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See Benefit Election Worksheet Instructions and or Benefit Election Worksheet How to Presentation.
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Passive enrollment allows employees to simply keep their current benefit elections. If no changes are required to your benefit elections, no action required.
Please make note; if the following applies to you, a Benefit Election Worksheet in addition to a Benefit Enrollment or Change form is required.
Yes, Flexible Spending Account contributions require an annual re-enrollment.
No, any funds remaining in an FSA account at the end of the calendar year will be automatically rolled over after the 3 month grace period. Grace period is provided to allow employees time to submit and process receipts for the previous calendar year.
Yes, if submitting your paperwork during the Open Enrollment period and wish to have the change effective for the new calendar year.
No, no action require as long as you have provided the City with proof of other coverage in the past.
*If your circumstances have changed and you no longer have other coverage you will need to submit a Benefit Election worksheet.
Log onto CalPERS to view your current medical insurance election, view current premium rate change for new calendar year, compare plans and use auto CalPERS HBD-12 form generator (HBD-12 print and submit to HR with Benefit Election Worksheet).
No Cash-In-Lieu Option
Those hired on or After July 1, 2019, no cash-in-lieu option
Those hired on or After July 31, 2019, no cash-in-lieu option
Those hired on or after October 31 2019, No Cash-In-Lieu Option
Those hired on or after October 01 2019, No Cash-In-Lieu Option
You can use your Cafeteria Dollars to fund a CalPERS Health Insurance Plan, Flexible Spending Account (Medical or Dependent Care), or Taxable Cash if applicable above.
Participant Plan Effective Date: 1/1/2022
First Payroll date: 1/13/2022
Employee Annual Salary – This is the Employee Out of Pocket contribution (Section 6 on Benefit Election Worksheet).
Employer Annual Contribution – This is where an employee will place any allocated Cafeteria dollars.
Maximum Employee Annual Election – Add the two Columns for a total Contribution to FSA.
Deferred Compensation (ICRMA-RC & Nationwide)