Health Procedures
Open Enrollment is held each fall. You'll need to notify us if you have new employees or employees who need to change their health coverage. Refer to the information below for details on how to complete the process.
You can also direct your employees to our Active Members Health Benefits section to learn more about eligibility, enrollment, plans and rates, and access our Reference & Health Guides for more information on health procedures.
Mandatory transactions are additions or deletions from health enrollment required by law. Mandatory transactions include events such as:
- Birth or adoption of a child
- Death of a dependent
- Dependent children reaching age 26
- Divorce or termination of domestic partnership
- Enrollment of spouse, registered domestic partner, or child dependent in a CalPERS sponsored health plan
The effective date of change is the first of the month following the event date.
Permissive transactions are additions or deletions of dependents from an existing enrollment due to a voluntary request by the enrolled member. These transactions include:
- A child, spouse, or domestic partner who enters military service
- A child who reaches age 18 or obtains non-CalPERS sponsored coverage
- A spouse who moves out of the household
- Addition of a spouse, domestic partner, or stepchild
- Change in custody of a child
The transaction is effective the first day of the month after the Health Benefits Plan Enrollment for Active Employees (HBD-12) (PDF) is received in the employing office, subject to sufficient earnings.
If the State Controller's Office doesn't receive the enrollment form from CalPERS by the monthly cut-off date, the premium payment or adjustment will be delayed until a later pay period.
New Employee Appointments
If the appointment is on the last day of the month, which is the first day of the next pay period, the earliest effective date will be the first day of the second month following the appointment.
Example:
Appointed/HBD-12 completed
July 31 (August pay period)
Earliest effective date
September 1
Coverage cannot begin on August 1 because the August pay period is the first month a deduction can be taken. The above example only applies to the appointment date of new employees, not to enrollment changes.
The reason code is a 3-digit numerical code used to indicate the type of action or event resulting in a new health enrollment or change to an existing health enrollment. When adding or deleting family members, be sure to notice which reasons are permissive and which are mandatory, because effective dates and rights to COBRA coverage are affected.
CalPERS uses reason codes when processing:
- Administrative remedies
- COBRA enrollments
- Direct pay changes
- Enrollment changes for a member's health account
- HBD-12 forms
- Medicare status changes
Reason codes should be entered in Box 14 of the Health Benefits Plan Enrollment for Active Employees (HBD-12) (PDF). Refer to Health Enrollment Reason Codes (PDF) to ensure the correct code is used on the HBD-12 form.
The employee's HBD-12 and a copy of the following required documents must be retained in your office. In Box 35, "Remarks" of the HBD-12, note these documents are on file. Do not send these documents to CalPERS.
| Documents | Required for |
|---|---|
| Marriage Certificate | Adding a spouse |
| Affidavit of Parent-Child Relationship | Adding a child where a parent-child relationship exists |
| Divorce Decree | Deleting a spouse due to divorce |
| Declaration of Domestic Partnership and Financial Statement of Liability | Adding a domestic partner |
| Employer Designation Template | Designating full-time variable hour employees under the Affordable Care Act (ACA) as Public Employees' Medical & Hospital Care Act (PEMHCA) eligible |
There are nine methods (reasons or events) to determine the effective date for:
- Canceling your benefit
- Changing health plans
- New enrollees (employee, retiree, or survivor)
- ZIP code changes
The reason codes have an effective date number that corresponds to one of the methods shown below. This is the method used for that particular reason code.
| Effective Date Number | Effective Date Method Description |
|---|---|
| 1 | First day of the month following the event date (mandatory event) or Health Benefits Officer (HBO) received date (permissive event) |
| 2 | First day of the month following the HBO received date if within 60 days of the event date - If the HBO received date is beyond the 60th day, the effective date is the first day of the month following a 90-day waiting period from the HBO received date (permissive event). |
| 3 | Administratively determined |
| 4 | Open Enrollment effective date (January 1 of the contract year) |
| 5 | Special Open Enrollment effective date determined by CalPERS - The HBO received date must be within special enrollment dates established by CalPERS. |
| 6 | First day of the month following the HBO received date or most recent Open Enrollment effective date, whichever is latest |
| 7 | First day of the second month following the event date |
| 8 | First day of the month following the HBO received date if within 60 days of the contract date - If the HBO received date is after the 60th day, the effective date is the first day of the month following a 90-day waiting period from the HBO received date (permissive event). |
| 9 | State Permanent Intermittent Employees (PIs): First day of the month following the HBO received date if within 60 days of the event date - If the HBO received date is beyond 60 days, the effective date is the first day of the month following 90 days from the HBO received date. |
Life events, such as the death of a family member or change in marital status, can affect health coverage eligibility for your employee and any spouse or dependents.
To reduce health plan liability and help CalPERS control costs, reimbursement of excess health premiums is limited to no more than six months from the date of reporting.
Employees who don't report an enrollment change in a timely manner could be responsible for reimbursing the employer and premiums paid in excess of six months from the date the change was recorded.
For more information, visit the California Office of Administrative Law.