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UC2004

Behavioral Health Benefits for Blue Cross PLUS

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If you are a Survivor Annuitant, you may not enroll your legal spouse or same-sex domestic partner.

Effective Date

The following effective dates apply provided the appropriate enrollment transaction (paper form or electronic) has

been completed within the applicable enrollment period.

If you enroll during a PIE, coverage for you and your Family Members is effective the date the PIE starts.

If you are an Annuitant continuing enrollment in conjunction with retirement, coverage for you and your Family

Members is effective on the first of the month following the first full calendar month of retirement income.

The effective date of coverage for enrollment during an open enrollment period is the date announced by the

University.

For enrollees who complete a 90-day waiting period, coverage is effective on the 91st consecutive calendar day after

the date the enrollment transaction is completed.

An Employee or Annuitant already enrolled in adult plus child(ren) or family coverage may add additional children, if

eligible, at any time after their PIE. Retroactive coverage is limited to the later of:

(a) the date the Child becomes eligible, or

(b) a maximum of 60 days prior to the date your Child’s enrollment transaction is completed.

Change in Coverage

In order to change from single to adult plus child(ren) coverage, or two adult coverage, or family coverage, or to add

another Child to existing family coverage, contact the person who handles benefits at your location (or the University's

Customer Service Center if you are an Annuitant).

Effect of Medicare on Annuitant Enrollment

If you are an Annuitant and you and/or an enrolled Family Member is or becomes eligible for premium free Medicare

Part A (Hospital Insurance) as primary coverage, then that individual must also enroll in and remain in Medicare Part B

(Medical Insurance). Once Medicare coverage is established, coverage in both Part A and Part B must be continuous.

This includes anyone who is entitled to Medicare benefits through their own or their spouse's non-University

employment. Individuals enrolled in both Part A and Part B are then eligible for the Medicare premium applicable to

this plan. Beginning January 1, 2004, Annuitants or their Family Member(s) who become eligible for premium free

Medicare Part A and do not enroll in Part B, will permanently lose their UC-sponsored medical coverage.

Annuitants and their Family Members who were eligible for premium free Medicare Part A, but declined to enroll in

Part B of Medicare before January 1, 2004, were assessed a monthly offset fee by the University to cover increased

costs. The offset fee may increase annually, but will stop when the Annuitant or Family Member becomes covered

under Part B. Annuitants or Family Members who are not eligible for premium free Part A will not be assessed an

offset fee nor lose their UC-sponsored medical coverage. Documentation attesting to their ineligibility for Medicare

Part A will be required. (Annuitants/Family Members who are not entitled to Social Security and premium free

Medicare Part A will not be required to enroll in Part B.)

You should contact Social Security three months before your or your Family Member's 65th birthday to inquire about

your eligibility and how you enroll in the Hospital (Part A) and Medical (Part B) portions of Medicare. If you qualify

for disability income benefits from Social Security, contact a Social Security office for information about when you

will be eligible for Medicare enrollment.

Upon Medicare eligibility, you or your Family Member must complete a University of California Medicare

Declaration form. This notifies the University that you are covered by Part A and Part B of Medicare. The University's

Medicare Declaration forms are available through the University's Customer Service Center. Completed forms should

be returned to University of California, Human Resources and Benefits, Health & Welfare Administration-AH Unit,

Post Office Box 24570, Oakland, CA 94623-9909.

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