Continuing Health Plan Participants

If you are continuing Health Plan coverage from your previous benefit period without a break in coverage, follow these steps to ensure a smooth Open Enrollment process.

Step 1: Review Your Current Coverage Elections and Enrolled Dependents

If you are not making any changes to your Health Plan coverage or enrolled dependents, please complete and return the Coordination of Benefits Form to the Health Plan Office. All participants must complete and return this form annually or every benefit period.

If you have dependents who are continuing on your coverage, you will also need to submit the Dependent Confirmation Form (included in your enrollment materials) in addition to the Coordination of Benefits Form.

Step 2: Submit Your Payment (if applicable)

• The applicable dependent premium is due if you have qualified for earned coverage (met the minimum earnings requirement) and are covering one or more dependents.
• The applicable self-pay premium is due if you are covered under either COBRA or any of the Health Plan’s self-pay or retiree coverages.

You can make your payment by credit card, debit card or bank account via Online Bill Pay or Pay-by-Phone, or you may pay by check or automatic pension deduction.

Step 3: Forms to Complete

Complete the following applicable forms:

• Coordination of Benefits Form: This form must be completed annually (or once every benefit period) regardless of whether your information has changed, even if you do not have other insurance.
• If you live outside California, you are automatically enrolled in the Delta Dental PPO Plan.
• Dependent Confirmation Form: If you covered dependents during your previous benefit period, a tailored Dependent Confirmation Form, pre-populated with your dependents’ information, will be included in your enrollment packet. This form requires confirmation that your dependent(s) continue to meet the definition of eligible dependents pursuant to the Health Plan Summary Plan Description.
• Dependent Enrollment Form: If you are adding or dropping dependents from your coverage, complete and return this form. When you return the form, be sure to also include the required dependent enrollment documentation for each of your dependents. The required documentation is detailed on the form.

Step 4: Learn about Your Options

Refer to the March 2020 Health Plan Summary Plan Description for detailed benefit descriptions and requirements.

Step 5: Return Your Completed Forms

Return your completed forms to the Health Plan office prior to the end of your Open Enrollment Period.