How to Enroll in Healthcare Plans
Enrollment instructions start on page 4 of our Retiree Enrollment Guide.
Enrollment Forms
Avoid paper, ink, scanning, and hassle with DocuSign E-Forms.
PDF forms require Adobe Acrobat Reader (free).
Form | DocuSign E-Form | Manual PDF Form | Notes | |
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Medical Plan Enrollment Form |
DocuSign | Optional. If you’d like to enroll in an ACERA group medical plan | ||
Kaiser Permanente Senior Advantage Enrollment Form | DocuSign | Optional. If you’re Medicare-eligible and are enrolling in the Kaiser Permanente Senior Advantage Plan, you must fill this out in addition to the Medical Enrollment Form. | ||
Dental Plan Enrollment Form |
DocuSign |
Optional: Less than 10 years ACERA service credit Mandatory: 10+ years ACERA service credit, but there is no cost for member’s monthly premium |
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Vision Plan Enrollment Form |
DocuSign |
Optional: Less than 10 years ACERA service credit Mandatory: 10+ years ACERA service credit, but there is no cost for member’s monthly premium |
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Medicare Part B Reimbursement Plan (MBRP) Application Form | DocuSign |
Optional. With 10+ years of ACERA service credit or a service-connected disability retirement, get reimbursed for the federal cost of Medicare Part B. More info on the MBRP page. Before you start, have a scan or photo of your Medicare card available showing your Medicare Part B effective date to upload with the form. |
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Affidavit of Dependent Eligibility | DocuSign | Optional. Mandatory if you are electing coverage for your children (or other non-spouse dependents) age 19 through 25 or children age 26 and older if incapable of supporting themselves due to a mental or physical disability incurred prior to age 26 | ||
Affidavit of Domestic Partnership | Optional. Mandatory if you are electing healthcare coverage for a domestic partner. Since this requires notarization, you can’t submit it through DocuSign. Follow the instructions below to submit your form. |
Enrolling Dependents for the First Time
When enrolling dependents on ACERA health insurance plans for the first time, you must provide documentation as outlined in the table below.
First Time Dependent Enrollment Documentation | |
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If you enroll your spouse/ domestic partner | Spouse:
AND
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If you enroll your children under age 19 | One of the following documents:
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If you enroll your children age 19 to age 25 |
AND one of the following documents:
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If you enroll your children age 26+ if incapacitated |
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