Form Pers Hbd 85 PDF Details

Understanding the intricacies of health benefits post-employment or after major life changes can be quite daunting. The Pers Hbd 85 form, also known as the Public Employees' Retirement System (PERS) COBRA Continuation Coverage application, plays a pivotal role in this arena by offering a crucial bridge for individuals navigating the complexities of maintaining health coverage during transitional periods. Designed under the auspices of the Consolidated Omnibus Budget Reconciliation Act (COBRA), this document facilitates the extension of health benefits previously provided by public employers to employees, retirees, and their dependents in California. In essence, the form allows eligible individuals to continue their health insurance coverage when it would otherwise be lost due to specific qualifying events such as employment separation, divorce, or the death of the employee/retiree. Detailing essential information such as enrollee details, event dates, and coverage information, the form also outlines procedural guidelines for applying, including the necessary steps for electing COBRA coverage, the payment to carriers, and the implications of non-compliance. The form is not just a piece of paperwork but a crucial lifeline that ensures continuity of care for those in a state of transition, emphasizing the importance of timely and accurate submission to avoid any interruption in coverage.

QuestionAnswer
Form NameForm Pers Hbd 85
Form Length2 pages
Fillable?No
Fillable fields0
Avg. time to fill out30 sec
Other namesTIMEBASE, PERS-HBD-85, pers hbd 85, 1977

Form Preview Example

C

GROUP CONTINUATION COVERAGE

CONSOLIDATED OMNIBUS BUDGET RECONCILIATION ACT “COBRA”

PERS-HBD-85 (Rev 5/89)

PERS USE ONLY – DOCUMENT REFERENCE NUMBER

PUBLIC EMPLOYEES’ RETIREMENT SYSTEM

Office of Employer and Member Health Services

P.O. Box 942714

Sacramento, CA 94229-2714

(888) CalPERS (225-7377)

TDD - (916) 795-3240 FAX (916) 795-1277

INSTRUCTIONS FOR COMPLETING THIS FORM ARE ON THE REVERSE SIDE. PLEASE TYPE

PART A: ORIGINAL QUALIFYING EVENT AND DATES

1.Type of Action

1NEW

1Change

2. QUALIFYING EVENT

1EMPLOYMENT SEPARATION/TIMEBASE REDUCTION

1DIVORCE/LEGAL SEPARATION

1CHILD CEASES TO BE A DEPENDENT

1DEATH OF AN EMPLOYEE/RETIREE

1DEPENDENT CONTINUATION – ORIGINAL ENROLLEE ELIGIBLE

3. EVENT DATE

4. COBRA ENROLLMENT PERIOD

 

 

 

FROM

 

01

 

FOR MEDICARE

TO

 

 

 

 

 

 

 

 

 

PART B: ENROLLEE INFORMATION

5. COBRA ENROLLEE (MAY BE DIFFERENT THAN SUBSCRIBER)

6. SUBSCRIBER (EMPLOYEE/RETIREE)

 

 

SOCIAL SECURITY NUMBER

—

—

SOCIAL SECURITY NUMBER

 

—

—

 

 

 

NAME

 

 

NAME

 

 

 

 

 

 

 

 

 

ADDRESS

 

 

 

 

 

 

 

 

 

 

 

 

 

CITY, STATE, ZIP

Day Phone

 

Married 1Yes

1 No

 

(

)

 

 

 

 

 

 

 

 

BIRTHDATE

 

SEX 1 MALE

1 FEMALE

 

 

 

 

 

PART C: CARRIER INFORMATION

7. NAME AND ADDRESS OF HEALTH PLAN

PART D: DEPENDENT INFORMATION

A

 

 

 

DATE OF BIRTH

FAMILY

C C

LIST ALL PERSONS (including self)

RELATION

T O

TO BE ENROLLED IN:

 

 

 

 

 

I D

 

 

 

 

SHIP

O E

(FIRST)

(MI)

(LAST) MO. DAY YR

 

N

 

 

 

 

 

 

SELF

PLAN CODE:______________

PREMIUM: $____________

 

 

PHONE:

 

PART E: ENROLLMENT CHANGES

9. NAME OF PRIOR HEALTH PLAN

11. PERMITTING EVENT

12. PERMITTING EVENT

13. EFFECTIVE DATE OF

 

CODE

DATE

CHANGE

 

 

 

 

 

 

 

 

01

 

10. PRIOR PLAN CODE

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

PART F: ELECTION CERTIFICATION

14.I AGREE TO PAY THE PREMIUM FOR THE COVERAGE DIRECTLY TO THE CARRIER LISTED ABOVE. I UNDERSTAND THAT I AM REQUIRED TO SEND THE INITIAL PAYMENT PRIOR TO EFFECTIVE DATE OF ENROLLMENT AND AGREE TO MAKE FUTURE PAYMENTS IN A TIMELY MANNER AS REQUIRED BY THE CARRIER. I UNDERSTAND THAT FAILURE TO PAY THE PREMIUM WILL RESULT IN AUTOMATIC TERMINATION OF COVERAGE. I CERTIFY THAT THE INFORMATION PROVIDED BY ME IS TRUE AND CORRECT TO THE BEST OF MY KNOWLEDGE AND ABILITY.

______________________________________________________________________

__________________________

SIGNATURE OF COBRA ENROLLEE (SEE REVERSE FOR PRIVACY INFORMATION)

DATE SIGNED

PART G: AGENCY INFORMATION

15.

AGENCY NAME ________________________________________

AGENCY CODE _________________ UNIT CODE __________

16. HEALTH BENEFITS OFFICER’S SIGNATURE

PHONE ( ) __________________ DATE RECEIVED __________

PRIVACY INFORMATION

Submission of the requested information is mandatory. The information requested is collected pursuant to the Government Code Sections (20000. et seq.) and will be used for administration of the Board’s duties under the Retirement Law, the Social Security Act, and the Public Employees’ Medical and Hospital Care Act, as the case may be. Portions of this information may be transferred to another governmental agency (such as your employer) but only in strict accordance with current statutes regarding confidentiality. Failure to supply the information may result in the System being unable to perform its functions regarding your status.

You have the right to review your membership files maintained by the System. For questions concerning your rights under the Information Practices Act of 1977, please contact the Information Practices Act Coordinator, CalPERS, P.O. Box 942702, Sacramento, CA 94229-2702.

INSTRUCTIONS FOR THE COMPLETION OF FORM HBD-85 (11/04)

Part A: 1. Type of Action. Check “new” if this is a new enrollment.

Check “change” if family member is added, deleted, or for plan changes.

2.Check applicable original qualifying event.

3.Provide original event date (separation, date of divorce, etc.).

4.Original COBRA enrollment period. Examples:

 

Separation from employment 4-15-89 (Perm. Event) FROM 6-1-89 TO 11-30-90

 

Child attains age 23 on 6-15-89 (Perm. Event)

FROM 7-1-89 TO 6-30-92

Part B. 5.

Please provide all requested information.

 

6.

If the COBRA enrollee is a former dependent, the employee/retiree must be identified in Box 6.

Part C. 7. Please identify the carrier. The COBRA enrollee must continue the same coverage which he or she had as an employee or as a dependent. Carrier changes are only allowed during the open enrollment period of if the enrollee moves into or out of a carrier’s geographic service area. The carrier’s name, address, phone number, plan code, and premium can be found in the annual “Health Plan Decision Guide” which is available in all employing agencies. The monthly premium may not exceed 102% of the group rate.

Part D. 8. List all family members to be enrolled, including self.

Action Code: Use “A” to indicate which person is being added (or newly enrolled).

Use “D” to indicate individual is being deleted from an existing COBRA enrollment An Action Code is not required when changing carriers.

IMPORTANT: The addition or deletion of family members is regulated by time limits which are identical to those for active enrollees (subscribers).

Part E. 9-10. Name and plan code of prior health plan, if COBRA coverage is being changed 10-13. To be completed by the Health Benefits Officer.

Part F. 14. Signature of COBRA enrollee and date signed.

Part G. 15-16. To be completed by the (former) employing agency. For former dependents of retirees, PERS is the “employing agency.”

IMPORTANT: It is the responsibility of the COBRA enrollee to report enrollment changes in a timely manner. Enrollment change requests must be submitted in accordance with existing regulations, laws, and the time limits applicable to the Public Employees’ Medical and Hospital Care Act. All change requests are directed through the agency listed in Part G.

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