How to Enroll in Healthcare Plans

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

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 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.

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.