enrollment forms/periods

To enroll in benefits, newly eligible employees must complete a Benefits Enrollment Worksheet and submit it to Benefits Services via the Benefits Services Secure Dropbox or in Welch Hall 340 within 60 days of the effective date of their qualifying appointment.

If an employee submits the completed worksheet by the last business day of their hire month, coverage may begin on the first day of the following month.

Once an employee submits their worksheets (within the 60 days) coverage will always begin the first day of the following month.

The coverage effective date will be delayed if the Benefits Enrollment Worksheet and all necessary enrollment documents are not submitted in a timely manner.

Note: If you miss the initial 60-day enrollment period, you can still enroll but your coverage will not be effective until the first day of the month following a 90-day waiting period.

• Health Only Benefits Enrollment Worksheet
• Benefits Enrollment Worksheet
• Health Care /Dependent Care Reimbursement Account Enrollment Form
• VSP Premier Enrollment Form

Enrollment Periods

• New Hire Notice of Eligibility – All active eligible employees have 60 days from a qualifying appointment/re-appointment or eligible timebase change to enroll in CSU sponsored health, dental, flexcash, dependent care & health care reimbursement program. Benefits Eligible Faculty - We will automatically enroll you in Vision. If you elect health and dental coverage within the initial enrollment period, they will be effective the month following your 1st pay warrant or the following month that you submitted your enrollment forms. If you are on semester to semester status, your benefits will terminate the month following your last pay warrant. You will then be eligible for COBRA coverage for up to 18 months.
  
  
• Special Enrollment Due to Life Event – When certain life events or circumstances occur, you are entitled to request special enrollment updates within 60 days of the event or change. Some examples of the qualifying life events include the following:
   
  • Addition of a new dependent as a result of marriage or domestic partnership registration.
  • Birth or adoption of a child, or placement of a child for adoption
  • A court order that requires you to provide coverage for a spouse, domestic partner, or minor child
  • The loss of coverage under another program
    
    
• Open Enrollment – Open Enrollment is an annual period during the year (usually during September/October) when you can change plans, and/or add/delete family members without a qualifying event. The effective date is January 1 of the following year.

• Late Event – If you decline or cancel enrollment for yourself or your dependents and do not qualify for the special enrollment exceptions, you (or your dependents) will have limited rights to enroll in the future. You will either have to wait for 90 days or until the next annual Open Enrollment period. The earliest effective date of enrollment will be the first of the month following the 90-day waiting period or if the request is made during Open Enrollment, the effective date would be January 1 of the next year.

METHOD OF SUBMISSION

All forms must be completed and submitted to Benefits Services through the secure file transmission DropBox.

Please submit all forms to Benefits Services via the Benefits Services Secure Dropbox or in Welch Hall 340.

General questions can be e-mailed to benefitservices@csudh.edu.