Eligibility

Eligibility isn't based on your job classification. To be eligible for the CalPERS Health Program, you must:

  • Be appointed to a job that will last at least six months and one day
  • Work at least half time
  • Work for an employer who has contracted with CalPERS to administer their health benefits program

The Affordable Care Act has new provisions which expand the eligibility criteria for certain variable hour employees. Contact your employer for additional information.

Permanent-intermittent state employees are eligible for health benefits after working 480 hours during one of two control periods:

  • January 1 through June 30 (effective enrollment date of August 1)
  • July 1 through December 31 (effective enrollment date of February 1)

You cannot attain eligibility in the middle of a control period, even if you met the minimum hours at the beginning of the period. To become eligible, you must receive credit for a minimum of 480 paid hours at the end of a control period.

To continue your eligibility, you must either:

  • Be credited with at least 480 paid hours at the end of each control period
  • Have at least 960 hours in two consecutive control periods (current and prior)

June 30 and December 31 are the checkpoints we use to determine whether you've satisfied the hour requirements.

To be eligible to enroll, you must:

  • Have an appointment that is six months or greater
  • Work at least half time

Check with your personnel office for more information.

Temporary Leave

You can continue your health coverage during a temporary leave of absence by completing a Direct Payment Authorization (PDF) to pay the entire monthly premium directly to your health plan.

You're eligible for the direct payment option if you:

  • Are a state permanent-intermittent employee eligible for health benefits but in a non-pay status
  • Are awaiting approval of disability or service retirement
  • Are awaiting approval of Non-Industrial Disability Insurance (NDI) benefits
  • Are suspended from your job
  • Institute legal proceedings appealing a dismissal from service
  • Take a leave of absence without pay
  • Take temporary disability leave and do not use sick leave or vacation

You may elect direct pay only through the end of the qualifying control period.

If you do not elect the direct payment option while off pay status, your health benefits will be cancelled. You can re-enroll when you return to pay status if your earnings are sufficient to cover your share of the monthly premium.

Military Duty

When you take a leave of absence for military duty, you may continue coverage by making direct payments to your health plan. Your employer does not contribute to your health premium nor do you pay any administrative costs. Your CalPERS health coverage will resume the day you return to pay status.

Leaving Your Job

If you leave your job for reasons other than retirement, your health coverage will continue through the month you leave and the following month if you have sufficient earnings to cover your share of the premium. If you elect to cancel your coverage before you leave your job, your benefits will not continue and you will not be eligible for COBRA Continuation Coverage.

If you reinstate and your break in service is:

  • Less than one full pay period - Coverage will be continuous. Be sure to notify your personnel office if the deductions on your paycheck stub do not resume.
  • More than one full pay period - You must re-enroll. You will go back into the health plan you were previously enrolled in and you may not change plans until the next Open Enrollment.

If your employer contracts for the CalPERS Health Program, you may be eligible to enroll in or continue health coverage into retirement if you:

  • Retire within 120 days of your separation date with your employer
  • Receive a monthly retirement allowance
  • Are eligible for health enrollment on the date of your separation

If you are enrolled in a CalPERS health plan at the time you stop working and your retirement date is:

Then:

Within 30 days

Your coverage will continue into retirement without a break.

Between 31-120 days

You're eligible to re-enroll when you retire.

Contact us within 60 days of your retirement date or wait for the next Open Enrollment.

More than 120 days

You may not be eligible for coverage.

If you don't want your health insurance to continue into retirement, check the appropriate box on your retirement application indicating you do not want health benefits in retirement. You may also visit your personnel office prior to retirement and request to cancel your health insurance.

Enrollment

If you're eligible for the CalPERS Health Program, you have 60 calendar days from your appointment date to request enrollment. Below are other opportunities to enroll at a later date if you decline or cancel enrollment, or experience a qualifying life event. Use our Health Plan Search by ZIP Code tool to find plans available in your area. You can also log in to myCalPERS to use the Search Health Plans tool to research the plan coverage and benefits most important to you and your family.

Learn how to Enroll Family Members.

Health Enrollment Self-Service for Active Members

We’re launching new functionality that will allow you to submit many health enrollment changes online through your myCalPERS account. Visit Health Enrollment Self-Service for Active Members for more information.

Since the onset of the COVID-19 pandemic, some of the rules surrounding your health enrollment and coverage may have changed.

Passed on May 5, 2020, the COVID-19 Relief Rule aims to provide health coverage relief. For CalPERS members like you, this may mean extended health enrollment periods and/or coverage.

Specifically, the 60-day limitations for Special Enrollment Periods and COBRA elections are being waived during the national emergency period for those qualifying events that occurred after March 1, 2020.

The Rule will be in effect from March 1, 2020 until 60 days after the announced end of the national emergency. Upon the announced end of the national emergency, the timelines will revert to the applicable timelines associated with each qualifying event.

Special Enrollment Periods

Typically, a special enrollment period (SEP) is a 60-day period for members to notify CalPERS of a specific qualifying event.

The COVID-19 Relief Rule is focused on the following SEP qualifying events:

  • New enrollment due to loss of other coverage;
  • Adding a dependent due to marriage, birth, adoption, or placement for adoption; and
  • Loss of coverage under a state Children’s Health Insurance Program (CHIP) or Medicaid for employees and their dependents who are eligible to receive premium assistance under those programs.

The 60-day limitations for SEPs are being waived during the national emergency period for those qualifying events that occurred after March 1, 2020.

Note: This Rule doesn’t impact other types of enrollments, including, but not limited to, Parent Child Relationships, Dependent Eligibility Verifications, Disabled Dependent Enrollments, and health plan change requests. These enrollment types are not covered under HIPAA, therefore they are not subject to the COVID-19 Relief Rule.

COBRA

Typically, you have a 60-day window to elect continued health coverage through COBRA. The COVID-19 Relief Rule extends relief past the normal time frames, allowing individual COBRA enrollment rights throughout the national emergency. However, your COBRA enrollment must be continuous from the date your coverage ended.

Your specific health plan administers collection of COBRA premiums. Normal COBRA rules define timely payment as premiums paid within 30 days after the due date or within such longer period as applies to or under the plan.

The COVID-19 Relief Rule aims to prevent individual health cancellations due to late or nonpayment and has extended the timely collection of COBRA premiums to 90 days after the national emergency is declared over.

Effective Dates

  • Special Enrollment Periods: members have the option to enroll and/or add a dependent on a current or retroactive basis.
  • COBRA enrollments require continuous coverage. The effective date would be retroactive to the cancellation date.

Supporting Documentation

If CalPERS determines you’re unable to produce a marriage certificate or domestic partnership registration due to extenuating circumstances, you may execute and submit a signed and notarized CalPERS Affidavit of Marriage/Domestic Partnership (PDF).

Additionally, if you’re unable to obtain a government-issued birth certificate for a dependent child due to COVID-19, you may provide a hospital birth record to facilitate the enrollment and provide the government-issued birth certificate once it is available.

Extensions for Benefit Claims and Appeals

The COVID-19 Relief Rule extended the filing time frames through 60 days after the announced end of the national emergency:

  • Claims for benefit payment (generally limited to 15 months from the date of service, prior to the COVID-19 Relief Rule)
  • Health plan appeal (generally limited to 180 days from the date of the adverse benefit decision)
  • External independent medical review (generally limited to four months from the date the health plan issued its appeal denial)

Governor Gavin Newsom also issued an executive order, extending CalPERS Administrative Review (AR) and Administrative Hearing (AH) requests by an additional 60 days.

  • Administrative Review – Members have 90 days from the date of the health plan or external review adverse appeal decision to file a request (generally limited to 30 days prior to the executive order).
  • Administrative Hearing – Members have 90 days from the date of the CalPERS AR decision to file a request (generally limited to 30 days prior to the executive order).

Health Enrollment Questions

For assistance with your enrollment request or questions about the COVID-19 Relief Rule, contact your employer.

We’re committed to ensuring that health care is equitable and individualized for all members, regardless of race, ethnicity, language, sexual orientation or gender identity. By completing your Health Demographic Profile in myCalPERS, you’re helping us to better understand our members and work towards better health outcomes for all.

Open Enrollment takes place each fall. 2022 Open Enrollment will take place September 19 – October 14. Changes made during 2022 Open Enrollment will take effect January 1, 2023.

Access your health information year-round, including Open Enrollment updates, by logging in to myCalPERS, or learn more by visiting our Using myCalPERS page.

You can enroll yourself and eligible family members in a CalPERS health plan before the next Open Enrollment when you experience certain life events.

Special enrollment opportunities are available for:

  • An eligible spouse, domestic partner, or minor child requiring health coverage because of a court order
  • New children by birth or adoption, or placement of adoption
  • New family members due to marriage or domestic partnership registration
  • Those whose health plan was canceled due to an involuntary loss of coverage (you must provide proof your coverage ended)

You must submit your request within 60 days following the life event.

For more information about special enrollment opportunities, read the Health Program Guide (HBD 120) (PDF).

If you decline or cancel enrollment for yourself or your dependents and do not qualify for special enrollment, you or your dependents will have limited opportunities to enroll in the future. You may enroll during the next CalPERS Open Enrollment or at any time with within a 90-day waiting period. The earliest effective date of enrollment will be the first of the month following the 90-day waiting period or the January 1 after Open Enrollment.



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