enrollment (new enrollment or changes)
Outside of annual open enrollment (in September/October) you may only change your benefits due to a change in family status called Life-Qualifying Event (LQE) (e.g., birth, marriage, divorce, death, change in employment, etc.) and in accordance to the Dependent Coverage Provision.
Note: You may update your beneficiaries at any time for any reason (see below).
To find more information and RATES on medical plan options, please click on the MEDICAL section.
If you have a LQE and need to add/delete a dependent, you must complete the Universal Enrollment Form and provide the additional documentation listed. All paperwork must be received by the HR-Benefits department within thirty-one (31) calendar days** from the date of the LQE.
Required Paperwork to Add a Dependent:
- Universal Enrollment Form (for ALL dependents)
- CalPERS Health Plan Enrollment for Employees - Form HBD-12 (for ALL dependents)
- Spouse or Domestic Partner:
- Child:
- CalPERS Affidavit of Parent-Child Relationship - Form HBD-40 (if applicable; not for natural-born or legally adopted child)
- CalPERS Disabled Dependent Questionnaire - Form PERS HBD-98 (if applicable)
- CalPERS Disabled Dependent Medical Certification - Form HBD-34 (if applicable)
IN ADDITION, copies of the following must be turned in:
- birth certificate(s) (for ALL dependents being added),
- social security card(s) (for ALL dependents being added),
- marriage certificate, State of CA Declaration of Domestic Partnership(Form NP/SF DP-1)or Domestic Partner Affidavit , (if applicable)
- adoption papers or proof of legal guardianship (if applicable), AND
- letter from dependent's former employer announcing the effective date for change in employment or benefits coverage (if applicable)
Required Paperwork to Delete a Dependent:
- Universal Enrollment Form
- CalPERS Health Plan Enrollment for Employees - Form HBD-12 (for ALL dependents)
IN ADDITION, copies of the following must be turned in:
- finalized divorce decree signed by a judge with effective date, OR
- copy of official death certificate, OR
- documentation from a state or official agency confirming eligibility for medical financial assistance, OR
- letter from dependent's employer announcing the effective date for change in employment or benefits coverage
For all deletions, see COBRA and HIPAA information. Through COBRA, your former dependent may be eligible to continue his/her benefits coverage by paying the full premium. If eligible, information will be mailed to the dependent, or you may inquire with the benefits department within 45 daysof the last date of coverage.
**If you fail to notify the District and submit the appropriate documentation within 31 days, then you may add the dependent later during the annual open enrollment.If you have turned in the Universal Enrollment Form within 31 days and need additional time to secure legal documentation, please contact our office for review.
In addition to medical coverage, you may also elect to enroll, dis-enroll or change your status for the following programs. You may also want to verify and update your beneficiaries* at this time:
- FSA
- CalSTRS / CalPERS Retirement (beneficiaries)
- Group Term Life Insurance
*Note: Only the most recent designation of your beneficiaries will receive these benefits, even if you are no longer married to or associate with the individual designated on your latest form. With any changes in status, please review and/or update your forms!