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1403 - Dental (Historical View)

** Effective: 7/7/2017 9:10:49 AM - 7/7/2017 11:06:20 AM **

Status: Active

Change Notes

fixed typos

Category

Benefits and Insurance

Audience List

Synopsis

This policy:

Introduction

The California Department of Human Resources (CalHR) administers the state's dental insurance program and sets policy and procedures on enrollment and eligibility.

Statement

Eligibility for participation in the state’s dental benefit 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 HR staff are responsible for ensuring that only eligible employees and their dependents are enrolled in state-sponsored dental benefits. 

Eligibility and Enrollment

Employees are eligible for dental benefits if they:

A Permanent Intermittent (PI) employee may be eligible to enroll in dental benefits if he/she has earned 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 BU 8 are eligible for state-sponsored dental benefits.  Refer to the bargaining unit contracts on the CalHR website for current eligibility information.

Eligible employees may enroll in a dental plan within the first 60 days of employment or eligibility, or during the annual open enrollment period.  Open enrollment for dental benefits is held each fall and allows eligible employees to:

Employer contribution rates are found in the bargaining unit contracts and in the Benefits Calculator on the CalHR website.  This calculator allows employees to compare dental premiums and see the employer contribution rates based on their bargaining unit.  Employees can also see the amount that will be deducted from or added to their pay warrant based on the dental plan they choose.

24-Month Prepaid Dental Plan Restriction

Newly hired eligible employees enrolling into dental benefits must enroll in a prepaid dental plan until they complete 24 months of state service.  After completing 24 months of service, they may enroll into a Delta Dental plan.

Exception to this are:

12 Month CCPOA Western Dental Plan Restriction

All newly hired eligible employees in BU 6 enrolling into dental benefits must enroll into the CCPOA Western Dental plan for 12 months to be eligible for enrollment in the CCPOA Primary Dental plan.

Exception to this are:

Dependent Eligibility

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

The Dependent Eligibility Verification Checklist (CalHR Form 781) is on the CalHR website, and assists the departmental human resources (HR) office to ensure that only eligible dependents are enrolled in benefits.  Employees and departmental HR staff must complete and retain the Checklist for every enrollment transaction that involves adding dependents to health, dental, or vision benefits; and 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 HR staff and employee must complete all relevant sections of the Checklist before enrolling dependents.

The Checklist includes three sections:

HR 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 HR office in the receiving department to see that all required documentation was submitted and reviewed prior to enrollment.

The following information provides 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 dental benefits.  Under no circumstances shall:

The employee must provide a marriage certificate, Declaration of Domestic Partnership, Certificate of Registry of Marriage, 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 tax return or any of the following documents dated within the last 60 days:  statement of account, household bill, or other document showing financial interdependency (it is acceptable to black out financial information).  The document must include the names of the employee and dependent, address and date, and must confirm the dependent as the employee’s spouse/domestic partner.

For newly married employees who submit a Certificate of Registry of Marriage, he/she is required to provide a copy of his/her marriage certificate within one year.  It is the responsibility of the department to create a follow-up process to ensure that the marriage certificate is obtained from the employee within this time period.

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 dental benefits under any circumstances.

It is essential that HR staff, supervisors, and managers communicate to employees that it is the obligation of the employee to inform their HR 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, he/she is required to provide a copy of the official birth certificate within one year.  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 born, adopted, or stepchild.  An eligible PCR dependent must be under age 26.

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

Initial Enrollment:

Employee must complete and submit the Dental Plan Enrollment Authorization (STD. 692), CalHR Affidavit of Parent-Child Relationship (CalHR Form 025),  Dependent Eligibility Verification Checklist (CalHR Form 781), and the required verification documents.

Departmental HR staff must follow the certification process in accordance with CalPERS Circular Letter #600-008-15. 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 HR staff are responsible for tracking their PCR dependent enrollments in the state’s dental benefits (including dependents of transferred employees) and notifying employees of the annual PCR recertification requirement.

A sample tracking tool has been developed for departments to track enrollment of PCR dependents.  The tracking tool is available in the HR Net section of CalHR’s website.

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.

Departmental HR staff are responsible for:

Additionally, departmental HR staff must complete a Dental Plan Enrollment Authorization (STD. 692) to document the administrative cancellation of benefits for each ineligible dependent, 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 Dental Benefits

Initial Enrollment:

Employee must complete and submit a Health Benefit Plan Enrollment Form (CalPERS Form HBD-12), Declaration of Health Coverage (HBD-12A), Dental Plan Enrollment Authorization (STD. 692), CalPERS Affidavit of Parent-Child Relationship (CalPERS Form HBD-40), the Dependent Eligibility Verification Checklist (CalHR Form 781), and the required verification documents.

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 dental benefit as receipt of the CalPERS Affidavit of Parent-Child Relationship (CalPERS Form HBD-40) is sufficient.

Departmental HR staff must follow the certification process in accordance with (CalPERS Circular Letter #600-008-15). 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:

Employee 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 parent-child relationship.  Follow the recertification process in accordance with (CalPERS Circular Letter #600-058-12).

CalPERS is responsible for notifying employees of the annual recertification requirement and administratively disenrolling PCR dependents that fail to recertify their eligibility for participation in the state’s health benefits program.  These dependents are identified for departmental HR staff on the CalPERS departmental monthly “Employer Health Event” Cognos report.

Departmental HR staff are responsible for:

Additionally, departmental HR staff must complete a Dental Plan Enrollment Authorization (STD. 692) to document the administrative cancellation of benefits for each ineligible dependent, as needed.

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

Disabled Adult Dependents

A child age 26 and over who is incapable of self-support because of a mental or physical condition may be eligible for dental benefits if the disability existed prior to reaching age 26 and the dependent has been continuously since age 26, as certified by a licensed physician.  CalPERS determines the eligibility of a disabled adult child upon receipt of the required Member Questionnaire for the CalPERS Disabled Dependent Health Benefit (CalPERS Form HBD-98) and the Medical Report for the CalPERS Disabled Dependent Benefit (CalPERS Form HBD-34) and will inform the departmental HR office of its determination.  The initial certification of the Disabled Dependent must occur either (1) within 60 days before and ending 60 days after the child’s 26th birthday; the employee and child must currently be enrolled for dental benefits, or (2) within 60 days of a newly eligible employee’s initial enrollment in dental benefits.

Departmental HR staff must follow the certification process for disabled dependents in accordance with the State Health Benefits Guide and contact the dental plan carrier of 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 should be evaluated on a case-by-case basis.  The information provided by the physician in the Medical Report for the CalPERS Disabled Dependent Benefit (CalPERS Form HDB-34) and the status of the disability (e.g., permanent, extended) will determine if, and when, recertification is necessary.  For example, if the dependent’s current disability renders him or her 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 that time.

Departmental HR staff are responsible for:

Additionally, departmental HR staff must complete a Dental Plan Enrollment Authorization (STD. 692) to document the administrative cancellation of benefits for each ineligible dependent, as needed.

Accountability

Departmental HR staff are responsible for monitoring the eligibility of employees and their dependents, and for holding employees accountable for failure to notify their HR 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 HR office of changes to dependent eligibility.  This may include reimbursing their employer and the dental benefit plan for expenditures incurred for dental 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

CalPERS administers the retiree dental program on behalf of CalHR. Retiring employees who, at the time of enrollment, meet the eligibility requirements of Government Code Section 22959.4, may enroll in dental coverage and are subject to the same eligibility criteria and dependent verification procedures as active employees.

Departmental HR staff are responsible for enrolling employees retiring from state service in dental benefits.  They can enroll the retiree prior to their separation date through the my|CalPERS system or send the enrollment document to CalPERS. 

Dental Plans

The bargaining unit designation of the employee determines the plans available to the employee.  The state pays all or part of the employee’s premium, depending on the plan selected and the number of dependents enrolled.

Currently, the state offers six dental plans:

BU 6 employees have their dental insurance provided through their respective union-sponsored trust and BU 5 employees who are members of the California Association of Highway Patrolmen (CAHP) have their own indemnity dental plan, but may enroll in any of the four state-sponsored prepaid dental plans.

Employees in BU 5 and BU 6 may enroll in their respective union-sponsored plan through their personnel office using the Dental Plan Enrollment Authorization (STD. 692) form, following the normal enrollment procedures.  Once enrolled, employees in these bargaining units should contact their union directly regarding questions or issues regarding their dental coverage.

For current details of the dental plans, refer to the Dental Program section of the Benefits Administration Manual web page.

Application

Not Applicable.

Authorities

Resources

FAQs

Forms

PML

Related Policies

Web Pages

Contact Person

Sandra Lobatos-Chico
Dental Program Analyst , Dental
Phone: 916-322-0300
Fax: 855-290-0158
Email: dental@calhr.ca.gov

Authorized By

Ralph Cobb
Chief (Acting), Benefits Division