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 | |
|---|---|---|---|---|
|
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 |
||
|
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. | |||