Benefits Administration Manual

Consolidated Omnibus Budget Reconciliation Act (COBRA)

419. Completion of COBRA Enrollment Forms

Delta Dental Plans - Delta Premier and Delta Preferred Provider Option (PPO)

The Dental Plan Enrollment Authorization (STD. 692) will serve as the COBRA Continuation Enrollment Form for all COBRA enrollments in the Delta Premier and Delta Preferred Provider Option (PPO) plans. Instructions are provided below. The Personnel Office should contact the eligible employee, spouse, or domestic partner to obtain the information necessary to complete the form.

Wolfpack Insurance Services, Inc., a company that provides administrative COBRA services, handles COBRA enrollments for Delta Dental (Delta).

Note: Dependents of rank and file employees have a lower level of coverage under the Delta Premier - Basic Plan and pay a lower COBRA premium for dependent only coverage. The Personnel Office should reflect the dependent only COBRA premium when completing the STD. 692.

PrePaid Dental Plans - DeltaCare USA, SafeGuard, Premier Access, and Western Dental

The Dental Plan Enrollment Authorization (STD. 692) will serve as the COBRA Continuation Enrollment Form for all COBRA enrollments in the DeltaCare USA , SafeGuard, Premier Access and Western Dental plans. Instructions are provided below. The Personnel Office should contact the eligible employee, spouse, or domestic partner, to obtain the information necessary to complete the form.

Wolfpack Insurance Services, Inc., a company that provides administrative COBRA services, handles COBRA enrollments for DeltaCare USA. SafeGuard, Premier Access and Western Dental, handles the COBRA enrollments for their enrollees.

Bargaining Unit 5

For employees in Bargaining Unit 5, COBRA enrollment forms for dental coverage should be sent to the California Association of Highway Patrolmen (CAHP) Dental Trust. Contact CAHP for COBRA dental premiums information. Unit 5 employees have vision coverage through the State-sponsored Vision Service Plan (VSP) and COBRA enrollments for their vision coverage should be sent to the vision plan.

Bargaining Unit 6

For employees in Bargaining Unit 6, COBRA enrollment forms should be sent to the California Correctional Peace Officers Association (CCPOA) Benefit Trust. Personnel Offices should assist employees, spouses, domestic partners, and dependent children with the completion of the COBRA enrollment forms and submit forms to CCPOA. Contact CCPOA for COBRA dental and vision premium information.

Telephone numbers and mailing addresses

Telephone numbers and mailing addresses are listed in Section 421. Do not send the COBRA enrollment forms or premium payments to DPA, SCO, or CalPERS.

Instructions for completion of the STD. 692:

Section A:

• A1. Check COBRA Box.
• A2 - A6. Enter the name, address, marital status, sex, and social security number of the eligible enrollee.
• A7. Enter spouse's or domestic partner's social security number.

Section B:

• B1 - B2. Enter name of dental plan (e.g., Delta Premier-Enhanced, Delta Premier-Basic, Delta Premier-Basic - Dependent Only, Delta Preferred Provider Option (PPO), DeltaCare USA, SafeGuard-Standard, or SafeGuard-Enhanced), Premier Access and Western Dental . For Bargaining Units 5 and 6 employees, reflect the appropriate dental plan name. Enter provider/facility number, if applicable.
• B3. List all persons to be enrolled (include self).

Section D:

• D2 - D3. Enrollee's signature/date required.

Section E:

• E-9 Enter the total monthly premium to be paid by the eligible enrollee.
• E-12 Enter the date of the qualifying event (e.g. divorce, termination of domestic partnership, termination from employment, child ceases to be a dependent).
• E-14 Enter effective date of action (the first day of the month after loss of coverage).
• E-17 Enter State employee's agency name.
• E-18 Enter the qualifying event (e.g. divorce, termination of domestic partnership, termination from employment, child ceases to be a dependent). If the enrollee is not the employee, then enter the name and social security number of the employee. Provide a telephone number if available.
• E-19 Signature of authorized agency representative.
• E-20 Telephone number of authorized agency representative.
• E-21 Enter date completed.

Note: If the employee elects coverage and enrolls his/her family members at the same time, then only one form listing all family members is needed. Retain the agency copy (pink copy) of the completed STD. 692 in the employee's personnel file and send the original (white copy) and plan copy (yellow copy) to the plan or its designee. The green copy of the STD. 692 should be sent to the enrollee. Do not send the original or copy to DPA, SCO, or CalPERS.

Vision Coverage

The Vision Plan Enrollment Authorization (STD. 700) will serve as the COBRA Continuation Enrollment Form for all COBRA enrollments in the vision plan. Instructions are provided below. The Personnel Office should contact the eligible employee, spouse, or domestic partner, to obtain the information necessary to complete the form. For Bargaining Units 5 and 6 employees, reflect the appropriate vision plan name.

Instructions for completion of the STD. 700:

Section A:

• A1 - A6. Enter the social security number, date of birth, martial status, sex, name, and address of the eligible enrollee.
• A7. Check COBRA Box.
• A8 - A10. Enter spouse's or domestic partner's name, social security number, and date of birth.
• A11 - A22. List all other family members to be enrolled (if more members than space available, then attach an additional form).

Section B:

• B1 - B2. Enter name of vision plan. Enter provider/facility number, if applicable.

Section D:

• D1. Enrollee's signature/date required.

Section E:

• E-6 Enter effective date of action (the first day of the month after loss of coverage).
• E-9 Enter the total monthly premium to be paid by the eligible enrollee.
• E-10 Enter the date of the qualifying event (e.g. divorce, termination of domestic partnership, termination from employment, child ceases to be a dependent).
• E-14 Enter State employee's agency name.
• E-15 Enter the qualifying event (e.g. divorce, termination of domestic partnership, termination from employment, child ceases to be a dependent). If the enrollee is not the employee, then enter the name and social security number of the employee. Provide a telephone number if available.
• E-17 Signature of authorized agency representative.
• E-18 Telephone number of authorized agency representative.
• E-19 Enter date completed.

Note: If the employee elects coverage, then all family members are enrolled at the same time and only one form is needed. Retain the agency copy (pink copy) of the completed STD. 700 in the employee's personnel file and mail the original (white copy) to the plan or its designee. The goldenrod copy of the STD. 700 should be sent to the enrollee. Do not send the original or copy to DPA, SCO, or CalPERS.

Updated February 14, 2011 at 5:00 PM.