[City of Sacramento] Retiree Open Enrollment Form-2018

Personal Information

Are you the retiree or beneficiary?

Retiree

Beneficiary

Full Name (First & Last Name)

Full Address

Address Line 1*

Address Line 2

City*

State / Province / Region*

Postal Code / Zip*

Country*

Is this is a new address

Yes

Retirement System

CalPERS

SCERS

Social Security Number (xxx-xx-xxxx)

Date of Birth (MM/DD/YYYY)

Sex

Male

Female

Please select primary phone number

Home Telephone Number

Cell Phone Number

Home Telephone Number (xxx-xxx-xxxx)

Cell phone Number (xxx-xxx-xxxx)

Dental Plan

What changes are you making to your dental plan?

Enroll

Change coverage, including adding and/or dropping dependents

No Changes

Waive

I would like my coverage to be with

Delta Dental PPO (DPO)- Nationwide plan. Covered services are paid based on a percentage

DeltaCare (DHMO)- California only plan. Covered services are paid based on preset co payments

I would like coverage for

Retiree Only

Retiree + 1 dependent

Retiree + 2 or more dependents

I would like coverage for

Retiree Only

Retiree + 1 dependent

Retiree + 2 or more dependents

Add or Drop dependents from your dental plan

Complete this section if you are ADDING or DROPPING eligible dependents from your DENTAL plan. All eligible dependents currently on your DENTAL plan will remain on your plan.

Add/Drop

Add

Drop

Relationship

Name (First & Last Name)

Social Security Number (xxx-xx-xxxx)

Sex

Male

Female

Date of Birth (MM/DD/YYYY)

Add or Drop dependents from your dental plan

Complete this section if you are ADDING or DROPPING eligible dependents from your DENTAL plan. All eligible dependents currently on your DENTAL plan will remain on your plan.

Add/Drop First Dependent

Add

Drop

Relationship

Name (First & Last Name)

Social Security Number (xxx-xx-xxxx)

Sex

Male

Female

Date of Birth (MM/DD/YYYY)

Add/Drop Second Dependent

Add

Drop

Relationship

Name (First & Last Name)

Social Security Number (xxx-xx-xxxx)

Sex

Male

Female

Date of Birth (MM/DD/YYYY)

Add/Drop Third Dependent

Add

Drop

Relationship

Name (First & Last Name)

Social Security Number (xxx-xx-xxxx)

Sex

Male

Female

Date of Birth (MM/DD/YYYY)

Add or Drop dependents from your dental plan

Complete this section if you are ADDING or DROPPING eligible dependents from your DENTAL plan. All eligible dependents currently on your DENTAL plan will remain on your plan.

Add/Drop

Add

Drop

Relationship

Name (First & Last Name)

Social Security Number (xxx-xx-xxxx)

Sex

Male

Female

Date of Birth (MM/DD/YYYY)

Add or Drop dependents from your dental plan

Complete this section if you are ADDING or DROPPING eligible dependents from your DENTAL plan. All eligible dependents currently on your DENTAL plan will remain on your plan.

Add/Drop First Dependent

Add

Drop

Relationship

Name (First & Last Name)

Social Security Number (xxx-xx-xxxx)

Sex

Male

Female

Date of Birth (MM/DD/YYYY)

Add/Drop Second Dependent

Add

Drop

Relationship

Name (First & Last Name)

Social Security Number (xxx-xx-xxxx)

Sex

Male

Female

Date of Birth (MM/DD/YYYY)

Add/Drop Third Dependent

Add

Drop

Relationship

Name (First & Last Name)

Social Security Number (xxx-xx-xxxx)

Sex

Male

Female

Date of Birth (MM/DD/YYYY)

I would like my coverage to be with

Delta Dental PPO (DPO)- Nationwide plan. Covered services are paid based on a percentage

DeltaCare (DHMO)- California only plan. Covered services are paid based on preset co payments

I would like coverage for

Retiree Only

Retiree + 1 dependent

Retiree + 2 or more dependents

I would like coverage for

Retiree Only

Retiree + 1 dependent

Retiree + 2 or more dependents

Add or Drop dependents from your dental plan

Complete this section if you are ADDING or DROPPING eligible dependents from your DENTAL plan. All eligible dependents currently on your DENTAL plan will remain on your plan.

Add/Drop

Add

Drop

Relationship

Name (First & Last Name)

Social Security Number (xxx-xx-xxxx)

Sex

Male

Female

Date of Birth (MM/DD/YYYY)

Add or Drop dependents from your dental plan

Complete this section if you are ADDING or DROPPING eligible dependents from your DENTAL plan. All eligible dependents currently on your DENTAL plan will remain on your plan.

Add/Drop First Dependent

Add

Drop

Relationship

Name (First & Last Name)

Social Security Number (xxx-xx-xxxx)

Sex

Male

Female

Date of Birth (MM/DD/YYYY)

Add/Drop Second Dependent

Add

Drop

Relationship

Name (First & Last Name)

Social Security Number (xxx-xx-xxxx)

Sex

Male

Female

Date of Birth (MM/DD/YYYY)

Add/Drop Third Dependent

Add

Drop

Relationship

Name (First & Last Name)

Social Security Number (xxx-xx-xxxx)

Sex

Male

Female

Date of Birth (MM/DD/YYYY)

Add or Drop dependents from your dental plan

Complete this section if you are ADDING or DROPPING eligible dependents from your DENTAL plan. All eligible dependents currently on your DENTAL plan will remain on your plan.

Add/Drop

Add

Drop

Relationship

Name (First & Last Name)

Social Security Number (xxx-xx-xxxx)

Sex

Male

Female

Date of Birth (MM/DD/YYYY)

Add or Drop dependents from your dental plan

Complete this section if you are ADDING or DROPPING eligible dependents from your DENTAL plan. All eligible dependents currently on your DENTAL plan will remain on your plan.

Add/Drop First Dependent

Add

Drop

Relationship

Name (First & Last Name)

Social Security Number (xxx-xx-xxxx)

Sex

Male

Female

Date of Birth (MM/DD/YYYY)

Add/Drop Second Dependent

Add

Drop

Relationship

Name (First & Last Name)

Social Security Number (xxx-xx-xxxx)

Sex

Male

Female

Date of Birth (MM/DD/YYYY)

Add/Drop Third Dependent

Add

Drop

Relationship

Name (First & Last Name)

Social Security Number (xxx-xx-xxxx)

Sex

Male

Female

Date of Birth (MM/DD/YYYY)

Vision Plan

What changes are you making to you vision plan?

Enroll

Change coverage, including adding and/or dropping dependents

No Changes

Waive

Coverage Type

VSP Basic ($175 annual allowance for frames ($195 for featured frames) OR $150 for contacts).

VSP Enhanced ($200 annual allowance for frames ($220 for featured frames) OR $200 for contacts).

Both plans include hearing aid discounts.

I would like coverage for

Retiree Only

Retiree + 1 dependent

Retiree + 2 or more dependents

Coverage Type

VSP Basic ($175 annual allowance for frames ($195 for featured frames) OR $150 for contacts).

VSP Enhanced ($200 annual allowance for frames ($220 for featured frames) OR $200 for contacts).

Both plans include hearing aid discounts.

I would like coverage for

Retiree Only

Retiree + 1 dependent

Retiree + 2 or more dependents

Medical Plan

What changes are you making to your medical plan?

Enroll

Change coverage, including adding and/or dropping dependents

Waive

No Changes

Type of Plan

Non-Medicare Plans (Select one of these plans if neither you nor your eligible dependent(s) will be on Medicare as of 01/01/2018)

Medicare Plans (Select one of these plans if either you or your eligible dependent(s) are currently on Medicare or will be as of 01/01/2018)

Who is Medicare eligible? (Select all that apply)

Retiree

Spouse

Dependent

Select Provider

Kaiser

Western Health Advantage

Sutter Health Plus

Select Co-Pay

$25

$40

Select Coverage Level

Retiree only

Retiree + 1 dependent

Retiree + full family

ADD OR DROP DEPENDENTS FROM YOUR MEDICAL PLAN Complete this section if you are ADDING or DROPPING eligible dependents from your MEDICAL plan. All eligible dependents currently on your MEDICAL plan will remain on your plan.

Add/Drop

Add

Drop

Relationship

Name (First & Last Name)

Social Security Number (xxx-xx-xxxx)

Sex

Male

Female

Date of Birth (MM/DD/YYYY)

Add/Drop First Dependent

Add

Drop

Relationship

Name (First & Last Name)

Social Security Number (xxx-xx-xxxx)

Sex

Male

Female

Date of Birth (MM/DD/YYYY)

Add/Drop Second Dependent

Add

Drop

Relationship

Name (First & Last Name)

Social Security Number (xxx-xx-xxxx)

Sex

Male

Female

Date of Birth (MM/DD/YYYY)

Add/Drop Third Dependent

Add

Drop

Relationship

Name (First & Last Name)

Social Security Number (xxx-xx-xxxx)

Sex

Male

Female

Date of Birth (MM/DD/YYYY)

Select Provider

Kaiser Senior Advantage ($20 co-pay for Kaiser Senior Advantage/ $40 co-pay for those without Medicare)

Health Net ($15 co-pay)

Health Net: If one of you is not Medicare-eligible, please write who is not Medicare-eligible in the summary section and include what plan you would like them to be on.

Select Coverage Level

Retiree Only

Retiree + 1 dependent (both with Medicare)

Retiree + full family (full family with Medicare)

Retiree + 1 dependent (1 with Medicare, the other without)

Retiree + full family (one with Medicare, 2 or more without)

Retiree + full family (2 with Medicare, 1 or more without)

Add/Drop Dependent

Add

Drop

Relationship

Name (First & Last Name)

Social Security Number (xxx-xx-xxxx)

Sex

Male

Female

Date of Birth (MM/DD/YYYY)

Add/Drop First Dependent with Medicare

Add

Drop

Relationship

Name (First & Last Name)

Social Security Number (xxx-xx-xxxx)

Sex

Male

Female

Date of Birth (MM/DD/YYYY)

Add/Drop Second Dependent with Medicare

Add

Drop

Relationship

Name (First & Last Name)

Social Security Number (xxx-xx-xxxx)

Sex

Male

Female

Date of Birth (MM/DD/YYYY)

Add/Drop Third Dependent with Medicare

Add

Drop

Relationship

Name (First & Last Name)

Social Security Number (xxx-xx-xxxx)

Sex

Male

Female

Date of Birth (MM/DD/YYYY)

Add/Drop Dependent with Medicare

Add

Drop

Relationship

Name (First & Last Name)

Social Security Number (xxx-xx-xxxx)

Sex

Male

Female

Date of Birth (MM/DD/YYYY)

Add/Drop Dependent WITHOUT Medicare

Add

Drop

Relationship

Name (First & Last Name)

Social Security Number (xxx-xx-xxxx)

Sex

Male

Female

Date of Birth (MM/DD/YYYY)

Add/Drop Dependent WITH Medicare

Add

Drop

Name (First & Last Name)

Relationship

Social Security Number (xxx-xx-xxxx)

Sex

Male

Female

Date of Birth (MM/DD/YYYY)

Add/Drop Dependent WITHOUT Medicare

Add

Drop

Relationship

Name (First & Last Name)

Social Security Number (xxx-xx-xxxx)

Sex

Male

Female

Date of Birth (MM/DD/YYYY)

Add/Drop Dependent WITHOUT Medicare

Add

Drop

Relationship

Name (First & Last Name)

Social Security Number (xxx-xx-xxxx)

Sex

Male

Female

Date of Birth (MM/DD/YYYY)

Add/Drop Dependent WITHOUT Medicare

Add

Drop

Relationship

Name (First & Last Name)

Social Security Number (xxx-xx-xxxx)

Sex

Male

Female

Date of Birth (MM/DD/YYYY)

Add/Drop Dependent with Medicare

Add

Drop

Relationship

Name (First & Last Name)

Social Security Number (xxx-xx-xxxx)

Sex

Male

Female

Date of Birth (MM/DD/YYYY)

Add/Drop Dependent with Medicare

Add

Drop

Relationship

Name (First & Last Name)

Social Security Number (xxx-xx-xxxx)

Sex

Male

Female

Date of Birth (MM/DD/YYYY)

Add/Drop Dependent without Medicare

Add

Drop

Relationship

Name (First & Last Name)

Social Security Number (xxx-xx-xxxx)

Sex

Male

Female

Date of Birth (MM/DD/YYYY)

Add/Drop Dependent without Medicare

Add

Drop

Relationship

Name (First & Last Name)

Social Security Number (xxx-xx-xxxx)

Sex

Male

Female

Date of Birth (MM/DD/YYYY)

Select Coverage Level

Retiree Only

Retiree + 1 dependent (both with Medicare)

Add/Drop dependent with Medicare

Add

Drop

Relationship

Name (First & Last Name)

Social Security Number (xxx-xx-xxxx)

Sex

Male

Female

Date of Birth (MM/DD/YYYY)

Type of Plan

Non-Medicare Plans (Select one of these plans if neither you nor your eligible dependent(s) will be on Medicare as of 01/01/2018)

Medicare Plans (Select one of these plans if either you or your eligible dependent(s) are currently on Medicare or will be as of 01/01/2018)

Who is Medicare eligible? (Select all that apply)

Retiree

Spouse

Dependent

Select Provider

Kaiser

Western Health Advantage

Sutter Health Plus

Select Co-Pay

$25

$40

Select Coverage Level

Retiree only

Retiree + 1 dependent

Retiree + full family

Add/Drop Dependent

Add

Drop

Relationship

Name (First & Last Name)

Social Security Number (xxx-xx-xxxx)

Sex

Male

Female

Date of Birth (MM/DD/YYYY)

Add/Drop First Dependent

Add

Drop

Relationship

Name (First & Last Name)

Social Security Number (xxx-xx-xxxx)

Sex

Male

Female

Date of Birth (MM/DD/YYYY)

Add/Drop Second Dependent

Add

Drop

Relationship

Name (First & Last Name)

Social Security Number (xxx-xx-xxxx)

Sex

Male

Female

Date of Birth (MM/DD/YYYY)

Add/Drop Third Dependent

Add

Drop

Relationship

Name (First & Last Name)

Social Security Number (xxx-xx-xxxx)

Sex

Male

Female

Date of Birth (MM/DD/YYYY)

Select Provider

Kaiser Senior Advantage ($20 co-pay for Kaiser Senior Advantage/ $40 co-pay for those without Medicare)

Health Net ($15 co-pay)

Health Net: If one of you is not Medicare-eligible, please write who is not Medicare-eligible in the summary section and include what plan you would like them to be on.

Select Coverage Level

Retiree Only

Retiree + 1 dependent (both with Medicare)

Retiree + full family (full family with Medicare)

Retiree + 1 dependent (1 with Medicare, the other without)

Retiree + full family (one with Medicare, 2 or more without)

Retiree + full family (2 with Medicare, 1 or more without)

Add/Drop

Add

Drop

Relationship

Name (First & Last Name)

Social Security Number (xxx-xx-xxxx)

Sex

Male

Female

Date of Birth (MM/DD/YYYY)

Add/Drop First Dependent with Medicare

Add

Drop

Relationship

Name (First & Last Name)

Social Security Number (xxx-xx-xxxx)

Sex

Male

Female

Date of Birth (MM/DD/YYYY)

Add/Drop Second Dependent with Medicare

Add

Drop

Relationship

Name (First & Last Name)

Social Security Number (xxx-xx-xxxx)

Sex

Male

Female

Date of Birth (MM/DD/YYYY)

Add/Drop Third Dependent with Medicare

Add

Drop

Relationship

Name (First & Last Name)

Social Security Number (xxx-xx-xxxx)

Sex

Male

Female

Date of Birth (MM/DD/YYYY)

Add/Drop Dependent with Medicare

Add

Drop

Relationship

Name (First & Last Name)

Social Security Number (xxx-xx-xxxx)

Sex

Male

Female

Date of Birth (MM/DD/YYYY)

Add/Drop Dependent without Medicare

Add

Drop

Relationship

Name (First & Last Name)

Social Security Number (xxx-xx-xxxx)

Sex

Male

Female

Date of Birth (MM/DD/YYYY)

Add/Drop dependent with Medicare

Add

Drop

Relationship

Name (First & Last Name)

Social Security Number (xxx-xx-xxxx)

Sex

Male

Female

Date of Birth (MM/DD/YYYY)

Add/Drop dependent without Medicare

Add

Drop

Relationship

Name (First & Last Name)

Social Security Number (xxx-xx-xxxx)

Sex

Male

Female

Date of Birth (MM/DD/YYYY)

Add/Drop dependent without Medicare

Add

Drop

Relationship

Name (First & Last Name)

Social Security Number (xxx-xx-xxxx)

Sex

Male

Female

Date of Birth (MM/DD/YYYY)

Add/Drop dependent without Medicare

Add

Drop

Relationship

Name (First & Last Name)

Social Security Number (xxx-xx-xxxx)

Sex

Male

Female

Date of Birth (MM/DD/YYYY)

Add/Drop Dependent with Medicare

Add

Drop

Relationship

Name (First & Last Name)

Social Security Number (xxx-xx-xxxx)

Sex

Male

Female

Date of Birth (MM/DD/YYYY)

Add/Drop Dependent with Medicare

Add

Drop

Relationship

Name (First & Last Name)

Social Security Number (xxx-xx-xxxx)

Sex

Male

Female

Date of Birth (MM/DD/YYYY)

Add/Drop Dependent without Medicare

Add

Drop

Relationship

Name (First & Last Name)

Social Security Number (xxx-xx-xxxx)

Sex

Male

Female

Date of Birth (MM/DD/YYYY)

Add/Drop Dependent without Medicare

Add

Drop

Relationship

Name (First & Last Name)

Social Security Number (xxx-xx-xxxx)

Sex

Male

Female

Date of Birth (MM/DD/YYYY)

Select Coverage Level

Retiree Only

Retiree + 1 dependent (both with Medicare)

Add/Drop dependent with Medicare

Add

Drop

Relationship

Name (First & Last Name)

Social Security Number (xxx-xx-xxxx)

Sex

Male

Female

Date of Birth (MM/DD/YYYY)

OUT OF AREA/CASH IN-LIEU

If you are enrolled in an individual MEDICAL insurance plan, you may be eligible to receive the allowed City Contribution. Proof of coverage and monthly premium are required.

Are you requesting Out of Area/Cash In-Lieu reimbursement?

Yes

My monthly premium for 2018 (if known) is

OUT OF AREA/CASH IN-LIEU

If you are enrolled in an individual MEDICAL insurance plan, you may be eligible to receive the allowed City Contribution. Proof of coverage and monthly premium are required.

Are you requesting Out of Area/Cash In-Lieu reimbursement?

Yes

My monthly premium for 2018 (if known) is

Summary

Summarize your open enrollment changes. For example: "I am enrolling in the Kaiser $40 HMO and my spouse in Kaiser Senior Advantage." If your covered dependent lives at a different address, please provide the address here.

Emergency Contact

Phone Number (xxx-xxx-xxxx)

Relationship

May we discuss your benefits with this emergency contact?

Yes

Signature

First Name

Last Name

Choose how to sign

Draw Type

I consent to be covered under the City of Sacramento's Group insurance plan(s) effective January 1, 2018, and authorize the City to deduct from my pension payroll checks the applicable premium(s) minus any eligible City Contribution beginning with the January 2018 check (paid at the end of January or beginning of February, depending on retirement plan).