documents and templates provided by the California Public Employees' Retirement System.

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Download Form HBD-12 "Health Benefits Plan Enrollment for Active Employees" - California

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Health Account Management Division
P.O. BOX 942715
Sacramento, CA 94229-2715
Health Benefits Plan Enrollment
888 CalPERS (or 888-225-7377) | TTY (877) 249-7442
FAX (800) 959-6545
for Active Employees (HBD-12)
www.calpers.ca.gov
SECTION A: Applicant Information
1.
2.
Employee Name:
Hire Date:
(M.I.)
(Last)
(First)
(mm/dd/yyyy)
3.
5.
4.
CalPERS ID or Social Security Number:
Gender:
Date of Birth:
(mm/dd/yyyy)
Male
Female
Nonbinary
6.
Physical Address:
(State)
(County)
(City)
(ZIP)
(Street)
7.
Mailing Address
:
(City)
(State)
(ZIP)
(County)
(Street)
(If different)
Use Work ZIP Code for Health Eligibility:
8.
Yes
No
If yes, enter zip code here: (ZIP)
9.
10.
E-mail Address:
Alternate:
Primary Phone:
SECTION B: Type of Action
11.
Enroll in a Health Plan
Add/Delete Dependents
Change Health Plan
Cancel All Coverage
Decline Coverage
SECTION C: Type of Permitting Event
12.
New Contracting
Open
New Employee
Marriage or Domestic Partnership Date
:
Move
(mm/dd/yyyy)
Agency
Enrollment
Birth/
Delete Dependent Due to Death
Divorce or Domestic Partnership Termination
Other:
Adoption
13.
14.
Permitting Event Date:
Name of Health Plan:
(mm/dd/yyyy)
(If changing health plans, list new plan name)
SECTION D: Subscriber and Dependent Information
(List yourself and all of your dependents)
15.
Date of
Primary Care
Relationship
CalPERS ID or Social
Name (First, M.I., Last)
Gender
Action
Birth
Code *
1
Security Number
Physician
(mm/dd/yyyy)
M
F
Add
SELF
Nonbinary
Delete
M
F
Add
Nonbinary
Delete
Add
M
F
Delete
Nonbinary
M
F
Add
Nonbinary
Delete
Add
M
F
Delete
Nonbinary
M
F
Add
Delete
Nonbinary
*
1
Relationship Codes:
S - Spouse
DP - Domestic Partner
NC - Natural Child
SC - Step Child
AC - Adopted Child
DPC - Domestic Partner Child
PCR - Parent Child Relationship
SECTION E: Enrollment
To enroll, carefully review the information in this section and check the box:
16.
I ELECT TO ENROLL in (or MAKE CHANGES TO) a health benefits plan as indicated above and agree to authorize deductions from (1) my salary to cover my share
of the cost of enrollment as it is now or as it may be in the future (2) my retirement allowance to continue health benefits coverage into retirement. I CERTIFY that the
information provided herein is accurate and listed dependents are eligible family members as defined in the Public Employees' Medical and Hospital Care Act.
I VOLUNTARILY enroll into the selected Health Plan. I AGREE to read the associated Evidence of Coverage (EOC) and any subsequent EOCs in the following years
to understand the benefits of the plan. The Subscriber and all eligible dependents agree to all the terms and conditions of the EOC and the Health Plan.
I UNDERSTAND that enrolling in certain health plans requires binding arbitration and that any dispute as to medical malpractice, that is as to whether any medical
services rendered under this contract were unnecessary or unauthorized or were improperly, negligently, or incompetently rendered, will be determined by submission
to arbitration as provided by California Law and not by a lawsuit or resort to court process except as California law provides for judicial review of arbitration
proceedings. The parties to this agreement, by entering into it, are giving up their constitutional right to have any such dispute decided in a court of law before a jury
and instead are accepting the use of arbitration.
17.
To decline, carefully review the information in this section and check the box:
I DECLINE ENROLLMENT into the CalPERS Health Program for myself and my dependents.
I UNDERSTAND that if I choose to enroll at a later date, I must wait at least 90 days after I request enrollment or until the next Open Enrollment (OE) period
before enrolling in the CalPERS Health Program. Furthermore, if I or my dependents involuntarily lose other health insurance coverage, I may request
enrollment into the Program within 60 days from the date of lost coverage. If I do not request enrollment within 60 days, I must wait at least 90 days or until
the next OE period before I can enroll. The effective date of coverage will be the first of the month following the 90 day waiting period or the OE effective
date.
18.
Employee Signature:
19.
Date:
(mm/dd/yyyy)
HBD-12 (Rev 06/2020)
Page 1 of 2
Health Account Management Division
P.O. BOX 942715
Sacramento, CA 94229-2715
Health Benefits Plan Enrollment
888 CalPERS (or 888-225-7377) | TTY (877) 249-7442
FAX (800) 959-6545
for Active Employees (HBD-12)
www.calpers.ca.gov
SECTION A: Applicant Information
1.
2.
Employee Name:
Hire Date:
(M.I.)
(Last)
(First)
(mm/dd/yyyy)
3.
5.
4.
CalPERS ID or Social Security Number:
Gender:
Date of Birth:
(mm/dd/yyyy)
Male
Female
Nonbinary
6.
Physical Address:
(State)
(County)
(City)
(ZIP)
(Street)
7.
Mailing Address
:
(City)
(State)
(ZIP)
(County)
(Street)
(If different)
Use Work ZIP Code for Health Eligibility:
8.
Yes
No
If yes, enter zip code here: (ZIP)
9.
10.
E-mail Address:
Alternate:
Primary Phone:
SECTION B: Type of Action
11.
Enroll in a Health Plan
Add/Delete Dependents
Change Health Plan
Cancel All Coverage
Decline Coverage
SECTION C: Type of Permitting Event
12.
New Contracting
Open
New Employee
Marriage or Domestic Partnership Date
:
Move
(mm/dd/yyyy)
Agency
Enrollment
Birth/
Delete Dependent Due to Death
Divorce or Domestic Partnership Termination
Other:
Adoption
13.
14.
Permitting Event Date:
Name of Health Plan:
(mm/dd/yyyy)
(If changing health plans, list new plan name)
SECTION D: Subscriber and Dependent Information
(List yourself and all of your dependents)
15.
Date of
Primary Care
Relationship
CalPERS ID or Social
Name (First, M.I., Last)
Gender
Action
Birth
Code *
1
Security Number
Physician
(mm/dd/yyyy)
M
F
Add
SELF
Nonbinary
Delete
M
F
Add
Nonbinary
Delete
Add
M
F
Delete
Nonbinary
M
F
Add
Nonbinary
Delete
Add
M
F
Delete
Nonbinary
M
F
Add
Delete
Nonbinary
*
1
Relationship Codes:
S - Spouse
DP - Domestic Partner
NC - Natural Child
SC - Step Child
AC - Adopted Child
DPC - Domestic Partner Child
PCR - Parent Child Relationship
SECTION E: Enrollment
To enroll, carefully review the information in this section and check the box:
16.
I ELECT TO ENROLL in (or MAKE CHANGES TO) a health benefits plan as indicated above and agree to authorize deductions from (1) my salary to cover my share
of the cost of enrollment as it is now or as it may be in the future (2) my retirement allowance to continue health benefits coverage into retirement. I CERTIFY that the
information provided herein is accurate and listed dependents are eligible family members as defined in the Public Employees' Medical and Hospital Care Act.
I VOLUNTARILY enroll into the selected Health Plan. I AGREE to read the associated Evidence of Coverage (EOC) and any subsequent EOCs in the following years
to understand the benefits of the plan. The Subscriber and all eligible dependents agree to all the terms and conditions of the EOC and the Health Plan.
I UNDERSTAND that enrolling in certain health plans requires binding arbitration and that any dispute as to medical malpractice, that is as to whether any medical
services rendered under this contract were unnecessary or unauthorized or were improperly, negligently, or incompetently rendered, will be determined by submission
to arbitration as provided by California Law and not by a lawsuit or resort to court process except as California law provides for judicial review of arbitration
proceedings. The parties to this agreement, by entering into it, are giving up their constitutional right to have any such dispute decided in a court of law before a jury
and instead are accepting the use of arbitration.
17.
To decline, carefully review the information in this section and check the box:
I DECLINE ENROLLMENT into the CalPERS Health Program for myself and my dependents.
I UNDERSTAND that if I choose to enroll at a later date, I must wait at least 90 days after I request enrollment or until the next Open Enrollment (OE) period
before enrolling in the CalPERS Health Program. Furthermore, if I or my dependents involuntarily lose other health insurance coverage, I may request
enrollment into the Program within 60 days from the date of lost coverage. If I do not request enrollment within 60 days, I must wait at least 90 days or until
the next OE period before I can enroll. The effective date of coverage will be the first of the month following the 90 day waiting period or the OE effective
date.
18.
Employee Signature:
19.
Date:
(mm/dd/yyyy)
HBD-12 (Rev 06/2020)
Page 1 of 2
SECTION F: CalPERS Privacy Notice
The privacy of personal information is of the
SSN
6. Resolve member appeals, complaints, or
utmost importance to CalPERS. The following
Social Security numbers are collected on a
grievances with health plan carriers
information is provided to you in compliance with
mandatory and voluntary basis. If this is CalPERS
Information Disclosure
the Information Practices Act of 1977 and the
first request for disclosure of your SSN, then
Portions of this information may be transferred to
Federal Privacy Act of 1974.
disclosure is mandatory. If your SSN has already
other state agencies (such as your employer),
been provided, disclosure is voluntary. Due to the
Information Purpose
physicians, and insurance carriers, but only in
use of Social Security numbers by other agencies
The information requested is collected pursuant
strict accordance with current statutes regarding
for identification purposes, we may be unable to
to the Government Code Sections (20000
confidentiality.
verify eligibility for benefits without the number.
et seq.) and will be used for administration of
Your Rights
Board duties under the Retirement Law, the
Social Security numbers are used for the following
You have the right to review your membership
Social Security Act, and the Public Employees'
purposes:
files maintained by the system. For questions
Medical and Hospital Care Act, as the case may
1. Enrollee identification
about this notice, our
Privacy
Policy, or your
be. Submission of the requested information is
2. Payroll deduction / state contributions
rights, please write the CalPERS Privacy Officer
mandatory. Failure to comply may result in the
3. Billing of contracting agencies for employee /
at 400 Q Street, Sacramento, CA 95811 or call
system being unable to perform its functions
employer contributions
our Customer Contact Center at 888-CalPERS
regarding your status.
4. Reports to the CalPERS system and other
(888-225-7377).
state agencies
Please do not include information that is not
5. Coordination of benefits among carriers
requested.
SECTION G: Privacy Information
Submission of the requested information is mandatory. The information requested is collected pursuant to the California Government Code (sections
20000 et seq.) and is used for administration of the CalPERS Board's duties under the Public Employees' Retirement Law, the Social Security Act, and
the Public Employees' Medical and Hospital Care Act, as the case may be. Portions of this information may be transferred to other governmental
agencies (such as your employer), physicians and insurance carriers but only in strict compliance with current statutes regarding confidentiality. Failure
to supply the information may result in CalPERS being unable to perform its functions regarding your status.
You have the right to review your CalPERS membership files. For questions concerning your rights under the Information Practices Act of 1977, please
contact the CalPERS Customer Contact Center at 1-888-CalPERS (or 1-888-225-7377).
Section 7(b) of the Privacy Act of 1974 (Public Law 93-579) requires that any federal, State, or local governmental agency requesting an individual to
disclose a Social Security account number to inform the individual whether that disclosure is mandatory or voluntary, by which statutory or other
authority such number is solicited, and what uses will be made of it. Section 111 of Public Law 101-173 requires group health plans to collect and
provide member Social Security numbers for the coordination of federal and State benefits. Furthermore, the CalPERS health program requires each
enrollee's Social Security number for identification purposes and to verify eligibility for benefits.
The CalPERS health program uses Social Security numbers for the following purposes:
1. Enrollee identification for eligibility processing and eligibility verification
2. Payroll deduction and State contribution for State employees.
3. Billing of contracting agencies for employee and employer contributions.
4. Reports to CalPERS and other state agencies.
5. Coordination of benefits among health plans.
6. Resolution of member complaints, grievances and appeals with health plans.
IMPORTANT: It is your responsibility to notify your personnel office when there are any changes in your family situation. Changes include domestic
partnership termination, establishment of a parent-child relationship, acquisition of a dependent child, change of address, marriage, divorce, legal
separation, and death. Failure to notify your personnel office may result in adverse consequences.
SECTION H: For Employer Use
Please retain original signed form and all supporting documentation or affidavits in employee file. DO NOT send to CalPERS.
Retirement
20.
21.
22.
Agency Name:
Date of Hire:
(mm/dd/yyyy)
System:
CalPERS
CalSTRS
Other
23.
24.
Division ID:
25.
Employee Bargaining Unit/Employee Group:
CalPERS Employer ID:
Payroll
26.
27.
28
Date Received by Employer:
Effective Date:
(mm/dd/yyyy)
State Controller's
Public Agency
Non Central
Office:
Office
Billing
I hereby certify under the penalty of perjury that I am a duly appointed, qualified and acting Health Benefits Officer (HBO) of the above named agency, and the
payment by the agency as provided by Section 22870-22905 of the Government Code is hereby approved. Final determination of eligibility for the enrollment
action specified will be made by the Board of Administration, Public Employees' Retirement System, in accordance with the Public Employees' Medical and
Hospital Care Act and the regulations implementing the Act.
29.
30.
Health Benefits Officer:
Signature:
31.
Date:
32.
Phone Number:
(mm/dd/yyyy)
(Print name)
33.
Remarks:
HBD-12 (Rev 06/2020)
Page 2 of 2
Privacy Notice
The privacy of personal information is of the utmost importance to CalPERS.
The following information is provided to you in compliance with the Information
Practices Act of 1977 and the Federal Privacy Act of 1974.
Information Purpose
Social Security numbers are used for the
following purposes:
The information requested is collected pursuant
1.
Enrollee identification
to the Government Code (sections 20000 et seq.)
2. Payroll deduction/state contributions
and will be used for administration of Board
3. Billing of contracting agencies for employee/
duties under the Retirement Law, the Social
employer contributions
Security Act, and the Public Employees’ Medical
4. Reports to CalPERS and other state agencies
and Hospital Care Act, as the case may be.
5. Coordination of benefits among carriers
Submission of the requested information is
6. Resolving member appeals, complaints,
mandatory. Failure to comply may result in
or grievances with health plan carriers
CalPERS being unable to perform its functions
regarding your status.
Information Disclosure
Please do not include information that is
Portions of this information may be transferred
not requested.
to other state agencies (such as your employer),
physicians, and insurance carriers, but only
Social Security Numbers
in strict accordance with current statutes
regarding confidentiality.
Social Security numbers are collected on a
mandatory and voluntary basis. If this is CalPERS’
Your Rights
first request for disclosure of your Social Security
number, then disclosure is mandatory. If your
You have the right to review your membership
Social Security number has already been provided,
files maintained by the System. For questions
disclosure is voluntary. Due to the use of Social
about this notice, our Privacy Policy, or your rights,
Security numbers by other agencies for
please write to the CalPERS Privacy Officer at
identification purposes, we may be unable to
400 Q Street, Sacramento, CA 95811 or call us
verify eligibility for benefits without the number.
at 888 CalPERS (or 888-225-7377).
May 2016
Page of 3