Open Enrollment for Regular-Benefited Employees

September 15 – October 10, 2015

All changes are effective January 1, 2015

During Open Enrollment, you may:

  1. Change your CalPERS health plan
  2. Enroll in a CalPERS health plan if you do not currently have CalPERS health coverage
  3. Drop your existing CalPERS health coverage and enroll in cash-in-lieu of medical benefits
  4. Add new dependents to your health coverage
  5. Delete dependents from your health coverage
  6. Enroll in a dental or vision plan
  7. Cancel your dental or vision benefits and enroll in cash-in-lieu of benefits
  8. Enroll in the Flexible Benefit Plan
  9. Change your MetLife insurance benefit election (Optional & Voluntary AD&D)
  10. Enroll in an AFLAC insurance plan

If you do not wish to make any changes, there is no need to do anything. If you wish to continue enrollment in the Flexible Spending Account or Dependent Care Programs, you are required to complete a new enrollment form each year. If you have any questions about Open Enrollment, please contact Human Resources at [email protected] or call x 66446.


Cal Poly Corporation will make the following medical contributions on your behalf in 2015:

  • Employee only: $586
  • Employee +1: $1,172
  • Employee +Family: $1,523

Employee Monthly Medical Premiums For 2015

This includes Fresno, Imperial, Inyo, Kern, Kings, Madera, Riverside, Orange, San Diego, San Luis Obispo, Santa Barbara and Tulare Counties (for other county premiums contact Human Resources at extension 6-6446)

Employee Employee+1 Employee 2+
Anthem HMO Traditional (NEW) $157.12 $314.24 $409.11
Blue Shield Access+ $12.66 $25.32 $33.52
Blue Shield NetValue $0.00 $0.00 $0.00
PERS Choice $8.40 $16.80 $22.44
PERS Select $0.00 $0.00 $0.00
PERS Care $71.32 $142.64 $186.03

Visit the CalPERS website at and click on Health Open Enrollment for complete information on medical plans and options. If you want to make a change to your medical plan and/or cancel your medical plan and sign up for cash-in-lieu of benefits, please follow instructions below.

How to Make a Medical Plan Change:

  1. Complete the Open Enrollment Worksheet (pdf)
  2. Complete the HBD12A (pdf)
  3. Submit to Human Resources, Building 15, Room 131 by October 11, 2014

You will be contacted by Human Resources at a later date to sign the HBD12, a CalPERS required form that needs to be prepared for your signature. Any changes will be effective January 1, 2015.


  • Medical: $200/month
  • Dental: $15/month
  • Vision: $10/month

Note, if you are currently receiving cash-in-lieu of benefits, you do not need to re-enroll. You must be enrolled in a benefit plan in order to be eligible for cash-in-lieu of benefits. If you wish to sign up for cash-in-lieu of benefits, please follow instructions below.

How to Sign Up for Cash-In-Lieu of Benefits:

  1. Complete the Flexible Benefit Plan-Participation Election Form (pdf)
  2. Complete the HBD12A (pdf)
  3. Submit to Human Resources, Building 15, Room 131 by October 10, 2014. You cash-in-lieu of benefits are effective January, 2015 and are paid in two biweekly installments per month.

Employees who have cash-in-lieu of benefits and lose their medical, dental or vision benefits at any time during the year may enroll in the Cal Poly Corporation benefits if they submit a letter from their current plan indicating when they are losing their benefits. Notification must be given within 60 days of the loss of coverage, however it is best to notify us far in advance to ensure there is no lapse in coverage.

Cal Poly Corporation employees may enroll in the cash-in-lieu of program at other times during the year if there is a qualifying event, such as marriage, birth/adoption, an open enrollment period for the spouse/domestic partner or loss of spouse’s/domestic partner’s loss of employment.


  • Vision benefits end when the dependent reaches age 26.
  • Dental benefits end when the dependent marries or reaches age 26.

Employees are responsible for contacting us when a dependent is no longer eligible for benefits.

How to Sign Up Dental and/or Vision:

  1. Complete the dental or vision plan
  2. Complete the Flexible Benefit Plan-Participation Election Form (pdf) if you have been receiving cash-in-lieu of benefits
  3. Submit to Human Resources, Building 15, Room 131


Flexible Spending and Dependent Care Assistance

Both Flexible Spending and Dependent Care Assistance allow employees to set aside pre-tax dollars to pay for eligible expenses not covered by their health, vision, or dental insurance plans or for eligible dependent care. The maximum set aside for the flexible spending account is $2,500 per calendar year. The Dependent Care Assistance program may be established to cover the cost of employment related child care related to dependents less than 13 years of age with a maximum set aside of $5,000 (or $2,500 if married, filing separately).

The benefit to you of establishing one or both of these programs is that it sets aside pre-tax payroll dollars, lowering the taxes taken out of your pay. Below is an example of the savings an employee could experience by enrolling in both of these programs.

Let’s assume that an employee earned $2,000 per month and put $100 a month into a flexible spending account for medical/dental and $100 a month into a dependent care assistance account. By setting aside these funds, the employee would lower the taxable income $200 per month as it is withheld pre-tax by CPC. Therefore, the employee would not pay taxes on that $200. The monthly savings that could be achieved, assuming a federal income tax rate of 15% and a state income tax rate of 4.25%, are shown below.

Flexible Spending Account Deposit $200.00
FICA Savings $11.90
Medicare Savings $2.78
Federal Income Tax Savings $30.00
State Income Tax Savings $8.50
State Disability Insurance Savings $2.11
Total Savings $55.30

To file a claim on a flexible spending account or dependent care assistance account, the employee must provide a copy of the receipt (e.g., co-pay at the doctor, dentist or pharmacy) or receipt from the day care provider verifying that the expense has been incurred and the services rendered and submit to

Another advantage of the flexible spending account for medical and dental expenses is that you can be reimbursed prior to the funds actually being deducted from your pay check. This option is not available for dependent care expenses where you can only be reimbursed up to what has already been deducted from your paychecks.

Please note there can be some drawbacks:

  • Beginning in 2015, employees can carry-over a maximum of $500 from one year to the next. Unused amounts in excess of the $500 maximum in either the Flexible Spending Account or Dependent Care Assistance are forfeited at the end of the plan year. You are allowed 90 days after the plan year ending December 31 to submit eligible expenses for reimbursement for costs incurred in the prior year. Therefore, it is important to carefully assess how much you expect to incur during the year when electing your annual contribution amount. In addition, due to IRS restrictions, changes or cancellation to your elected employee contribution during the plan year can only be made under limited circumstances, so plan accordingly.
  • For employees earning less than Social Security’s maximum taxable amount ($115,500 for 2015), contributions to flexible spending accounts may reduce their future Social Security benefits. Because the contributions are not subject to Social Security tax, the taxable wages reported to the Social Security Administration are reduced. Those reported wages are used to determine future benefits. The reduction in future Social Security benefits due to making contributions to a flexible spending account is difficult to determine and varies from employee to employee.

In most cases, the value of the tax savings under the Flexible Benefit plans exceeds the value of the benefits lost by a considerable margin.

How To Sign Up For Flexible Spending and/Or Dependent Care:

  1. Complete the Flexible Benefit Plan-Participation Election Form (pdf)
  2. Complete the TakeCare Salary Redirection Agreement (pdf)
  3. Complete the TakeCare Direct Deposit Form (pdf)if you want direct deposit for your reimbursements.
  4. Complete the Take Dependent & Flexible Benefit Claim Form (if applicable)
  5. Submit to Human Resources, Building 15, Room 131


During this open enrollment period you are eligible to sign up for the Optional Term Life Insurance and Voluntary Accidental Death and Dismemberment Insurance (AD&D) coverage. You may sign up for Voluntary AD&D insurance coverage without having to be approved by MetLife. For Optional Term Life insurance coverage, you will need to complete a Statement of Health Form and be approved by the insurance carrier.

The following is a summary of the programs.

Optional Term Life Insurance Coverage Options

For You

1 to 5 times your basic annual earnings, to a maximum of $500,000

If you elect coverage for yourself, you can also elect coverage for your Spouse/Domestic Partner and your Dependent Children.

For Your Spouse/Domestic Partner


For Your Dependent Child(ren)

$100 – 15 days old to 6 months

$5,000 – Over 6 months old to age 25

Monthly Costs for Optional Term Life Insurance

Listed below are your monthly rates as well as those for your spouse/domestic partner (based on your age and the amount of coverage you want). Rates to cover your child(ren) are also shown.

Cost for your Child(ren)* $ 0.82 *Covers all eligible children

Age Your Monthly Cost
Per $1,000 of Coverage
Spouse/Domestic Partner Monthly Cost
For $10,000 of Coverage
Under 25 $ 0.05 $ 2.30
25 – 29 $ 0.06 $ 2.30
30 – 34 $ 0.08 $ 2.30
35 – 39 $ 0.10 $ 2.30
40 – 44 $ 0.13 $ 2.30
45 – 49 $ 0.19 $ 2.30
50 – 54 $ 0.30 $ 2.30
55 – 59 $ 0.51 $ 2.30
60 – 64 $ 0.72 $ 2.30
65 – 69 $ 1.29 $ 2.30
70 + $ 2.13 $ 2.30

Voluntary Accidental Death & Dismemberment Coverage Options

This valuable coverage is available to you even if you already have accident insurance. It provides benefits beyond your disability or life insurance for severe accidents or loss of life on or off the job -while commuting, traveling by public or private transportation and during business trips. MetLife’s AD&D insurance pays you benefits if you suffer an accident that results in paralysis or the loss of a limb, speech, hearing or sight, or brain damage or coma. If you suffer a fatal accident, benefits will be paid to your beneficiary.

Voluntary AD&D Coverage Amounts for You:

1 to 10 times your base annual earnings up to $500,000

Voluntary AD&D Coverage Amounts for Spouse/Domestic Partner and Child(ren):

You can choose to cover your dependent spouse/domestic partner and child(ren) with AD&D Coverage under the Family Protection Plan Plus.

Monthly Cost for Accidental Death & Dismemberment (AD&D) Insurance
Voluntary Coverage Monthly Cost Per $1,000 of Coverage

Employee Only $0.03M
Employee & Family $0.04M

Please note the above information is only intended to be a summary of available options. Actual plan limitations and exclusions are available in Human Resources.

How to Sign Up for Metlife Optional Life Insurance:

  1. Complete the MetLife Enrollment Form (pdf)
  2. Complete the MetLife Medical Information for Optional Life Insurance Form (pdf)
  3. Submit to Human Resources, Building 15, Room 131

How to Sign Up for Metlife Voluntary AD&D Life Insurance:

  1. Complete the MetLife Insurance Enrollment Form (pdf)
  2. Submit to Human Resources, Building 15, Room 131


AFLAC is a voluntary supplement to your current insurance programs. Unlike normal insurance programs that pay your doctor, AFLAC pays you cash in the case of injuries/illnesses and for preventative care services.

  • Personal Accident Indemnity Plan
  • Personal Cancer Indemnity Plan
  • Personal Sickness Indemnity Plan
  • Dental Supplement Plan (this would be in addition to your CPC plan)
  • Specified Health Event Protection

Sheila Kearns is our AFLAC representative. Please contact her directly at 805-478-5493 or email [email protected] if you are interested in enrolling or setting up an appointment. You may look at the different plans by visiting