Open Enrollment is retirees’ annual opportunity to consider their benefit needs and options and to make changes, if needed. You can change plans and add or drop coverage for you and/or your eligible dependents.

How to Enroll During Open Enrollment

Enrollment instructions start on page 4 of our Retiree Enrollment Guide.

Retiree Enrollment Guide

For our group plan enrollment forms, ACERA accepts faxes of completed enrollment forms faxed to 510-268-9574. We also accept scanned copies of completed enrollment forms emailed to info@acera.org. Enrollment forms submitted by DocuSign, email, or fax must be time stamped by 11:59 pm PST on November 30, 2022. Mailed enrollment forms must be postmarked by November 30, 2022. Enrollment forms are below.

If you’re enrolling in an individual plan through Via Benefits, you must conclude your enrollment with Via Benefits by the dates specified in the chart below. You must contact Via Benefits by phone or through the Via Benefits website. Instructions for enrollment through Via Benefits can be found in the Retiree Enrollment Guide linked below.

Open Enrollment Periods and Plan Years

Healthcare Plans	Open Enrollment Period	Plan Year
Kaiser Permanente HMO California Kaiser Permanente Senior Advantage California (Medicare) UnitedHealthcare SignatureValue HMO UnitedHealthcare SignatureValue Advantage HMO Delta Dental Vision Service Plan (VSP)	Nov 1 – Nov 30	The following Feb 1 – Jan 31
Via Benefits Non-Medicare Plans	Nov 1 – Dec 15	The following Jan 1 – Dec 31
Via Benefits Medicare Plans	Oct 15 – Dec 7	The following Jan 1 – Dec 31

Open Enrollment 2023 Packet

(Mailed in October 2022)

All retirees and payees receive a paper packet in the mail in mid-October. Here’s the electronic packet:

2023 Retiree Enrollment Guide

2023 Open Enrollment Letter

Making Your Via Benefits Reimbursements Easier flyer

Getting Your Affairs In Order Flyer

2022 Virtual Health Fair Flyer

Virtual Retiree Health Fair Website

Kaiser Permanente Flyer - Balancing Act Live Event

Delta Dental PPO Plan Description Flyer

VSP Plan Summary Flyer

Medicare Part D Creditable Coverage Notice (mailed separately to some enrollees)

Healthcare Plan Summary Flyers

• DeltaCare USA HMO Plan Summary
• Delta Dental PPO Plan Summary
• Delta Dental Dual Coverage Flyer
• VSP Vision Plans Summary

Group Plan 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	PDF	Optional. If you’d like to enroll in an ACERA group medical plan
Kaiser Permanente Senior Advantage Enrollment Form	DocuSign	PDF	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. IMPORTANT IF USING DOCUSIGN: Upon receipt, ACERA will submit this form to Kaiser on your behalf. Kaiser will call you to confirm your electronic signature on this form. YOU MUST ANSWER THIS CALL. If you do not answer Kaiser’s call, you will have 7 days to return Kaiser’s Medicare Team’s call to confirm your requested enrollment. Kaiser’s Medicare Team can be reached at 877-251-1532. TAKE NOTE: If you delay in responding to Kaiser’s Medicare Team, your effective date of insurance on ACERA’s Kaiser Senior Advantage Group Plan may be impacted.
Dental Plan Enrollment Form	DocuSign	PDF	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	PDF	Optional: Less than 10 years ACERA service credit Mandatory: 10+ years ACERA service credit, but there is no cost for member’s monthly premium
Medicare Part B Reimbursement Plan (MBRP) Application Form	DocuSign	PDF	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.
Affidavit of Dependent Eligibility	DocuSign	PDF	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		PDF	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.