"Ineligibility of Medicare Certification" - California

Ineligibility of Medicare Certification is a legal document that was released by the California Public Employees' Retirement System - a government authority operating within California.

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Health Account Management Division
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
California Public Employees' Retirement System
Ineligibility of Medicare Certification
Instructions for completing Ineligibility of Medicare Certification
• Complete Section 1: CalPERS member information
• Complete either Section 2 or 3: Choose only one
• Complete Section 4: Sign, date, and mail to:
Section 1: Member's / Dependent's name and CalPERS ID(s)
CalPERS Retiree Name:
CalPERS Retiree CalPERS ID:
Medicare Eligible Dependent's Name:
Dependent's CalPERS ID:
Section 2: For Member/Dependent claiming Medicare Ineligibility
I am not eligible for Medicare Part A at no cost (in my own right or through the work history
of a current, former, or deceased spouse). I have verified this with the SSA and have
attached a copy of supporting documentation from the SSA.
Section 3: For Member/Dependent who works and has Employer Group Health Plan Coverage
I have deferred enrollment in Medicare Part B due to working beyond age 65 and have
health coverage through my or my spouse’s Employer Group Health Plan. I have attached a
copy of supporting documentation showing enrollment in the Employer Group Health Plan.
1. Name of your current employer:
2. Name of your Group Health Plan provided by your employer:
Section 4: Member/Dependent Signature. I certify that the above information is true and correct.
Primary Phone Number
Signature
Date
____________________________________________________________________________________________
Health Account Management Division
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
California Public Employees' Retirement System
Ineligibility of Medicare Certification
Instructions for completing Ineligibility of Medicare Certification
• Complete Section 1: CalPERS member information
• Complete either Section 2 or 3: Choose only one
• Complete Section 4: Sign, date, and mail to:
Section 1: Member's / Dependent's name and CalPERS ID(s)
CalPERS Retiree Name:
CalPERS Retiree CalPERS ID:
Medicare Eligible Dependent's Name:
Dependent's CalPERS ID:
Section 2: For Member/Dependent claiming Medicare Ineligibility
I am not eligible for Medicare Part A at no cost (in my own right or through the work history
of a current, former, or deceased spouse). I have verified this with the SSA and have
attached a copy of supporting documentation from the SSA.
Section 3: For Member/Dependent who works and has Employer Group Health Plan Coverage
I have deferred enrollment in Medicare Part B due to working beyond age 65 and have
health coverage through my or my spouse’s Employer Group Health Plan. I have attached a
copy of supporting documentation showing enrollment in the Employer Group Health Plan.
1. Name of your current employer:
2. Name of your Group Health Plan provided by your employer:
Section 4: Member/Dependent Signature. I certify that the above information is true and correct.
Primary Phone Number
Signature
Date
____________________________________________________________________________________________
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
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