Instructions for Form HBD-30 "Health Benefits Plan Enrollment for Retirees and Survivors" - California

This document contains official instructions for Form HBD-30, Health Benefits Plan Enrollment for Retirees and Survivors - a form released and collected by the California Public Employees' Retirement System. An up-to-date fillable Form HBD-30 is available for download through this link.

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Health Benefits Plan Enrollment for Retirees and Survivors (HBD-30) Instructions
Contact CalPERS if you have questions about your health enrollment. To enroll or decline enrollment in a CalPERS Health
Program, or to make changes to a health plan, you can submit this form to CalPERS. If you have more than three
dependents, please complete another HBD-30 form. Once you retire, CalPERS becomes your Health Benefits Officer or
personnel office.
SECTION A: Applicant Information
Enter your basic information as indicated. If you are eligible for Medicare, complete part 5.
SECTION B: Qualifying Retirement Employer Information
Please enter information about the agency you retired from.
SECTIONS C & D: Type of Action and Type of Permitting Event
Select the type of action and your permitting event. Below is a list of permitting events and the required documentation. The
required documents in the table below are not inclusive; you may need to submit additional documentation upon CalPERS'
request.
Permitting Event
Required Documentation
• Health Benefits Plan Enrollment for Retirees and Survivors
New Retiree
Form (HBD-30)
• Health Benefits Plan Enrollment for Retirees and Survivors
New Contracting Agency
Form (HBD-30)
Medicare Enrollment
• Certification of Medicare Status Form (PERS08M0021DMC)
(see the CalPERS Medicare Enrollment Guide)
• Copy of your Medicare Card
(HBD-65)
• Marriage Certificate or
• Declaration of Domestic Partnership from the Secretary of
Marriage or Domestic Partnership
State's Office
• Death Certificate
Delete Dependent Due to Death
• Divorce Decree or
Divorce or Domestic Partnership Termination
• Termination of Domestic Partnership submitted to the
Secretary of State's Office
• New address - Please provide your new address to CalPERS
Move
Birth/Adoption
• Birth Certificate/Adoption Paperwork
• Health Benefits Plan Enrollment for Retirees and Survivors
Open Enrollment
Form (HBD-30)
SECTION E: Subscriber and Dependent Information
List yourself and other dependents and the actions you are requesting (add or delete). Use the relationship codes to identify the
type of dependents.
SECTION F: Enrollment
To enroll in a CalPERS health plan, you must review the information and check the box in part 22. To decline enrollment in
a CalPERS health plan, you must review the information and check the box in part 23. Sign and date the form in parts 24
and 25.
SECTION G: Additional Information
Please review the important Medicare and dental reminders.
SECTIONS H & I: CalPERS Privacy Notices
Please review these important privacy notices.
More Information
You can obtain health benefits publications, required forms, and other information about your CalPERS health benefits through
our website at www.calpers.ca.gov or by calling CalPERS at 888 CalPERS (or 888-225-7377).
HBD-30 Instructions (Rev 01/2018)
Page 1 of 1
Health Benefits Plan Enrollment for Retirees and Survivors (HBD-30) Instructions
Contact CalPERS if you have questions about your health enrollment. To enroll or decline enrollment in a CalPERS Health
Program, or to make changes to a health plan, you can submit this form to CalPERS. If you have more than three
dependents, please complete another HBD-30 form. Once you retire, CalPERS becomes your Health Benefits Officer or
personnel office.
SECTION A: Applicant Information
Enter your basic information as indicated. If you are eligible for Medicare, complete part 5.
SECTION B: Qualifying Retirement Employer Information
Please enter information about the agency you retired from.
SECTIONS C & D: Type of Action and Type of Permitting Event
Select the type of action and your permitting event. Below is a list of permitting events and the required documentation. The
required documents in the table below are not inclusive; you may need to submit additional documentation upon CalPERS'
request.
Permitting Event
Required Documentation
• Health Benefits Plan Enrollment for Retirees and Survivors
New Retiree
Form (HBD-30)
• Health Benefits Plan Enrollment for Retirees and Survivors
New Contracting Agency
Form (HBD-30)
Medicare Enrollment
• Certification of Medicare Status Form (PERS08M0021DMC)
(see the CalPERS Medicare Enrollment Guide)
• Copy of your Medicare Card
(HBD-65)
• Marriage Certificate or
• Declaration of Domestic Partnership from the Secretary of
Marriage or Domestic Partnership
State's Office
• Death Certificate
Delete Dependent Due to Death
• Divorce Decree or
Divorce or Domestic Partnership Termination
• Termination of Domestic Partnership submitted to the
Secretary of State's Office
• New address - Please provide your new address to CalPERS
Move
Birth/Adoption
• Birth Certificate/Adoption Paperwork
• Health Benefits Plan Enrollment for Retirees and Survivors
Open Enrollment
Form (HBD-30)
SECTION E: Subscriber and Dependent Information
List yourself and other dependents and the actions you are requesting (add or delete). Use the relationship codes to identify the
type of dependents.
SECTION F: Enrollment
To enroll in a CalPERS health plan, you must review the information and check the box in part 22. To decline enrollment in
a CalPERS health plan, you must review the information and check the box in part 23. Sign and date the form in parts 24
and 25.
SECTION G: Additional Information
Please review the important Medicare and dental reminders.
SECTIONS H & I: CalPERS Privacy Notices
Please review these important privacy notices.
More Information
You can obtain health benefits publications, required forms, and other information about your CalPERS health benefits through
our website at www.calpers.ca.gov or by calling CalPERS at 888 CalPERS (or 888-225-7377).
HBD-30 Instructions (Rev 01/2018)
Page 1 of 1