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California State University, Long BeachCalifornia State University, Long Beach

How to Complete Open Enrollment Forms

Forms

Changing Health and/or Dental Plan

  • Complete the Benefits Enrollment Worksheet page 1: Select under Type of Action - Change Plan - select which plan you want to change with an "X".
  • Under the Plan Option - write the name of the Medical and/or Dental plan you want to switch to.
  • If you currently have dependents enrolled, you do not need to provide dependent information, they will be switched to the new plan you selected effective January 1, 2018.
  • Please complete the CalPERS Declaration of Health Coverage on page 2.
  • Submit the completed and signed forms to Benefits Services located in Brotman Hall 353. You will receive an email confirmation that your forms were received and if they were complete or missing information.

Adding/Deleting Dependents

  • Complete the Benefits Enrollment Worksheet page 1: Select under Type of Action - add/delete dependents - select which plan you want to add/delete the dependents from with an "X".
  • Under the Plan Option - leave this blank, we will delete them or add them to the plan you are currently enrolled in or will be enrolling in if you are making an Open Enrollment change.
  • If you are adding dependents, you need to provide dependent information (i.e. proof of relationship and social security number and name) in order for them to be added effective January 1, 2018.
  • If you are deleting dependents, you only need to provide their information in the "Dependent Enrollment Selections" section, no proof of relationship is required, unless you are getting a divorce or if the dependent is deceased.
  • Please complete the CalPERS Declaration of Health Coverage on page 2.
  • Submit the completed and signed forms to Benefits Services located in Brotman Hall 353. You will receive an email confirmation that your forms were received and if they were complete or missing information.

Flex Cash Medical and/or Dental Enrollment or Cancellation and Enrollment in Health/Dental

  • Complete the Benefits Enrollment Worksheet page 1: Select under Type of Action - Enroll in Plan - select which plan type you want to enroll in with an "X". Also select under Type of Action - Cancel Plan - select with plan type you want to cancel with an "X".
  • Under the Plan Option - write the name of the Medical and/or Dental plan you want to enroll in or complete the Flex Cash enrollment information and provide proof of your alternate employer health and/or dental plan (i.e. benefits verification letter or copies of medical/dental cards).
  • If you are adding dependents, you need to provide dependent information (i.e. proof of relationship and social security number and name) in order for them to be added effective January 1, 2018.
  • If you are canceling health and/or dental coverage, you do not need to provide the dependents information.
  • Submit the completed and signed forms to Benefits Services located in Brotman Hall 353. You will receive an email confirmation that your forms were received and if they were complete or missing information.

Enroll/Re-Enroll in Health or Dependent Care Reimbursement

  • Complete the Benefits Enrollment Worksheet page 1: Select under Type of Action - Enroll in Plan - select HCRA/DCRA with an "X". Then sign and date the bottom of the form. Proceed to page 4, the HCRA/DCRA Enrollment Form.
  • Complete the HCRA/DCRA Enrollment Form by providing your Full Social Security Number, Marital Status and Name. Please initial near where it says "Employee Initial Here" in Section 5. In Section 7, write the monthly deduction amount you want to come out of your check beginning January 1, 2018. (Note: The minimum amount is $20 and the maximum amount for HCRA is $216.66 and DCRA is $416.66).
  • Please sign where it says employee signature and date.
  • Submit the completed and signed forms to Benefits Services located in Brotman Hall 353. You will receive an email confirmation that your forms were received and if they were complete or missing information.

PLEASE NOTE: Open Enrollment forms will be accepted beginning September 11 and ending on October 6, 2017. THERE WILL BE NO EXCEPTIONS MADE.

Questions? Please contact Benefits Services at (562) 985-2381 or benefits@csulb.edu.