Form HBD-85R "Cobra Election Form (Retirees)" - California

What Is Form HBD-85R?

This is a legal form that was released by the California Public Employees' Retirement System - a government authority operating within California. As of today, no separate filing guidelines for the form are provided by the issuing department.

Form Details:

  • Released on October 1, 2017;
  • 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-85R by clicking the link below or browse more documents and templates provided by the California Public Employees' Retirement System.

ADVERTISEMENT
ADVERTISEMENT

Download Form HBD-85R "Cobra Election Form (Retirees)" - California

1347 times
Rate (4.3 / 5) 94 votes
Health Account Management Division
1
P.O. BOX 942715, Sacramento, CA 94229-2715
888 CalPERS (or 888-225-7377) | TTY (877) 249-7442
FAX (800) 959-6545 |
www.calpers.ca.gov
HBD-85R (Rev 10/17)
SUBJECT: CONSOLIDATED OMNIBUS BUDGET RECONCILIATION ACT
(COBRA)
General
Information – Election
This form is to be used by Retirees
only.
For active members, please
use the HBD-85 form.
The Federal COBRA legislation allows the
continuation
of health
and dental coverage
to family
members who lost their eligibility for
coverage as
dependents
on
or
after
August
1, 1986,
for one of
the following reasons:
a. Divorce
or
legal
separation
b.
Attainment
of
age 26
(child)
c. Death
of employee/annuitant (if
enrolled family member is not eligible for
a
monthly
survivor/beneficiary
allowance from CalPERS)
The coverage
can
be
continued
for up to
36
months, but the premium payment
(102% of the
group
rate) is the responsibility of the enrollee. No
state
contribution is available to
pay
for
the
COBRA
coverage.
To enroll under
COBRA,
please fill out the information below:
Name and Social Security Number of (former) prime life enrollee:
_________________________________________________ SSN: _______ - ________ - ________
Name and Social Security Number of
COBRA
enrollee,
if
different
from
above:
Name: ___________________________________________________ SSN: _____ - _____ - ______
Address: _______________________________________________________________________________
Primary Phone
Number: (
) __________________________________________________________
QUALIFYING EVENTS: Length
of coverage
is
36 months.
Divorce
or
legal
separation
Death of
employee/annuitant
Child attained
age
26
Date
of the above qualifying event: ______________________________________________________
ELECTION TO ENROLL IN OR DECLINE COBRA CONTINUATION
COVERAGE:
Enroll
Health Benefits
Decline
Dental
Coverage Enroll
Decline
Signature
of COBRA
Enrollee:
____________________________________
Date:
_____________
(mm/dd/yyyy)
below.
Please return this
election within 60 days after
receipt
to the address i n d i c a t e d
CalPERS
will
prepare
the
actual enrollment
document
and send a copy
to the
COBRA enrollee and to
the
carrier.
A premium
check
payable to
the
carrier
may
be enclosed, or the carrier will
bill
the enrollee
directly. The
effective
date for
COBRA coverage is
the
same as
the date
on
which coverage as a
dependent is
terminated.
Health Account Management Division
P.O. BOX 942715, Sacramento, CA 94229-2715
Health Account Management Division
1
P.O. BOX 942715, Sacramento, CA 94229-2715
888 CalPERS (or 888-225-7377) | TTY (877) 249-7442
FAX (800) 959-6545 |
www.calpers.ca.gov
HBD-85R (Rev 10/17)
SUBJECT: CONSOLIDATED OMNIBUS BUDGET RECONCILIATION ACT
(COBRA)
General
Information – Election
This form is to be used by Retirees
only.
For active members, please
use the HBD-85 form.
The Federal COBRA legislation allows the
continuation
of health
and dental coverage
to family
members who lost their eligibility for
coverage as
dependents
on
or
after
August
1, 1986,
for one of
the following reasons:
a. Divorce
or
legal
separation
b.
Attainment
of
age 26
(child)
c. Death
of employee/annuitant (if
enrolled family member is not eligible for
a
monthly
survivor/beneficiary
allowance from CalPERS)
The coverage
can
be
continued
for up to
36
months, but the premium payment
(102% of the
group
rate) is the responsibility of the enrollee. No
state
contribution is available to
pay
for
the
COBRA
coverage.
To enroll under
COBRA,
please fill out the information below:
Name and Social Security Number of (former) prime life enrollee:
_________________________________________________ SSN: _______ - ________ - ________
Name and Social Security Number of
COBRA
enrollee,
if
different
from
above:
Name: ___________________________________________________ SSN: _____ - _____ - ______
Address: _______________________________________________________________________________
Primary Phone
Number: (
) __________________________________________________________
QUALIFYING EVENTS: Length
of coverage
is
36 months.
Divorce
or
legal
separation
Death of
employee/annuitant
Child attained
age
26
Date
of the above qualifying event: ______________________________________________________
ELECTION TO ENROLL IN OR DECLINE COBRA CONTINUATION
COVERAGE:
Enroll
Health Benefits
Decline
Dental
Coverage Enroll
Decline
Signature
of COBRA
Enrollee:
____________________________________
Date:
_____________
(mm/dd/yyyy)
below.
Please return this
election within 60 days after
receipt
to the address i n d i c a t e d
CalPERS
will
prepare
the
actual enrollment
document
and send a copy
to the
COBRA enrollee and to
the
carrier.
A premium
check
payable to
the
carrier
may
be enclosed, or the carrier will
bill
the enrollee
directly. The
effective
date for
COBRA coverage is
the
same as
the date
on
which coverage as a
dependent is
terminated.
Health Account Management Division
P.O. BOX 942715, Sacramento, CA 94229-2715
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 2