September 2016
Office of the Chancellor 401 Golden Shore Long Beach, CA 90802-4210 (562) 951-4411
To: From:
California State University Retirees, Faculty Early Retirement Participant (FERP), and/or Dependent(s) Human Resources Management - Benefits
Subject:
CSU ANNUAL OPEN ENROLLMENT – EFFECTIVE JANUARY 1, 2017
The CSU annual open enrollment period for dental coverage is September 12, 2016, through October 7, 2016. During open enrollment, you can: • • • •
Enroll in a dental plan Change from one plan to another Add or delete eligible family members Cancel dental coverage
General Information Currently, CSU pays 100% of the monthly premium cost for dental coverage for you and your eligible dependents, including a spouse or a registered domestic partner and/or children up to age 26. CSU employees that retire from a benefits eligible position within 120 days of separation are eligible for basic dental plan coverage for the duration of his/her retirement. Eligible CSU faculty employees that retire from the CSU and enter into the Faculty Early Retirement Program (FERP) are eligible for enhanced dental plan coverage for the duration of participation in the FERP Program as long as weighted teaching units (WTU) time base requirements are met. The California State University (CSU) Dental program offers two dental plan coverage types from Delta Dental of California: Delta Dental PPO is a plan that allows you to select the dentist of your choice. Both you and Delta Dental have a shared responsibility of paying the dentist for services received. If you choose a dentist who participates in the Delta Dental PPO Network and/or the Delta Dental Premier Network in California, claims will be filed on your behalf. Please note: If you select a dentist from the Delta Dental PPO Network, you will pay fewer out-of-pocket expenses. DeltaCare USA is a prepaid dental maintenance organization (DMO), available for California residents only. All covered dental services must be performed by DeltaCare USA panel dentists. Under this plan, no claim forms are required. Each covered dental service has a specific co-payment amount and several services are covered at no charge. You will receive an identification card and welcome letter. The welcome letter will list your DeltaCare USA panel dentist. You may change your assigned dentist by contacting DeltaCare USA. Actions for You •
Please review the enclosed information.
•
IF YOU ARE NOT MAKING ANY CHANGES TO YOUR DENTAL PLAN ENROLLMENT, NO FURTHER ACTION IS REQUIRED.
•
If you are making a change, please complete the enclosed “CSU Dental Open Enrollment Change Request” form and fax it or mail it directly to CalPERS. CalPERS must receive this form by fax at (800) 959-6545 or postmarked no later than October 7, 2016.
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Contact Delta Dental PPO directly at (800) 765-6003 or Delta Care USA at (800) 422-4234, for plan coverage questions. You may view information regarding both dental plans at the following website: www.deltadentalins.com/csu/.
Annual Dental Open Enrollment – Basic Dental Plans, Effective January 1, 2017
What’s New! CSU Retirees can now contact CalPERS directly with Dental Eligibility, Enrollment and Access Questions As a CSU retiree, CalPERS is responsible for maintaining your dental benefit enrollment records, processing your dental open enrollment changes, and submitting eligibility information to the appropriate dental plan. CalPERS also is responsible for maintaining your contact information to ensure your receive ongoing retiree dental communications. CSU Retirees with questions regarding eligibility, enrollment and access, may now contact CalPERS directly at (888) CalPERS or (888) 225-7377. As a reminder, it is important that you keep your home address and email current with CalPERS at all times, to report address changes contact the CalPERS Member Account Management Division of CalPERS at (888) 225-7377. CSU Retiree Benefits Website We are excited to announce the creation of a benefits website just for CSU Retirees! This new website will provide information on the following retirement benefits: • • • • • •
CalPERS Service and Disability Retirement Dental Benefits Health Benefits Vision Benefits Voluntary Benefits in Retirement Open Enrollment
The new website address is www.csuretirees.calstate.edu. We are supporting the efforts of CalPERS for a Go - Green community, and after this year will no longer be mailing open enrollment information to CSU retirees. We are requesting that retirees visit the CSU Retirees website for annual open enrollment information, to view covered benefits, and/or download any necessary forms or evidence of coverage booklets. As a reminder, CalPERS members have the opportunity to access and manage their retirement account through my|CalPERS online services tool if they are registered. Retired members are able to make changes and updates to their accounts immediately. To register please visit www.my.calpers.ca.gov and follow the necessary steps. If you have any questions about the new CSU Retirees website or dental plan design, contact the CSU Office of the Chancellor at (562) 951-4411.
Annual Dental Open Enrollment – Basic Dental Plans, Effective January 1, 2017
Plan Level Eligibility and Comparison of Basic Dental Plans for CSU Retirees CSU employees that retire from a benefits eligible position within 120 days of separation are eligible for basic dental plan coverage for the duration of his/her retirement. DeltaCare USA (must reside in Plan Benefit: Preventive and Diagnostic Dentistry Prophylaxis (cleaning) & Oral Exams Emergency Office Visits X-rays Basic Dentistry Fillings Anesthesia Extractions Oral Surgery Endodontics Periodontics Denture Relining Prosthetic Dentistry Crowns and Bridges Prosthetic Appliance Repair Dentures Implants Maximum Benefit for Preventive, Basic and Prosthetic Dentistry Deductible
CA)
Group Plan #72034-0004 Basic Plan Charges: (No Deductible) No charge – limit 2 per calendar year No charge No charge (No Deductible) No charge for amalgam
Local – no charge; General – not covered
Uncomplicated – no charge $15-$25 for bony impactions (not covered for orthodontia) No charge Root canal – $20 anterior, $40 bicuspid, $60 molars $10 per quadrant for Scaling/Root Planing (limit 4 in a 12 month period) $80 –Osseous surgery per quadrant Office – no charge; Lab – $15 (No Deductible) $35-$50 per unit; plus additional cost for precious metals and porcelain on molars Up to $15 Full – $60 each; Partials – $70 each Not covered No maximum $0 Deductible
Delta Dental PPO Group Plan #4018-2071 Basic Plan Pays: (No Deductible) 75% – limit 2 per calendar year 75% 75% (Deductible) 75% 75% – limited to oral surgery and select
endodontic and periodontic procedures
75% 75% 75% 75%
75% (Deductible) 50% 50% 50% 50% $1,500 per calendar year per person $50 per calendar year per person; Maximum $150 per family per calendar year
The preceding information is not all inclusive. The information is offered only as a brief description of your dental program, what Delta Dental pays for services covered under the program and is not intended for use as a summary plan description nor is it designed to serve as an Evidence of Coverage for the program. If you have specific questions regarding benefit structure, limitations or exclusions consult your Evidence of Coverage or call Delta Dental PPO at (800) 765-6003 or Delta Care USA at (800) 422-4234.
Annual Dental Open Enrollment – Basic Dental Plans, Effective January 1, 2017
Plan Level Eligibility and Comparison of Dental Plans for
CSU Faculty Early Retirement Program (FERP) Participants Eligible CSU faculty employees that retire from the CSU and enter into the Faculty Early Retirement Program (FERP) are eligible for enhanced dental plan coverage for the duration of participation in the FERP program as long as weighted teaching units (WTU) timebase requirements are met.
Plan Benefit Preventive and Diagnostic Dentistry
Prophylaxis (cleaning) & Oral Exams Emergency Office Visits
X-rays
Fillings Anesthesia
Basic Dentistry
Extractions Oral Surgery Endodontics Periodontics Denture Relining Prosthetic Dentistry Crowns and Bridges Prosthetic Appliance Repair Dentures Implants Maximum Benefit for Preventive, Basic and Prosthetic Dentistry Deductible
DeltaCare USA (must reside in CA) Group Plan #: 72034-0008 Enhanced Plan Charges: (No Deductible)
Delta Dental PPO Group Plan #: 4018-3031 Enhanced Level II Plan Pays: (No Deductible)
No charge – limit 2 per calendar year
100% – limit 2 per calendar year
No charge No charge (No Deductible) No charge for amalgam Local – no charge; General – covered for extractions only and only when medically necessary No charge No charge No charge No charge No charge (No Deductible) No charge; however, additional cost for precious metals and porcelain on molars is applicable No charge No charge Not covered No maximum $0 Deductible
100% 100% (Deductible)* 80% 80% – limited to oral surgery and select endodontic and periodontic procedures 80% 80% 80% 80% 80% (Deductible) 80% 80% 80% 80% $2,000 per calendar year per person $50 per calendar year per person; Maximum $150 per family per calendar year
The preceding information is not all inclusive. The information is offered only as a brief description of your dental program, what Delta Dental pays for services covered under the program and is not intended for use as a summary plan description nor is it designed to serve as an Evidence of Coverage for the program. If you have specific questions regarding benefit structure, limitations or exclusions consult your Evidence of Coverage or call Delta Dental PPO at (800) 765-6003 or Delta Care USA at (800) 422-4234.
Retiree Dental Open Enrollment Change Request Form The open enrollment period for the CSU Dental Program is September 12, 2016, through October 7, 2016, with an effective date of January 1, 2017. RETIREE INFORMATION - Please print legibly Please indicate the name of the campus you retired from: Social Security Number or CalPERS ID:
Last Name
Date of Birth (Month/Day/Year)
Mailing Address
Telephone Number
City
□ Enroll In A Dental Plan □ Change My Dental Plan
First Name
State
Zip
TYPE OF CHANGE:
MI
□ □ □
Gender □ Male □ Female
Registered Domestic Partnership Married Single
□ Add Or Delete Eligible Family Members □ Cancel My Dental Enrollment
DENTAL PLAN ELECTION (Check only one plan)
□ Delta Dental PPO - Basic (#4018-2071) □ DeltaCare USA* (HMO) - Basic (#72034-0004) □ Delta Dental PPO – Enhanced (#4018-3031) FERP Only □ DeltaCare USA* (HMO) – Enhanced (#72034-0008) FERP Only
*Please note: DeltaCare USA enrollment is limited to California residents only.
ADDITION OR DELETION OF RETIREE AND/OR DEPENDENTS (See Reverse of Form for Additional Information)
If you are adding a new spouse or dependent, indicate the relationship below. If you are adding Registered Domestic Partner family member(s) (as defined by the Secretary of State), please use the following codes to describe the relationship: A = DP Adult Female; B = DP Adult Male; C = DP Child Female; D = DP Child Male Note: Include a copy of your marriage certificate if you are adding a spouse; or if you are adding a Registered Domestic Partner, please include a copy of the “Declaration of Domestic Partnership” from the Secretary of State or a similar document from another jurisdiction. Include copy of birth certificate if adding a dependent up to age 26. (Last Name, First Name, MI)
Add
Delete
Social Security Number or CalPERS ID
Date of Birth (Month, Day, Year)
Relationship
Self
RETIREE CERTIFICATION AND SIGNATURE (Please initial each statement below, then sign and date the form.) _____I hereby certify under penalty of perjury that the information provided by me is true and correct to the best of my knowledge. _____I understand that the appropriate supporting documents (e.g., birth certificate(s), marriage license, Certificate of Registration of Domestic Partnership, “Affidavit of Parent-Child Relationship” are required for each of my dependents that I plan to add during open enrollment. Signature of Retiree
Date Signed
FAX THIS FORM TO: (800) 959-6545, or MAIL THIS FORM TO: CalPERS – Member Account Management Division P.O. Box 942715 - Sacramento, CA 94229-2715 To be processed, this form must be faxed or postmarked no later than October 7, 2016. If you need assistance, please contact CalPERS at (888) 225-7377.
CSU Guidelines for Enrolling Family Members are as follows: Spouse: You may add your spouse to your dental plan within 60 days of your marriage. You are required to provide a copy of the marriage certificate and the spouse’s Social Security Number. You may complete an affidavit of marriage if you are unable to provide a copy of the marriage certificate. Registered Domestic Partner: You may add your registered domestic partner to your dental plan within 60 days of registration of the domestic partnership. You must register your domestic partnership through the California Secretary of State’s Office. CSU requires that you submit a copy of the Certificate of Registration of Domestic Partnership, and the registered domestic partner’s Social Security Number. Same sex domestic partnerships between persons who are both at least age 18 and certain opposite sex domestic partnerships (one partner must be 62 years of age or older and the other partner at least 18 years of age) are eligible to register with the California Secretary of State. Children: Natural-born (within 60 days of birth), adopted (within 60 days of physical custody), domestic partner’s, and stepchildren (within 60 days after the date of your marriage or registration of domestic partnership) who are under age 26 may be added to your retiree dental coverage. The CSU requires that you submit a copy of the child’s birth certificate or adoption papers and their social security number(s). Disabled Children over Age 26: A child over age 26, who is incapable of self-support because of a mental or physical condition that existed prior to age 26 and continuously since age 26, must have his or her condition documented by a physician. If the dependent is also covered on a CalPERS health plan, the certification will suffice. If the dependent is not covered on a CalPERS health plan, a document certifying the condition must be forwarded directly to the dental carrier for approval. Parent-Child Relationship: Other children may be eligible if they are under age 26 and a parent-child relationship exists when the employee has: (1) assumed a parental role or (2) is considered the primary care “parent.” You have 60 days from the date you assumed a primary custodial parental role to request enrollment. You must submit an Affidavit of Parent-Child Relationship at the time of enrollment for each child and annually thereafter up to age 26. The Chancellor’s Office must approve or disapprove each affidavit before enrollment can occur. Dual Coverage: Retirees and their eligible dependents may only be enrolled in one CSU or state sponsored dental plan at a time (this includes COBRA enrollment). This is called dual coverage and it is not permitted. When dual coverage is discovered, the coverage will be retroactively canceled. You may have to pay for all costs incurred from the date the dual coverage began. Late Enrollment: If you fail to add your eligible dependents to dental coverage within 60 days of the change in status event, there is a 90-day waiting period before benefits will be activated, or you can opt to add your eligible dependents during any subsequent open enrollment period. Effective Date: Coverage begins on the first of the month following the submission of an approved enrollment request form to the Chancellor’s Office.
September 2016; HRM-Benefits
