Form PERS-HBD-85 "Group Continuation Coverage (Cobra)" - California

What Is Form PERS-HBD-85?

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 May 1, 2019;
  • 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 PERS-HBD-85 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 PERS-HBD-85 "Group Continuation Coverage (Cobra)" - California

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Health Account Management Division
P.O. BOX 942715, Sacramento, CA 94229-2715
GROUP CONTINUATION COVERAGE
888 CalPERS (or 888-225-7377) | TTY (877) 249-7442 FAX
CONSOLIDATED OMNIBUS BUDGET RECONCILIATION ACT
(COBRA) PERS-HBD-85 (Rev 05/19)
(800) 959-6545 |
www.calpers.ca.gov
INSTRUCTIONS FOR COMPLETING THIS FORM ARE ON THE REVERSE SIDE. PLEASE TYPE
PART A: TYPE OF ACTION AND DATES
2. TYPE OF PERMITTING EVENT
1.Type of Action
.
EMPLOYMENT SEPARATION/TIME BASE REDUCTION
NEW
3. EVENT DATE
4. COBRA ENROLLMENT PERIOD
DIVORCE/LEGAL SEPARATION
CHILD CEASES TO BE A DEPENDENT
CHANGE
DEATH OF AN EMPLOYEE/RETIREE
FROM
01
DEPENDENT ELIGIBILITY VERIFICATION
CANCEL
DEPENDENT CONTINUATION-ORIGINAL ENROLLEE ELIGIBLE FOR MEDICARE
SSA CERTIFIED DISABILITY - 11 MONTH EXTENSION
TO
PART B: ENROLLEE INFORMATION
6. CalPERS SUBSCRIBER/MEMBER (EMPLOYEE)
5. COBRA ENROLLEE (MAY BE DIFFERENT THAN SUBSCRIBER)
CalPERS ID or
CalPERS ID or
SOCIAL SECURITY NUMBER
SOCIAL SECURITY NUMBER
NAME
SUBSCRIBER NAME
MEDICAL GROUP OR CBU
ADDRESS
PART D: DEPENDENT INFORMATION
CITY, STATE, ZIP
PRIMARY PHONE NUMBER
8. LIST OF ALL PERSONS (including self) TO BE ENROLLED:
ACTION
MARRIED
YES
NO
CODE
FIRST
MI
LAST
CalPERS ID or SSN
GENDER
DATE OF BIRTH
DATE OF BIRTH
FAMILY RELATIONSHIP
FEMALE
NON-BINARY
MALE
Self
PART C: CARRIER INFORMATION
FIRST
MI
LAST
CalPERS ID or SSN
7. NAME AND ADDRESS OF HEALTH PLAN
DATE OF BIRTH
FAMILY RELATIONSHIP
(SUBMIT PAYMENT DIRECTLY TO THE CARRIER)
FIRST
MI
LAST
CalPERS ID or SSN
DATE OF BIRTH
FAMILY RELATIONSHIP
FIRST
MI
LAST
PLAN CODE: ________________
PREMIUM: $ ________________
CalPERS ID or SSN
PHONE:
FAMILY RELATIONSHIP
DATE OF BIRTH
PART E: ENROLLMENT CHANGES
9. NAME OF PRIOR HEALTH PLAN
11. TYPE OF PERMITTING
13. EFFECTIVE DATE OF
12. PERMITTING EVENT
EVENT
DATE
CHANGE
_____________________________________________
10. PRIOR PLAN CODE
01
PART F: SIGNATURE OF ENROLLEE
14. I AGREE TO PAY THE PREMIUM FOR THE COVERAGE DIRECTLY TO THE CARRIER LISTED IN PART C. I UNDERSTAND
THAT I AM REQUIRED TO SEND THE INITIAL PAYMENT PRIOR TO EFFECTIVE DATE OF ENROLLMENT AND AGREE TO MAKE
FUTURE PAYMENTS IN A TIMELY MANNER AS REQUIRED BY THE CARRIER. I UNERSTAND THAT FAILURE TO PAY THE
PREMIUM WILL RESULT IN AUTOMATIC TERMINATION OF COVERAGE. I CERTIFY THAT THE INFORMATION PROVIDED BY ME
IS TRUE AND CORRECT TO THE BEST OF MY KNOWLEDGE AND ABILITY.
_____________________________________
____________________________________________________________________
SIGNATURE OF COBRA ENROLLEE (SEE ATTACHMENT FOR PRIVACY INFORMATION)
DATE SIGNED
PART G: AGENCY INFORMATION
15. AGENCY NAME ______________________________________
16. HEALTH BENEFITS OFFICER'S SIGNATURE
AGENCY CODE ______________
UNIT CODE _________
DATE RECEIVED ___________
PHONE ______________
www.calpers.ca.gov
Health Account Management Division
P.O. BOX 942715, Sacramento, CA 94229-2715
GROUP CONTINUATION COVERAGE
888 CalPERS (or 888-225-7377) | TTY (877) 249-7442 FAX
CONSOLIDATED OMNIBUS BUDGET RECONCILIATION ACT
(COBRA) PERS-HBD-85 (Rev 05/19)
(800) 959-6545 |
www.calpers.ca.gov
INSTRUCTIONS FOR COMPLETING THIS FORM ARE ON THE REVERSE SIDE. PLEASE TYPE
PART A: TYPE OF ACTION AND DATES
2. TYPE OF PERMITTING EVENT
1.Type of Action
.
EMPLOYMENT SEPARATION/TIME BASE REDUCTION
NEW
3. EVENT DATE
4. COBRA ENROLLMENT PERIOD
DIVORCE/LEGAL SEPARATION
CHILD CEASES TO BE A DEPENDENT
CHANGE
DEATH OF AN EMPLOYEE/RETIREE
FROM
01
DEPENDENT ELIGIBILITY VERIFICATION
CANCEL
DEPENDENT CONTINUATION-ORIGINAL ENROLLEE ELIGIBLE FOR MEDICARE
SSA CERTIFIED DISABILITY - 11 MONTH EXTENSION
TO
PART B: ENROLLEE INFORMATION
6. CalPERS SUBSCRIBER/MEMBER (EMPLOYEE)
5. COBRA ENROLLEE (MAY BE DIFFERENT THAN SUBSCRIBER)
CalPERS ID or
CalPERS ID or
SOCIAL SECURITY NUMBER
SOCIAL SECURITY NUMBER
NAME
SUBSCRIBER NAME
MEDICAL GROUP OR CBU
ADDRESS
PART D: DEPENDENT INFORMATION
CITY, STATE, ZIP
PRIMARY PHONE NUMBER
8. LIST OF ALL PERSONS (including self) TO BE ENROLLED:
ACTION
MARRIED
YES
NO
CODE
FIRST
MI
LAST
CalPERS ID or SSN
GENDER
DATE OF BIRTH
DATE OF BIRTH
FAMILY RELATIONSHIP
FEMALE
NON-BINARY
MALE
Self
PART C: CARRIER INFORMATION
FIRST
MI
LAST
CalPERS ID or SSN
7. NAME AND ADDRESS OF HEALTH PLAN
DATE OF BIRTH
FAMILY RELATIONSHIP
(SUBMIT PAYMENT DIRECTLY TO THE CARRIER)
FIRST
MI
LAST
CalPERS ID or SSN
DATE OF BIRTH
FAMILY RELATIONSHIP
FIRST
MI
LAST
PLAN CODE: ________________
PREMIUM: $ ________________
CalPERS ID or SSN
PHONE:
FAMILY RELATIONSHIP
DATE OF BIRTH
PART E: ENROLLMENT CHANGES
9. NAME OF PRIOR HEALTH PLAN
11. TYPE OF PERMITTING
13. EFFECTIVE DATE OF
12. PERMITTING EVENT
EVENT
DATE
CHANGE
_____________________________________________
10. PRIOR PLAN CODE
01
PART F: SIGNATURE OF ENROLLEE
14. I AGREE TO PAY THE PREMIUM FOR THE COVERAGE DIRECTLY TO THE CARRIER LISTED IN PART C. I UNDERSTAND
THAT I AM REQUIRED TO SEND THE INITIAL PAYMENT PRIOR TO EFFECTIVE DATE OF ENROLLMENT AND AGREE TO MAKE
FUTURE PAYMENTS IN A TIMELY MANNER AS REQUIRED BY THE CARRIER. I UNERSTAND THAT FAILURE TO PAY THE
PREMIUM WILL RESULT IN AUTOMATIC TERMINATION OF COVERAGE. I CERTIFY THAT THE INFORMATION PROVIDED BY ME
IS TRUE AND CORRECT TO THE BEST OF MY KNOWLEDGE AND ABILITY.
_____________________________________
____________________________________________________________________
SIGNATURE OF COBRA ENROLLEE (SEE ATTACHMENT FOR PRIVACY INFORMATION)
DATE SIGNED
PART G: AGENCY INFORMATION
15. AGENCY NAME ______________________________________
16. HEALTH BENEFITS OFFICER'S SIGNATURE
AGENCY CODE ______________
UNIT CODE _________
DATE RECEIVED ___________
PHONE ______________
www.calpers.ca.gov
PRIVACY INFORMATION
Submission of the requested information is mandatory. The information is collected pursuant to the Government
Code Sections (20000 et. seq) and will be used for administration of the Board's duties under the California 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 another government agency (such as your
employer) but only in strict accordance with current statutes regarding confidentiality.
Failure to supply the
information may result in the System being unable to perform its functions regarding your status.
You have the right to review your membership files maintained by the System. For questions concerning your rights
under the Information Practices Act of 1977, please contact the Information Security and Privacy Officer,
CalPERS, 400 Q Street, Sacramento, CA 95811.
INSTRUCTIONS FOR THE COMPLETION OF THE FORM HBD-85 (05/2019)
Part A
1. Type of Action
a. Check " NEW " if this your new/initial enrollment
i. (Note: There cannot be a break in coverage between the end of CalPERS active health coverage and the
beginning of COBRA enrollment)
b. Check " CHANGE " if you are adding or deleting dependents, or for a plan change
c. Check "Cancel" if you are canceling your COBRA enrollment
i. You can skip the rest of the sections in Part A
ii. Complete Part B (5 & 6), Part E (13)
2. Check applicable Type of Permitting Event
3. Provide original Event Date (permanent separation, divorce date, etc.)
4. Enter original COBRA Enrollment Period
Examples:
Permanent Separation date 4/15/19 (COBRA Enrollment Period: From 6/1/2019 to 11/30/2020)
Child attains age 26 on 6/15/19 (COBRA Enrollment Period: From 7/1/19 to 01/01/2021)
Part B
5. Provide all requested information
6. Identify the employee if the COBRA enrollee is a former dependent
Part C
7. Identify the carrier. New COBRA enrollees may choose any carrier within their residential or work ZIP code area.
Carrier changes are also allowed during the Open Enrollment period or due to a move. The health plan carrier's name,
address, and phone number can be found in the annual Health Benefit Summary available in all employing agencies.
COBRA premium payments is the responsibility of the COBRA enrollee and must be made directly to the carrier.
Part D
8. List all dependents to be enrolled, including self (if applicable)
Action Code:
i. Use "A" to indicate which dependent is being added (or newly enrolled)
ii. Use "D" to indicate if a dependent is being deleted from an existing COBRA enrollment
iii. An Action Code is not required when changing carriers
Important Note: The addition and deletion of dependents is regulated by time limits which are identical to those
for active employees.
Part E
9. Name of Prior Health Plan (if changing carriers)
10-13. To be completed by the current or former agency's Health Benefits Officer
Part F
14. Signature of COBRA enrollee and date signed
Part G
15-16. To be completed by the current or former employing agency's Health Benefits Officer. CalPERS is the
"employing agency" for former dependents of retirees.
IMPORTANT: It is the responsibility of the COBRA enrollee to report enrollment changes in a timely
manner. Enrollment change requests must be submitted in accordance with existing regulations,
laws, and the time limits applicable to the Public Employees' Medical and Hospital Care Act. All
change requests are directed through the agency listed in Part G.
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
Enrollee identification
1.
pursuant to the Government Code (sections
Payroll deduction/state contributions
2.
20000 et seq.) and will be used for
Billing of contracting agencies for
3.
administration of Board duties under the
employee/employer contributions
Retirement Law, the Social Security Act, and
Reports to CalPERS and other state
4.
the Public Employees’ Medical and Hospital
agencies
Care Act, as the case may be. Submission of
Coordination of benefits among carriers
5.
the requested information is mandatory.
Resolving member appeals, complaints,
6.
Failure to comply may result in CalPERS
or grievances with health plan carriers
being unable to perform its functions
Information Disclosure
regarding your status.
Portions of this information may be transferred
Please do not include information that is
to other state agencies (such as your
not requested.
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
Your Rights
CalPERS’ first request for disclosure of your
Social Security number, then disclosure is
You have the right to review your membership
mandatory. If your Social Security number has
files maintained by the System. For questions
already been provided, disclosure is voluntary.
about this notice, our Privacy Policy, or your
Due to the use of Social Security numbers by
rights, please write to the CalPERS Privacy
other agencies for identification purposes, we
Officer at 400 Q Street, Sacramento, CA
may be unable to verify eligibility for benefits
95811 or call us at 888 CalPERS (or
without the number.
888-225-7377).
May 2019
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