1404 - Vision

Category

Benefits and Insurance

Audience List

• Personnel Officers
• Personnel Transactions Staff
• Personnel Transactions Supervisors
• Employee Relations Officers

Synopsis

This policy:

• Provides information about the state-sponsored vision insurance plans for eligible employees, retirees, and their eligible dependents.
• Describes the state’s policies for eligibility and enrollment procedures.
• States monthly premium information.

Introduction

The California Department of Human Resources (CalHR) administers the state’s vision insurance coverage for eligible state employees, retirees, and their eligible dependents. CalHR sets policy and procedures on eligibility and enrollment.

Statement

Eligibility for participation in the state’s Vision Care Program is governed by the California Public Employees’ Retirement System’s (CalPERS) Public Employees’ Medical and Hospital Care Act, which also determines eligibility for participation in the state’s health benefit program.

Departmental personnel office staff are responsible for ensuring that only eligible employees and their dependents are enrolled in state-sponsored vision benefits.

Eligibility and Enrollment

Employees are eligible for vision benefits if they:

• Have a permanent appointment or limited-term appointment with a duration of more than six months and,
• Work at least half-time.

Limited Exam and Appointment Program (LEAP) employees are eligible for vision benefits if they meet the required tenure and time base similar to other state employees.

A Permanent Intermittent (PI) employee may be eligible to enroll in vision benefits if they were credited with a minimum of 480 paid hours at the end of a control period, or at least 960 paid hours in two consecutive control periods. The control periods are January 1 to June 30, and July 1 to December 31.

Certain seasonal lifeguards in Bargaining Unit (BU) 7 and seasonal Firefighters in BU8 are eligible for state-sponsored vision benefits. Refer to the bargaining unit contracts on the CalHR website for current eligibility information.

Represented employees in BU6 have vision coverage through their union trust fund and are not eligible to enroll in the state’s vision program unless otherwise designated by the state as eligible.

Enrollment into the state's Basic Vision Plan for eligible employees and their eligible dependents is automatic. Eligible employees who positively elect to enroll into the Premier Vision Plan must enroll within the first 60 days of employment or eligibility, or during the annual Open Enrollment period. Open Enrollment for vision benefits is traditionally held each fall and allows eligible employees to:

• Enroll
• Change vision plans
• Add/delete eligible dependents
• Cancel coverage

Employer contribution rates are found in the bargaining unit contracts and in the Benefits Calculator located on the CalHR website. This calculator allows employees to compare vision premiums and see employer contribution rates based on their bargaining unit. Employees can also see the pay check deduction amount based on the vision plan they choose.

12-Month Minimum Requirement for Enrollment in Premier Vision Plan

Once enrolled into the Premier Vision Plan, the employee will be required to maintain their enrollment for a 12-month minimum enrollment period. The enrollee may disenroll during any Open Enrollment period, with their enrollment ending January 1 of the next calendar year (after they have completed the minimum 12-month enrollment period).

Dependent Eligibility

Dependents eligible for vision benefits include the employee’s spouse, registered domestic partner, and their children up to age 26, including natural, adopted (including children placed for adoption), stepchildren, domestic partner children, or other children for whom the employee assumed a parent-child relationship.

The Dependent Eligibility Verification Checklist (CalHR Form 781) is on the CalHR website and assists the departmental personnel office to ensure that only eligible dependents are enrolled in benefits. Employees and departmental personnel office staff must complete and retain the Checklist for every enrollment transaction that involves adding dependents to health, dental, or vision benefits; for the annual recertification of parent-child relationship (PCR) dependents. Employees must initial and sign the Checklist where indicated and provide the required documents to substantiate dependent eligibility. Departmental personnel staff and employees must complete all relevant sections of the Checklist before enrolling dependents.

Departmental personnel staff must provide a copy of the completed and signed Checklist to the employee. The Checklist must also be retained in the employee’s Official Personnel File (OPF) along with current enrollment forms and the supporting documentation used to substantiate dependent eligibility. These documents should not be purged from the employee’s OPF.

When an employee is appointed by another state department, proper retention of these documents enables the departmental personnel office in the receiving department to see that all required documentation was submitted and reviewed prior to enrollment.

The following information provides further guidance for determining and documenting dependent eligibility for the different dependent types:

Spouse/Registered Domestic Partner

Only the employee’s legally-joined spouse or registered domestic partner may be enrolled in vision benefits. Under no circumstances shall:

• A registered domestic partner be enrolled as the employee’s spouse (registered domestic partners must be enrolled as registered domestic partners); and
• Any individual, other than a legally-joined spouse or registered domestic partner, be enrolled as the employee’s spouse or registered domestic partner.

The employee must provide a government-issued marriage certificate, declaration of domestic partnership, or affidavit of marriage/domestic partnership demonstrating a legally-recognized marriage or domestic partnership. If the date of marriage/registration is not within the preceding 60 days, the employee must also provide a copy of the front page of their most recent federal or state income tax return or a combination of the following documents dated within the last 60 days:  statement of account, household bill, or other documents substantiating a current marriage or domestic partnership (it is acceptable to black out financial information). The documents must include the names of the employee and dependent, address and date, and must confirm the dependent as the employee’s spouse/domestic partner.

Ex-Spouses/Ex-Domestic Partners

Ex-spouses and ex-domestic partners are not eligible to be enrolled and are not permitted to remain as dependents for vision benefits under any circumstances.

It is essential that departmental personnel staff, supervisors, and managers communicate to employees that it is the obligation of the employee to inform their departmental personnel office in writing within 60 days of the dissolution of a marriage or domestic partnership and to submit an enrollment cancellation of the former spouse/domestic partner.

If an employee is court-ordered to provide coverage for an ex-spouse or ex-domestic partner, it is the obligation of the employee, not the state, to provide that coverage.

Children

Only natural, adopted (including children placed for adoption), or stepchildren of the employee may be enrolled as “children.” The employee must provide a birth certificate, official hospital birth record, adoption certificate, or court document demonstrating that the employee is the legal parent of the child. Birth certificates must be reviewed to verify that the employee is listed as one of the birth parents on the birth certificate. If the name of the birth parent has changed since the birth certificate was issued, additional supporting documentation must be submitted to validate the name change.

For employees who submit a hospital birth record, they are required to provide a copy of the official birth certificate within 60 days after the effective date. It is the responsibility of the department to create a follow-up process to ensure that the official birth certificate is obtained from the employee within this time period.

Under no circumstances shall employees enroll children who are not their natural, adopted, or stepchildren, as "children." Children of a registered domestic partner are to be enrolled using the reason code for “domestic partner children.” The employee must provide a birth certificate, official hospital birth record, adoption certificate, or court document demonstrating that the registered domestic partner is the legal parent of the child.

Other children for whom the employee has assumed a parent-child relationship must meet the eligibility criteria for enrollment as a PCR- dependent (see Parent-Child Relationship Dependents section) and the employee must provide appropriate documentation to substantiate eligibility.

Parent-Child Relationship Dependents (PCRs)

In a parent-child relationship, the employee has intentionally assumed parental status or parental duties for a child who is not their natural, adopted, step, or domestic partner child. An eligible PCR dependent must be under age 26.

PCR Dependents Enrolled Only in Vision and/or Dental Benefits (e.g., not enrolled in Health Benefits)

Initial Enrollment

Employee must complete and submit the Vision Plan Enrollment Authorization (STD. 700) or Premier Vision Plan Enrollment (CalHR Form 774), CalHR Affidavit of Parent-Child Relationship (CalHR Form 025), the Dependent Eligibility Verification Checklist (CalHR Form 781), and the required verification documents to their departmental personnel office. 

Departmental personnel office staff must follow the certification process in accordance with CalPERS Circular Letter #600-046-23. Only upon receipt and review of documents provided by the employee to substantiate an eligible relationship with the dependent shall the child be enrolled.

Additionally, departmental personnel office staff are responsible for tracking their PCR dependent enrollments in the state’s vision benefits (including dependents of transferred employees) and notifying employees of the annual PCR recertification requirement.

Departmental personnel office staff are responsible to inform employees of the requirements for making changes to their vision enrollment. Employees are responsible to report changes to their departmental personnel offices in a timely manner. Retroactive processing is limited to six months for reimbursement of vision premiums for mandatory cancellations and/or deletions to employees' vision coverage.

Changes to Enrollment

The employee may seek financial remedy by filing a governmental claim with the Department of General Services against his/her department for the amount of money they believe they did not receive. For additional information regarding the filing of a governmental claim, please visit the CalHR Benefits Administration Manual, Section 1203.

Annual Recertification:

Employees must recertify each PCR dependent's eligibility annually, by the last day of the employee's birth month, by submitting a new signed and dated CalHR Affidavit of Parent-Child Relationship (CalHR Form 025), Dependent Eligibility Verification Checklist (CalHR Form 781), and the required verification documents to substantiate a continuance of the parent-child relationship to their departmental personnel office. Follow the recertification process in accordance with CalPERS Circular Letter #600-046-23.

Departmental personnel office staff are responsible for:

• Tracking the annual recertification of PCR dependent enrollments;
• Notifying employees of the annual recertification requirement;
• Determining the continuance of a PCR as evidenced upon review of documents provided by the employee; and
• Administratively disenrolling PCR dependents whose eligibility is not recertified and offering COBRA continuation of coverage to eligible dependents within 14 days from the loss of coverage.

Additionally, departmental personnel office staff must complete a Premier Vision Plan Enrollment form(CalHR Form 774) to document the administrative cancellation of benefits for each ineligible dependent enrolled in the Premier Vision Plan and notify employees of PCR dependents who are no longer eligible for the Basic Vision Plan, as needed.

A sample letter that departments can use to notify employees of the annual PCR recertification requirement is available in the HR Net section of CalHR’s website. Employees should be notified at least 60 days in advance of the recertification deadline.

PCR Dependents Enrolled in both Health and Vision Benefits

Initial Enrollment:

Employees must complete and submit a Health Benefit Plan Enrollment Form (CalPERS Form HBD-12), Vision Plan Enrollment Authorization (STD. 700) or Premier Vision Plan Enrollment (CalHR Form 774), CalPERS Affidavit of Parent-Child Relationship (CalPERS Form HBD-40), the Dependent Eligibility Verification Checklist (CalHR Form 781), and the required verification documents to their departmental personnel office.

If an employee has submitted the CalPERS Affidavit of Parent-Child Relationship (CalPERS Form HBD-40) for enrollment of a PCR dependent in the state’s health benefit program, the employee is not required to submit the CalHR Affidavit of Parent-Child Relationship (CalHR Form 025) for enrollment in the state’s vision benefits as receipt of the CalPERS Affidavit of Parent-Child Relationship (CalPERS Form HBD-40) is sufficient.

Departmental personnel office staff must follow the certification process in accordance with CalPERS Circular Letter #600-046-23. Only upon receipt and review of documents provided by the employee to substantiate an eligible relationship with the dependent shall the child be enrolled.

Annual Recertification:

Employees must recertify each PCR dependent’s eligibility annually by submitting a new signed and dated CalPERS Affidavit of Parent-Child Relationship (CalPERS Form HBD-40), Dependent Eligibility Verification Checklist (CalHR Form 781), and the required verification documents to substantiate a continuance of the PCR to their departmental personnel office. Follow the recertification process in accordance with CalPERS Circular Letter #600-046-23.

CalPERS is responsible for notifying employees of the annual recertification requirement and administratively disenrolling PCR dependents whose eligibility for participation in the state’s health benefits program is not recertified. These dependents are identified for departmental personnel office staff on the CalPERS departmental monthly “Employer Health Event” Cognos report.

Departmental personnel office staff are responsible for:

• Reviewing the CalPERS Cognos reports monthly to identify employees with PCR dependents who were disenrolled from the state’s health benefits because their eligibility was not recertified;
• Administratively disenrolling ineligible PCR dependents from the state’s vision benefits; and
• Offering COBRA continuation coverage to eligible dependents within 14 days from the loss of coverage.

Additionally, departmental personnel office staff must complete a Premier Vision Plan Enrollment form (CalHR Form 774) to document the administrative cancellation of benefits for each ineligible dependent enrolled in the Premier Vision Plan and notify employees of PCR dependents who are no longer eligible for the Basic Vision Plan, as needed.

The CalPERS Cognos reports are available on the my|CalPERS website.

Disabled Dependents

A child age 26 and over who is incapable of self-support because of a mental or physical condition may be eligible for vision benefits if the disability existed prior to reaching age 26 and the dependent has been continuously disabled since age 26, as certified by a licensed physician.

Initial Enrollment and Certification:

For the initial enrollment of a disabled dependent, the employee must follow the instructions on the Disabled Dependent Member Questionnaire and Medical Report (CalPERS HBD-34) and Authorization to Disclose Protected Health Information Form (PERS BSD-35).

CalPERS determines the eligibility of a disabled dependent upon receipt of the required Disabled Dependent Member Questionnaire and Medical Report and will inform the departmental personnel office of its determination. The initial certification of the disabled dependent must occur either (1) within 90 days before and ending 60 days after the child’s 26th birthday; the employee and child must currently be enrolled for vision benefits, or (2) within 60 days of a newly eligible employee’s initial enrollment in the CalHR administered Vision Care Program.

Departmental personnel office staff must follow the certification process for disabled dependents in accordance with the State Health Benefits Guide and contact Vision Service Plan (VSP) at 1-800-877-7195 for each disabled adult dependent, within 30 days of the dependent reaching age 26, to update the dependent’s eligibility to ensure no lapse in coverage.

Recertification:

Recertification is evaluated on a case-by-case basis. The information provided by the physician in the Disabled Dependent Member Questionnaire and Medical Report and the status of the disability (e.g., permanent, extended) will determine when recertification is necessary, with a maximum certification being five years. For example, if the dependent’s current disability renders them incapable of self-support, but the disability should resolve or improve sufficiently for the dependent to be capable of self-support at some point in time, recertification should then be completed at the time indicated by the physician. The longest a physician can certify a disabled dependent is five years; after that, recertification is required.

Departmental personnel staff are responsible for:

• Developing a follow-up process to ensure that recertification is obtained from the employee and the dependent’s physician in a timely manner;
• Disenrolling ineligible dependents from the state’s vision program; and
• Offering COBRA continuation coverage to eligible dependents within 14 days from the loss of coverage.

Additionally, departmental personnel staff must complete a Premier Vision Plan Enrollment form (CalHR Form 774) to document the administrative cancellation of benefits for each ineligible dependent enrolled in the Premier Vision Plan and notify employees of dependents who are no longer eligible for the Basic Vision Plan, as needed.

Accountability:

Departmental personnel office staff are responsible for monitoring the eligibility of employees and their dependents, and for holding employees accountable for failure to notify their departmental personnel office in writing within 60 days of a change to dependent eligibility.

Employees may be held accountable if any documentation is determined to be inaccurate or fraudulent, or for failure to notify their personnel office of changes to dependent eligibility. This may include reimbursing their employer, the vision benefit plan, and/or the CalPERS system for expenditures incurred for claims, processing fees, administrative expenses, and attorney fees on behalf of any ineligible family member, and disciplinary action.

CalHR may monitor eligibility and enrollment processes and may hold departmental management and/or employees accountable for compliance.

Retiree Eligibility and Enrollment

Retiring employees who, at the time of retirement, meet the eligibility requirements of Government Code Section 22959.4, may enroll in the Retiree Vision Program and are subject to the same eligibility criteria and dependent verification procedures as active employees.

Retirees must also meet one of the following requirements in order to be eligible to enroll in the Retiree Vision Program:

• The retiree was enrolled in a vision care plan at the time of separation for retirement, and retired within 120 days of the date of separation.
• The retiree was not enrolled in a vision care plan at the time of separation for retirement, but was eligible for enrollment as an employee at the time of separation for retirement, and retired within 120 days of the date of separation.
• The retiree is part of the Legislators’ Retirement System receiving an allowance pursuant to Article 6 (commencing with Section 9359) of Chapter 3.5 of Part 1 of Division 2.

Departmental personnel office staff are responsible for enrolling employees retiring from state civil service in vision benefits. They can enroll the retiree prior to their separation date by sending the completed Retiree Vision Plan Enrollment form (CalHR Form 695) to VSP at the following address, email or fax:

Vision Service Plan

Attn:  Client Services–MS 422

P.O. Box 997100

Sacramento, CA  95899-9986

Email: stateofca@vsp.com

or fax to: (916) 389-8304

Application

Refer to Benefits Administration Manual, Vision Section 1200 for instructions on completing enrollment and eligibility forms.

Authorities

• Bargaining Contracts - MOUs
• California Code of Regulations, title 2, section 599.927
• Government Code section 20128
• Government Code sections 22959.1 to 22959.6
• California Code of Regulations, title 2, sections 599.500 to 599.518
• Government Code sections 22750 - 22948
• California Code of Regulations, title 2, section 547.58.4

Resources

FAQs

• Health, Dental, and Vision: Frequently Asked Questions

Forms

• Affidavit of Marriage/Domestic Partnership: Affidavit of Marriage/Domestic Partnership
• CalHR 025: Affidavit of Parent-Child Relationship
• CalHR 695: Retiree Vision Plan Enrollment Authorization
• CalHR 774: Premier Vision Enrollment Authorization
• CalHR 781 : Dependent Eligibility Verification Checklist
• CalPERS HBD-12: Health Benefit Plan Enrollment Form
• CalPERS HBD-34: Medical Report for the CalPERS Disabled Dependent Benefit
• CalPERS HBD-40: Affidavit of Parent-Child Relationship
• CalPERS PERS-BSD-35: : Authorization to Disclose Protected Health Information
• Sample Notice to Employees: Annual PCR Rectification Requirement
• STD 692 Automated Dental Plan Enrollment Authorization: (redirect to Benefits Calculator)
• STD 700: Vision Plan Enrollment Authorization

Related Policies

• 1401: Health Benefits
• 1403: Dental
• 1406: Consolidated Benefits (CoBen)
• 1408: Consolidated Omnibus Budget Reconciliation Act (COBRA)

Web Pages

• Benefits Administration Manual section 1200: Vision Section
• CalHR Vision Web Page: Vision Benefits Information
• CalHR Website: CalHR Website
• CalPERS Circular Letter 600-016-22 : Eligibility Criteria, Responsibilities, and Certification Forms for Disabled Dependents
• CalPERS Circular Letter 600-046-23: Eligibility Criteria for Dependents in a Parent-Child Relationship and Updated Affidavit
• CalPERS Website: CalPERS Website
• my|CalPERS Website: Cognos Reports: my|CalPERS Website: Cognos Reports
• Open Enrollment Toolkit: Information and resources to assist HR Professionals in completing open enrollment forms.
• Permitting Event Codes/Effective Dates Chart Basic: BAM Vision Attachment C
• State Health Benefits Guide: State Health Benefits Guide

Authorized By

Benefits Division
Benefits Division Inquiries
Benefits Division

Contact Person

Vision Program
CalHR
Phone: 916-909-2863
Email: vision@calhr.ca.gov

Superseded Policies

History

View History