Open Enrollment for Active Members

• Is the UC Health System available through Blue Shield Access+ HMO and EPO?
  • All six universities in the University of California (UC) Health System are available through Blue Shield Access+ HMO and Blue Shield EPO. We are working to update our health plan search tool to reflect this information:
    • UC Davis
    • UC Irvine
    • UC Los Angeles
    • UC Riverside
    • UC San Diego
    • UC San Francisco
• Has Blue Shield of California Access+ HMO expansion into Monterey County been approved?
  • Yes. It is approved by Department of Managed Health Care (DMHC) approval. The Annual Health Plan Changes webpage has been updated.
• Members have heard a lot about vaccines in the news recently, especially the COVID-19 vaccine. Can members still get a COVID-19 vaccine if they want one and will it be paid for?
  • Yes. CalPERS remains committed to supporting our members' total health and well-being. As you may have seen, very recently the U.S. Food and Drug Administration (or FDA) announced that while the latest COVID-19 vaccine is ready for fall 2025, it is now limited to individuals ages 65 and over and those between 6 months and 64 years old with at least one condition that puts them at high risk for severe outcomes from COVID-19.
  • It’s important to CalPERS to ensure that we continue to provide our members with evidence-based, preventive care. Because of that, CalPERS has provided guidance to our health plan and pharmacy benefits partners — OptumRx for now and CVS Caremark starting in January — that we’ll continue to provide and cover the latest COVID-19 vaccine for any CalPERS members aged 6 months and older who choose to receive it, without cost sharing and without the recent FDA limitations. This is consistent with the approach recommended by the California Department of Public Health.
  • There have been no changes to the recommendations for the other two seasonal vaccines, flu and respiratory syncytial virus (RSV). Members can continue to receive those vaccines as they have in the past. A PERSpective article is available for more information on this topic.
• How can I confirm which health plans accept my provider/medical group? How do I know if the primary doctor, specialist, or group I prefer is covered by a specific health plan?
  • The Health Plan Search by ZIP Code on our website and the Search Health Plans tool in myCalPERS allow members to enter the name of a doctor, specialist, or medical group to find out which health plans they are available through. Members are always encouraged to confirm doctor and medical group availability directly with the carrier or doctor before making a change.
• What health plans offer health and wellness programs and other benefits? What kinds of benefits are offered like gym memberships, nutrition classes, behavioral health, etc.?
  • All of our health plans offer health and wellness programs along with other benefits, including comprehensive behavioral health services. The benefits may include gym memberships, health and nutrition classes, wellness coaching, discounts on several wellness activities and memberships, individual and group therapy, and more. Programs vary by health plan. Learn more by visiting Health & Wellness Programs by Health Plan.
• How do I calculate my cost? Where can I find the health plan premiums? Where can I find out how much my employer contributes?
  • Health plan premiums and state employer contribution amounts are located on our Plans & Rates webpages for both active and retired members.
    • To calculate costs, state members can visit the CalHR Benefits Calculator located on the CalHR website.
    • Public agency and school members should contact their employer to obtain their employer contribution amounts.
    • To determine your out-of-pocket premium amount, deduct your employer contribution from the gross premium.
    • o    Members may log in to their myCalPERS account and find their current premium, as well as future premium amounts if no change is made during Open Enrollment. While there, members can utilize the Search Health Plans tool to compare health plan premiums as well as co-insurance amounts, copays, and annual deductibles.
• Why isn’t a provider/medical group contract termination a qualifying event to change health plans?
  • Changes to medical groups and contract terminations occur often and throughout the course of the year. These are not qualifying events to change health plans. Most of the time, contract negotiations are successful in negotiating a new contract and the services are maintained. While we understand the confusion and anxiety created by these events, as a purchaser of health care, CalPERS can’t guarantee you will be able to indefinitely continue your relationship with your provider, if your provider or health plan ends their contract.
    
    It’s also important to note that the California Department of Managed Health Care requires health plans to have sufficient providers available in each health plan’s network at all times to provide services to all members.
  • If a new contract isn’t negotiated successfully, and you’re  undergoing a course of treatment, you may request continuity of care from your health plan to complete your treatment with your provider. Once the treatment is complete, you’ll need to transition services to an available in-network provider.
• How often and when during the year can a provider/medical group negotiate their health plan contract? Can members be notified prior to Open Enrollment to make an informed decision?
  • Most provider/medical groups are multi-year contracts, typically lasting three years, but the negotiations can take place anytime of the year. And the timing sometimes coincides with Open Enrollment. Unfortunately, CalPERS can’t notify members when health plans are negotiating with providers at any time of year until the outcomes are decided. The CalPERS policy is to allow the health plans and provider to continue negotiations and work toward resolution together, without our intervention. To do otherwise might result in higher premiums for you. We closely follow the progress of negotiations and will act appropriately to assure you have health care coverage if it appears a contract termination will occur.
• Can members change health plans when they move? What are the permitting events in which members can change their health plan outside of Open Enrollment?
  • Yes, moving is a qualifying event to change a health plan. Other qualifying events include retirement and Medicare eligibility. For any of these qualifying events, members have 60 days from the qualifying event date to request a health plan change. For more information, visit Life Events to learn how certain events impact coverage or benefits.
• If a member's child is disabled, what paperwork is needed to add that child after 26 years of age?
  • Disabled children are to be enrolled at the time of the initial enrollment or are to be continued on the member’s enrollment from before age 26 to be eligible for our health program. The required paperwork is our Disabled Dependent Member Questionnaire and Medical Report (HBD-34) (PDF). We also have an Authorization to Disclose Protected Health Information form (BDS-35) (PDF) to authorize the doctor to release the information. This form isn’t required, and your doctor might have a different authorization form they would like you to complete. CalPERS doesn’t need any authorization forms back. The Disabled Dependent Member Questionnaire and Medical Report (HBD-34) (PDF) form has a portion for the member to complete and a portion for the doctor to complete. The doctor must send the completed form back to CalPERS directly from the doctor’s office by fax or mail. All of the instructions are on the HBD-34 form and the forms can be found in Forms & Publications.
• Is it possible to add a parent as a dependent for health insurance due to loss of coverage? Who is eligible to be a dependent for health coverage?
  • Parents are not eligible for employer-sponsored health plans. Eligible dependents include spouses, registered domestic partners, children, adopted children, domestic partners, stepchildren, and domestic partners’ children. Another person's child under age 26 may be eligible for coverage if a parent-child relationship exists. An Affidavit of Parent-Child Relationship (PDF) must be filed prior to enrollment and be updated upon request. Certified disabled dependent children aged 26 and older are also eligible. More information regarding who is eligible can be found on the Enroll Family Members page.
• I am retiring in October, and I understand I am covered under my same plan which will transition to a Medicare plan December 1. But if I want to change my health plan, does it have to be effective January 1, 2026, for Open Enrollment?
  • Medicare eligibility and retirement are qualifying events to change your health plan. Under this scenario, you can change your health plan effective December 1 with a qualifying event of retirement or Medicare eligibility. Some members change health plans due to retirement and later become Medicare eligible and change plans again as both are qualifying events. More information can be found on our Medicare (Retirees) webpage.
• Am I required to enroll in Medicare while I'm still working? Do I then change to a Medicare plan?
  • If you are working past age 65 and covered by an employer group health plan, you are not required to enroll. If you are eligible for premium-free Part A, you can enroll in Part A when you turn 65 even if you are working. This does not affect your CalPERS coverage.
  • Three months before you turn 65, or before you retire if you work past 65, enroll in Medicare Parts A and B if you are eligible for premium-free Medicare Part A.
  • For most members, we’ll receive your Medicare information directly from the Centers for Medicare & Medicaid Services (CMS) and your health coverage will automatically change to a CalPERS Medicare plan with the same carrier of your non-Medicare plan. Medicare enrollment is a qualifying event to change your plan. Let CalPERS know within 60 days if you'd like to change carriers. If CalPERS is unable to obtain your Medicare information from CMS, you'll need to complete and submit the Certification of Medicare Status (PDF) form to CalPERS with copies of supporting documentation for manual processing in order to keep your CalPERS health plan.
• What happens to my dependents when I go on Medicare?
  • CalPERS requires all family members to have the same health carrier. A combination plan means at least one family member is enrolled in a Medicare health plan and at least one family member is enrolled in a Basic (non-Medicare) health plan through the same health carrier.
  • If your current health carrier doesn't offer a CalPERS-sponsored Medicare health plan, and you don't choose one when transitioning to Medicare, CalPERS will enroll you in a combination plan based on your ZIP code. Some CalPERS Basic plans do not offer CalPERS Medicare plans (e.g., Health Net and Western Health Advantage). For 2026, if you are in Health Net or Western Health Advantage and you're turning 65 this year, you can change plans during Open Enrollment or within 60 days of enrolling in Medicare.
• When retired with lifetime health benefits, why do we have to pay $185 a month for Medicare part B? Is this required?
  • If you are eligible for retiree health benefits and you are eligible for premium-free Medicare Part A, the Public Employees' Medical and Hospital Care Act (PEMHCA) requires you enroll in Parts A and B. Part A is free, but the Centers for Medicare & Medicaid Services (CMS) does charge a monthly premium for Part B, which will be deducted from your Social Security benefits, or if you’re not receiving Social Security yet, you'll receive a quarterly bill. If you are a state of California or CSU retiree, you may be eligible to receive a reimbursement for some or all of your Part B premiums.
• Do I apply for Medicare when I turn 65 or during Open Enrollment?
  • If you are retired and eligible for premium-free Medicare Part A, we recommend you apply with the Social Security Administration during your Initial Enrollment Period. CalPERS health coverage will be canceled if required documentation is not received prior to your 65th birth month. More information can be found on pages four and five of the Medicare Enrollment Guide (PDF).
  • For most members, your health coverage changes to a CalPERS Medicare plan once you have enrolled in Medicare Part A and Part B with the Social Security Administration, retired, and are age 65 or older. You may find information on page two of the Medicare Enrollment Guide (PDF).
• When I apply for Medicare prior to turning 65, will my current health plan remain in effect until Medicare kicks in? Or does my current health care plan expire on my 65th birthday?
  • If you're under 65 and eligible for and enroll into Medicare Part A and Part B, you have the option of enrolling into a CalPERS Medicare plan or you can remain in a Basic plan until you turn 65. Your health coverage does not expire on your 65th birthday. If CalPERS does not receive information regarding your Medicare enrollment status prior to the start of your 65th birth month, your health coverage could be cancelled.
• If a member changes health plans, how do they select a new primary care physician (PCP)? Will their medical records and prescriptions be transferred over to the new provider?
  • If a member changes health plans, they can review the plan's in-network provider list online and can select a new in-network PCP there. Another option is to call the health plan's member services line and ask for assistance in selecting a new in-network PCP. Medical records can be transferred by requesting them from the previous provider, which often requires a medical release form. For prescriptions, members will want to coordinate with the new PCP and pharmacy for transfers. Members are encouraged to first verify medication coverage under the new plan and schedule initial appointments with the new PCP.
• Do preexisting conditions affect health coverage or ability to change plans?
  • No. CalPERS health plans comply with federal and state laws, including the Affordable Care Act (ACA). Under the ACA, health insurance providers cannot deny coverage or charge higher premiums based on preexisting health conditions. CalPERS health plans provide guaranteed coverage to eligible members regardless of their health status or preexisting conditions.
• For ongoing medical events such as pregnancy and birth, how is insurance handled when plans are changed during Open Enrollment, effective January 1, and if the birth is a few months later? How is billing and insurance handled?
  • When a member changes their plan during Open Enrollment, the previous plan will cover pregnancy-related services up until December 31, and the new plan will cover services starting January 1. Providers will bill each plan separately and deductibles and out-of-pocket maximums reset with the new plan. Members should confirm that their hospital and pregnancy provider are in-network with their new plan, and keep in mind that new authorizations for procedures may be required. The member will need to communicate clearly with the plan and provider for proper billing. For any questions, members should reach out to their new health plan.
• How do members ensure there are no delays in treatment when switching health plans during Open Enrollment? How does continuity of care work and how do members know if they are eligible?
  • When switching health plans during Open Enrollment, members can take steps to avoid treatment delays and maintain continuity of care by reviewing the new plan’s coverage, coordinating with their current provider, checking prior authorization requirements, and contacting the new plan early to confirm coverage, in-network providers, and steps to continue current treatment without interruption. Members who voluntarily switch plans during Open Enrollment are not usually eligible for continuity of care; however, any member may make a request for continuity of care for the treatment of ongoing acute or chronic conditions, including pregnancy. Members should contact their new plan to check eligibility for continuity of care.
• How can a member find a plan that would best cover a specific set of services for a condition? How can they find out if specific services or drugs are covered?
  • To select a plan that best meets your health care needs, start with  assessing your specific medical condition. Review the new plan’s Evidence of Coverage and Summary of Benefits and Coverage to verify the provider network, covered services and associated costs (premiums, deductibles and copays). To confirm if specific services or medications are covered, carefully review the plan's Evidence of Coverage, including the medical drug coverage, and contact the plan’s member services for clarification if needed. Proactively compare plans to ensure the selected plan aligns with your medical needs and budget. In addition, review the new pharmacy benefits manager Evidence of Coverage to verify if the medications you need  are covered.
• Which health plans can cover my dependents out of state? Can my dependents be enrolled in different health plans?
  • All of our plans allow for urgent or emergency care for members traveling or temporarily away from home. However, if you have an eligible dependent residing outside California, you might consider Anthem Blue Cross HMO or Blue Shield's HMO plans. These include certain programs for dependents temporarily away from home. Additionally, PERS Platinum is available nationwide and internationally. Refer to those EOCs or contact the health plan carriers directly for the specifics of your situation. PEMHCA, which is the law that governs the CalPERS Health Program, require all family members to have the same health plan.
• What health plans are available outside of the United States?
  • Only PERS Platinum Basic plan is available for members who reside outside the United States.
• Will members be able to access the formulary, find which drugs are covered, and the cost during Open Enrollment so that they can make an informed decision?
  • Both Basic and Medicare formularies are available for members to access on the CVS Caremark: Pharmacy Benefits webpage. The formulary provides covered medications, the tiering for each drug and those tiers determines the copayments. Tiering information can be found in our Health Benefit Summary.
• Will members be able to get 90-day prescriptions at the pharmacy instead of mail order?
  • Yes, Basic plan members will again be able to get a 90-day supply of many medications through the retail in-network pharmacies as well as through the mail order pharmacy. This was always the case for Medicare members. For more information, visit the CVS Caremark: Pharmacy Benefits webpage.

Your Health Plan Statement will be available in myCalPERS on September 8. When you review it, ensure the health enrollment information is accurate. Use A Guide to Understanding Your Health Plan Statement if you have questions about the information on your Health Plan Statement.

Will your plan still be available next year, or is there a better option for you? If you change plans, will you still have access to your preferred doctors and/or specialists? Use How to Choose a Health Plan (PDF) as a checklist of factors to consider and resources to guide you as you explore your options.

• myCalPERS: Log in and use the Search Health Plans tool to find the best health plan for you and your family.
  • You can compare 2026 monthly premiums; find plans your doctors, specialists, or medical groups participate in; compare benefits and costs; and view member satisfaction ratings for each plan.
• Active Member Plans & Rates: View a full listing of 2026 health plans, premiums, and health plan websites and phone numbers. Access Evidence of Coverage and Summary of Benefits publications.
• Eligibility & Enrollment: Learn about the CalPERS Health Program, including eligibility requirements and general enrollment information.
• Online Health Enrollments: With your employer’s approval, make health enrollment changes through your myCalPERS account.
• Open Enrollment Newsletter: Review 2026 health program highlights, notable health plan changes, and important health reminders
  • 2025 Open Enrollment Newsletter (English) (PDF)
  • 2025 Open Enrollment Newsletter (Español) (PDF)
• 2026 Health Benefit Summary (PDF): Compare covered services, co-payments, and benefits for each CalPERS health plan.
• Medicare Enrollment Guide (PDF): Provides information on how Medicare works with your CalPERS health benefits.
• Medical Board of California: Learn how the state is protecting health care consumers and access to quality medical care.