pcos technical letter

THE CALIFORNIA STATE UNIVERSITY Office of the Chancellor

401 Golden Shore Long Beach, California 90802-4210

(562) 951-4411

Distribution: CSU Presidents Vice Chancellor, Human Resources

Date: March 5, 2004 Code: TECHNICAL LETTER HR/Benefits 2004-10 To: Human Resources Directors Benefits Managers Payroll Managers From: Cathy Robinson, Assistant Vice Chancellor Human Resources Administration Subject: Eligibility Criteria for CSU Voluntary Benefit Plans

The California State University (CSU) provides multiple voluntary benefit plans to eligible represented and unrepresented employees. To assist campuses in administration of voluntary benefit plans, Human Resources Administration has compiled and attached the Description of Benefit, Enrollment Periods, Eligibility Criteria, and Enrollment Forms and Codes for each of the following voluntary benefit plans:

A. FlexCash B. Tax Advantage Premium Plan (TAPP) C. Health Care Reimbursement Account Plan (HCRA)

Dependent Care Reimbursement Account Plan (DCRA) D. DPA Savings Plus Plan (401(k)/457) E. Tax Sheltered Annuity (TSA) 403(b) Plan F. Pre Tax Parking G. Voluntary Life Insurance H. Voluntary Automobile and Homeowner Insurance I. Voluntary Insurance Plans

Please refer to the referenced attachments for detailed information. Campuses also may refer to benefit Administrative Guides and Technical Letters for additional information, as appropriate. Please contact Human Resources Administration at (562) 951-4411 if you have questions regarding this information. This Technical Letter is also available via Human Resources Administration’s Web page at: http://www.calstate.edu/HRADm/memos.shtml. CR/pc Attachments

Associate Vice Presidents/Deans of Faculty Director, SOSS

http://www.calstate.edu/HRADm/memos.shtml

TECHNICAL LETTER HR/Benefits 2004-10

ATTACHMENT A Page 1 of 7

FlexCash Enrollment Code: 381-001

Effective Date of Benefit: August 1, 1992 Plan Year Period: January 1 – December 31

Pre-tax Benefit: No Enrollment Method: CSU FlexCash Form

Description of Benefit FlexCash allows eligible CSU employees to waive medical and/or dental coverage in exchange for a taxable cash allowance. Participants must submit proof of verifiable non-CSU medical and/or dental coverage. Current cash allowance is as follows:

Medical coverage waived - $128 Dental coverage waived - $12

Newly hired eligible employees have sixty days in which to enroll in the benefit. After the sixty-day limit, enrollment is allowable only in the occurrence of a change in status (as defined), or during the annual benefits open enrollment period (dates announced in benefits technical letter). Enrollment Periods First 60 days of employment Annual open enrollment Within 60 days of an allowable change in status (see Appendix B in FlexCash Admin Guide)

Change In Status Events Affect Plan Eligibility

Change in status events are defined by the IRS regulations. Allowable change in status events include: Marriage, divorce, annulment or legal separation, or dissolution of domestic partnership; Death of spouse, domestic partner, or dependent (or loss of eligible dependent status); Birth, adoption or placement for adoption of a child, or change in dependency status of an Employee’s

child; Change in custody that affects the child’s eligibility for coverage under this Plan or the plan of the child’s

parent; Termination or commencement of employment of employee, spouse or domestic partner, or dependent; Change from full-time to part-time employment (or vice versa) by either Employee or spouse or domestic

partner, if the change affects the Employee’s medical and/or dental coverage; Gain or loss of alternative non-CSU coverage; A significant change in the alternative non-CSU coverage; Entitlement to Medicare or Medicaid by an Employee, spouse or domestic partner, or dependent; or A change in worksite or residence resulting in eligibility or cessation of the Employee’s coverage under any

health maintenance organization offered through the plan; Starting or returning from an unpaid leave of absence by either Employee or spouse or domestic partner. Other circumstances approved by the Plan Administrator in a nondiscriminatory manner and consistent with

Applicable Laws and Regulations.

With the exception of the following, employees have sixty days in which to enroll, cancel or change due to a change in status event: Loss of alternative non-CSU medical and/or dental coverage (no limit) Employment change to less than half-time (no limit)



Pre-paid – The effective date of this benefit is the 1st of the month following the pay period that the first deduction is taken.

Staff and Non-AY Faculty example: 1. August appointment effective date 2. Enrollment form received and processed during August pay period 3. Additional cash added to employee’s September 1 pay warrant

Additional example: 1. August appointment effective date 2. Employee decides in October to enroll 3. Enrollment form received and processed during October pay period 4. Additional cash added to employee’s November 1 pay warrant

AY example:

1. August appointment effective date 2. Deduction taken 1st pay period of AY calendar (September) 3. Additional cash added to employee’s October 1 pay warrant

Enrollment End Date

Actives: The first day of the month employee is enrolled in a CSU paid health and/or dental plan, either as an

employee or a dependent. The first day of the month CSU is required to provide coverage to employee’s dependent child as required

by a medical child support under section 609(a) of ERISA. The first day of the following month in which the time base falls below 0.5, or 0.4 for AB 211 employees.

Separated Employees/Retirees: Last day of the month in which an active employee retires or separates from the campus.

Specific Eligibility Criteria Eligibility for enrollment is contingent upon the employee being considered “benefits eligible” for CSU medical

and dental benefits. Regular Eligibility Criteria Employee Group Eligible: All represented and unrepresented employee groups Eligible: All active positions Eligible: An employee who is a dependent of a CSU retiree is eligible for FlexCash for health only; no

FlexCash for dental Ineligible: Rehired annuitants, FERPS, hourly intermittent employees and employees appointed in any

classification excluded from benefits (refer to TL HR/Benefits 2004-09, Attachment F). Ineligible: Employees on unpaid leaves of absence, including FMLA Ineligible: Employees covered as a dependent of another active CSU employee

FTE Requirements (Time Base) Sum of FTE for all active positions must be > = 0.5 Employee is on a Pre-Retirement Reduction in Time Base (PIMS field, Item 962 = 7552) and was benefits

eligible previously (eligible faculty employees only – refer to TL HR/Benefits 2003-11).

Appointment Duration – at least one position must qualify Permanent/probationary appointments (no appointment expiration date). Employee on a Pre-retirement Reduction in Time Base who was benefits eligible previously. Temporary appointment of at least 6 months and 1 day from appointment effective date to appointment

expiration date.



Temporary appointment less than 6 months and 1 day continuous with no break in service between this appointment and previous benefits-eligible appointment. A transaction such as a temporary promotion, reclassification, or reassignment for less than 6 months and 1

day given to a benefits eligible permanent/probationary employee. Mid appointment increases to FTE and the original effective date of the appointment (not the effective date

of the increase in FTE) and appointment expiration date is at least 6 months and 1 day (TL HR/Benefits 2003-06). Summer quarter classes where the intent is to appoint the employee to a qualifying permanent position in

the fall quarter. Classes are 2389, 2390, 2402, 2395, 2367, 2394, 2368, and 2357. This is a campus manual process. Once an employee is benefits eligible, benefits continue in subsequent consecutive appointments as long as

FTE > = 0.5 regardless of length of appointment. Multiple Positions Sum FTE for all CSU positions meeting the criteria under Employee Group. The appointment with the longest appointment expiration date is used to determine eligibility based on

duration. AB 211 Eligibility Criteria (Effective Date Of Benefit: July 1, 2003) Employee Group Eligible: Part-time lecturers and coaches in class codes 0357, 0360, 0361, 0364, 0365, 0557, 0560, 0564,

2308, 2358, 2375, 2378, 2381, and 2384 who do not meet the regular eligibility criteria. Ineligible: Employees on unpaid leaves of absence, including FMLA.

FTE Requirements (Time Base) Sum of FTE for all qualifying positions in the CSU must be >= 0.4 (and up to 1.0)

Appointment Duration - at least one position must qualify Minimum of one semester or two consecutive quarters. Mid appointment increases to FTE and the original effective date of the appointment (not the effective date

of the increase in FTE) and appointment expiration date is at the end of one semester, two consecutive quarters or the Academic Year (TL HR/Benefits 2003-06). Once an employee is benefits eligible, benefits continue in subsequent consecutive appointments as long as


duration.

“Grandfathered” Eligibility Criteria Employee Group Eligible: Part-time lecturers and coaches in class codes 2308, 2358, 2375, 2378, 2381, or 2384 who do not

meet the regular eligibility criteria. Ineligible: Employees on unpaid leaves of absence, including FMLA.

FTE Requirements (Time Base) Sum of FTE for all qualifying positions in the CSU must be >= 0.4 but <= 0.49

Appointment Duration – at least one position must qualify Temporary appointment of at least six months and one day from appointment effective date to appointment

expiration date.



Mid appointment increases to FTE and the original effective date of the appointment (not the effective date of the increase in FTE) and appointment expiration date is at least 6 months and 1 day (TL HR/Benefits 2003-06). Once an employee is benefits eligible, benefits continue in subsequent consecutive appointments as long as

FTE is >= 0.4 but <= 0.49 regardless of length of appointment. Multiple Positions Sum FTE for all CSU positions meeting the criteria under Employee Group. The appointment with the longest appointment expiration date is used to determine eligibility based on

duration.

Enrollment Form and Codes The FlexCash enrollment form and the corresponding codes appear on the following pages.



The California State University
FLEXCASH PROGRAM ENROLLMENT AUTHORIZATION
Please type or use ballpoint pen, print clearly. Return completed form to campus Benefits Officer.

SEE PRIVACY NOTICE ON REVERSE OF EMPLOYEE COPY

2. SOCIAL SECURITY NO. 3. MARITAL STATUS Married Single

1. TYPE OF ENROLLMENT (Check appropriate box)

ANNUAL/OPEN ENROLLMENT NEWLY ELIGIBLE ENROLLMENT CHANGE DUE TO PERMITTING EVENT CANCELLATION

4. NAME (first) (initial) (last)

5. PLAN ELECTIONS – Refer to the FlexCash Brochure for cash option election information. Cash Option Type Monthly Payment Instructions for Completing Cash Option Elections

A. Cash in lieu of medical insurance $ If you are electing the cash option in lieu of medical insurance, enter the monthly cash amount in item A, otherwise enter “none.”

B. Cash in lieu of dental insurance $ If you are electing the cash option in lieu of dental insurance, enter the monthly cash amount in item B, otherwise enter “none.”

C. Plan Code 381-001 Monthly Total $

In Item C enter the total monthly cash option amount (sum of the amounts entered in items A and B).

6. Statement of Other Medical and/or Dental Coverage This section must be completed if you choose cash instead of your own CSU medical and/or dental insurance plans. I certify that I am covered by another non-CSU medical and/or dental plan(s). I certify that I will maintain coverage in this medical and/or dental insurance plan(s) on an ongoing basis and I agree to notify my campus Benefits Officer within 60 days if I lose coverage under the medical and/or dental insurance plan(s).

Alternative Coverage A. Medical insurance carrier’s name Policy Number

B. Dental insurance carrier’s name Policy Number

Complete this section ONLY if your “other” non-CSU medical and/or dental insurance coverage is through your spouse’s (or domestic partner’s*) plan(s).

Spouse’s (or domestic partner’s*) SSN: _____________________ I have reviewed the FlexCash Brochure describing the CSU’s optional FlexCash Plan, including the legal definitions and change in benefit election limitations authorized under Section 125 of the Internal Revenue Service (IRS) Code. I understand that regulations under the IRS Code require that my benefit choices authorized by this form are irrevocable during this plan year unless I experience an allowable “family status change event” as defined in these regulations or other permitting events as described in the FlexCash brochure. I understand that my FlexCash enrollment in lieu of medical and/or dental coverage will continue from year to year until I complete a new FlexCash Enrollment Authorization form to change or cancel FlexCash enrollment. I have read and agree to the terms and conditions of the FlexCash Program as outlined on this form and in the FlexCash Brochure. Employee’s Signature: ►

Date Signed: ►

FOR CAMPUS USE ONLY 7. Effective Date of Action 9. Permitting Event Date

Mo Day -1-

Year

8. Employee CBID Mo Day Year

10. Permitting Event Code

11. Health Form Attached? (HBD12)

□ Yes □ No

12. Dental Form Attached? (STD 692)

□ Yes □ No

13. Agency Code 14. Unit Code 15. Campus Name

16. Remarks: 17. Authorized Campus Signature I hereby certify under penalty of perjury as follows: That I am the duly appointed, qualified and acting officer of the herein named agency and that I am authorized to make this certification; that the employee named herein is eligible for enrollment in the CSU FlexCash Program. Signature: ►

18. Date Received:

19. Telephone Number:

*Employees who obtain “alternative” non-CSU coverage through a domestic partner are not required to submit proof of registration through the Secretary of State process to enroll in the FlexCash Program. DISTRIBUTION: ORIGINAL - State Controller’s Office COPY – Campus COPY- Employee (with privacy notice)



NEW ENROLLMENTS

PERMITTING EVENT CODE PERMITTING EVENT DATE TIME LIMIT

EFFECTIVE DATE

Description of the event Box 10 Box 9 Box 7 New employee 01 Appointment date 60 days Standard New enrollment during open enrollment 03

Open enrollment start date Open

enrollment period only

As determined by open enrollment schedule

Enrollment due to gain of alternative non-CSU medical and/or dental coverage

05a Date of Event 60 days Standard

Enrollment due to starting or returning from an unpaid leave of absence by either employee or spouse or registered domestic partner (also includes military, NDI and sabbatical paid leaves.)

07 Date of return to active work 60 days Standard

Enrollment due to new marriage, registration of domestic partnership, or birth or adoption of a child

17 Date of Event 60 days Standard

Enrollment due to termination or commencement of spouse’s or domestic partner’s employment; or change to/from full-time employment of employee or spouse or domestic partner, if change affects medical and/or dental coverage.


Enrollment due to significant change in alternative non-CSU coverage


CHANGE OF ENROLLMENT Change during open enrollment

03

Open enrollment start date Open enrollment period only


Change due to gain of alternative non-CSU medical and/or dental coverage

05a Date of Event 60 days Standard

Change due to loss of alternative non-CSU medical and/or dental coverage

05b Date of Event No limit Mandatory

Change due to starting or returning from an unpaid leave of absence by either employee or spouse or registered domestic partner (also include military and sabbatical paid leaves.)


Change due to new marriage, registration of domestic partnership, or birth or adoption of a child.


Change due to divorce or dissolution of domestic partnership (mandatory deletion from medical and dental plans); or death of spouse or registered domestic partner, or dependent (or loss of eligible dependent status).


Change due to significant change in alternative non-CSU coverage




CANCELLATIONS

PERMITTING EVENT CODE PERMITTING EVENT DATE TIME LIMIT

EFFECTIVE DATE

Description of the event Box 10 Box 9 Box 7 Cancel during open enrollment 03 Open enrollment start date Open

enrollment period only


Cancel due to loss of alternative non-CSU coverage

5a Date of Event No limit Mandatory

Cancel due to starting or returning from an unpaid leave of absence by either employee or spouse or registered domestic partner (also include military and sabbatical paid leaves.)


Cancel due to new marriage, registration of domestic partnership, or birth or adoption of a child.


Cancel due to divorce, or dissolution of domestic partnership (would also require mandatory deletion from medical and dental if enrolled), or death of spouse or registered domestic partner, or dependent (or loss of eligible dependent status).


Cancel due to termination or commencement of spouse’s or domestic partner’s employment; or change to/from fulltime employment of employee or spouse or domestic partner, if change affects medical and/or dental coverage.


Cancel due to employment change to less than half-time (no employee signature required).

38 Date status changes No limit First day of 2nd month following permitting event

Administrative deletion of ineligible employee (no employee signature required). For those who were never eligible.

42 Date of initial enrollment No limit Mandatory

Cancel due to significant change in alternative non-CSU coverage


OPEN ENROLLMENT PERIOD EVENT CODE New enrollment, cancellation, or change of FlexCash option

03 Open enrollment date start Open enrollment period only


EXCEPTIONS Exceptions 44 Apply dates to match the situation. Requires approval of President,

Chancellor, or his/her designee EXPLANATION OF EFFECTIVE DATE TERMS USED Standard Effective Date If a properly completed FlexCash Enrollment Authorization form is received in the State Controller’s Office by the 10th of the month, the effective date of enrollment, change of enrollment, or cancellation is the first of the month following. Mandatory Effective Date Enrollment ceases on the first of the month following the permitting event date. State Controller’s Office policy limits retroactive processing to 36 months (3 years).


ATTACHMENT B Page 1 of 3

Tax Advantage Premium Plan (TAPP) Enrollment Code: 376-XXX (X code tied to CalPERS health plan)

Effective Date of Benefit: January 1, 1990 Pre-tax Benefit: Yes

Enrollment Method: Automatic Description of Benefit The Tax Advantage Premium Plan is also known as the CSU Premium Conversion Plan. TAPP allows eligible employees to pay contributions toward CSU-sponsored health plans on a pre-tax basis. Under TAPP, health plan premiums are exempt from Federal and State income taxes and from FICA (Social Security) taxes. TAPP has no other impact on salary based benefits, including the employee’s CalPERS’ contributions. Employees eligible to enroll in a CSU health plan are automatically eligible for TAPP enrollment, and enrollment is coordinated between both benefit programs. When an employee enrolls in a health plan, enrollment in TAPP is automatic, unless the employee chooses to opt out of TAPP. If the employee opts out, the employee’s portion of the health premium is taken AFTER taxes. To opt out of TAPP, the campus benefits representative completes the 674 form specifying employee decision that health benefits be “non-TAPP.” The SCO codes the enrollment and forwards copy of the HBD-12 to CalPERS for processing. If “376” precedes the org code of the health plan, it is an indication that the employee is enrolled in TAPP. Data for employees not enrolled in TAPP will only reflect the three digits of the health plan’s org code. An employee can choose to enroll and/or opt out during the first 60 days of enrolling in a health plan, within sixty days of a change in status event (as defined), or during any subsequent open enrollment period. Enrollment Periods First 60 days of employment that an employee chooses to enroll in a health plan Annual open enrollment Within 60 days of an allowable change in status


Change in status events are defined by the IRS regulations. Allowable change in status events include: Marriage, divorce, annulment or legal separation, domestic partnership or dissolution of domestic

partnership; Death of spouse, domestic partner, or dependent (or loss of eligible dependent status); Birth, adoption or placement for adoption of a child, or change in dependency status of an Employee’s

child; Change in custody that affects the child’s eligibility for coverage under this Plan or the plan of the child’s

parent; Termination or commencement of employment of employee, spouse or domestic partner, or dependent; Change from full-time to part-time employment (or vice versa) by either Employee or spouse or domestic

partner, if the change affects the Employee’s medical and/or dental coverage; Gain or loss of alternative non-CSU coverage; A significant change in the alternative non-CSU coverage; Entitlement to Medicare or Medicaid by an Employee, spouse or domestic partner, or dependent; or A change in worksite or residence resulting in eligibility or cessation of the Employee’s coverage under any

health maintenance organization offered through the plan; Starting or returning from an unpaid leave of absence by either Employee or spouse or domestic partner; or Other circumstances approved by the Plan Administrator in a nondiscriminatory manner and consistent with

Applicable Laws and Regulations.



Pre-paid – The effective date of this benefit is the 1st of the month following the pay period that the first deduction is taken. Staff and Non-AY Faculty example: 1. August appointment effective date 2. Deduction taken August pay period 3. Coverage starts September pay period

AY example: 1. August appointment effective date 2. Deduction taken 1st pay period of AY calendar (September) 3. Coverage starts October pay period

Coverage End Date One month after final deduction

Regular Eligibility Criteria Employee Group Eligible: All represented and unrepresented employees. Eligible: All active positions. Ineligible: rehired annuitants, FERPS, hourly intermittents and employees in the classifications listed in TL

HR/Benefits 2004-09, Attachment F. Ineligible: Employee on a Family Medical Leave. The employee’s portion of health benefit premiums is

paid by an accounts receivable (AR) set up by the campus; therefore TAPP is not applied. Employer’s portion of health premiums is processed manually through the SCO via form 674). Ineligible: Employees on unpaid leaves of absence, causing health premiums to be interrupted. Ineligible: Employees who are on direct payment to continue health premiums.

FTE Requirements (Time Base) Sum of FTE for all active positions in the CSU must be >= 0.5; or, Employee is on a Pre-retirement Reduction in Time Base (PIMS field, Item 962 = 7552) and was benefits

eligible previously (eligible faculty employees only – refer to TL HR/Benefits 2003-11). Appointment Duration – at least one position must qualify Permanent/probationary appointments (no appointment expiration date). Employee on a Pre-retirement Reduction in Time Base who was benefits eligible previously. Temporary appointment of at least 6 months and 1 day from appointment effective date to appointment

expiration date. Temporary appointment less than 6 months and 1 day continuous with no break in service between this

appointment and previous benefits-eligible appointment. A transaction such as a temporary promotion, reclassification, or reassignment for less than 6 months and 1


of the increase in FTE) and appointment expiration date is at least 6 months and 1 day (TL HR/Benefits 2003-06). Summer quarter classes where the intent is to appoint the employee to a qualifying permanent position in

the fall quarter. Classes are 2389, 2390, 2402, 2395, 2367, 2394, 2368, and 2357. This is a campus manual process.

Multiple Positions Sum FTE for all CSU positions meeting the criteria under Employee Group. The appointment with the longest appointment expiration date is used to determine eligibility based on

duration.



AB 211 Eligibility Criteria Employee Group Eligible: Part-time lecturers and coaches in class codes 0357, 0360, 0361, 0364, 0365, 0557, 0560, 0564,

2308, 2358, 2375, 2378, 2381, and 2384 who do not meet the regular eligibility criteria. Ineligible: Employee on a Family Medical Leave. The employee’s portion of health benefit premiums is

paid by an accounts receivable (AR) set up by the campus; therefore TAPP is not applied. Employer’s portion of health premiums is processed manually through the SCO via form 674).


Appointment Duration – at least one position must qualify Minimum of one semester or two consecutive quarters. Mid appointment increases to FTE and the original effective date of the appointment (not the effective date

of the increase in FTE) and appointment expiration date is at the end of one semester, two consecutive quarters or the Academic Year (TL HR/Benefits 2003-06).


duration.


meet the regular eligibility criteria. Ineligible: Employee on a Family Medical Leave. The employee’s portion of health benefit premiums is

paid by an accounts receivable (AR) set up by the campus; therefore TAPP is not applied. Employer’s portion of health premiums is processed manually through the SCO via form 674).



expiration date. Mid appointment increases to FTE and the original effective date of the appointment (not the effective date

of the increase in FTE) and appointment expiration date is at least 6 months and 1 day (TL HR/Benefits 2003-06). Once an employee is benefits eligible, benefits continue in subsequent consecutive appointments as long as

FTE is >= 0.4 but <= 0.49 regardless of length of appointment. Multiple Positions Sum FTE for all CSU positions meeting the criteria under Employee Group. The appointment with the longest appointment expiration date is used to determine eligibility based on

duration.


ATTACHMENT C Page 1 of 10

Health Care Reimbursement Account Plan (HCRA) Enrollment Code: 378-017 (Code changes annually)

Administrative Fee Deduction Code: 375-001 Effective Date of Benefit: June 1, 2001

Plan Year Period: January 1 – December 31 Pre-tax Benefit: Yes

Enrollment Method: HCRA/DCRA Enrollment Form Description of Benefit The Health Care Reimbursement Account Plan (HCRA) allows eligible CSU employees to pay for eligible out-of-pocket medical expenses with pre-tax payroll deductions pursuant to Internal Revenue Service (IRS) code 125. The payroll deductions are taken in equally monthly installments based on an annual amount chosen by the employee. Yearly contributions to this plan can be a minimum of $240 up to a maximum of $5,000, which equates to a minimum monthly payroll deduction of $20 up to a maximum of $416.66. Participation in this plan automatically prompts the State Controller’s Office to apply an administrative fee for each contribution through deduction code 375-001. Currently, the administrative fee for this plan is $2.00 per month. Once enrolled in the plan, the employee’s participation is “locked” for the 12-month plan period unless the employee separates from the campus or has a qualifying change in status event. Newly hired eligible employees have sixty days in which to enroll in the benefit. After the sixty-day limit, enrollment is allowable only in the occurrence of a change in status (as defined), or during the annual benefits open enrollment period (dates announced in benefits technical letter). Enrollment Periods First 60 days of employment Annual open enrollment (required to continue or start enrollment from plan year to plan year) Within 60 days of an allowable change in status (see Appendix C in HCRA/DCRA Administrative Guide)


Change in status events are defined by the IRS regulations and allow eligible participants to stop, start, cancel or enroll in the plan outside of the standard initial enrollment and/or annual open enrollment period. Allowable change in status events include: Change in Legal Marital Status – Marriage, divorce, death of Spouse, legal separation or annulment; Change in Number of Dependents – The birth, death, adoption, loss or gain of domestic partner or loss or

gain of legal custody or placement for adoption of a child; Termination/Commencement of Employment – The beginning or the end of employment of the Employee,

Spouse or Dependent that impacts the Employee’s, Spouse’s, or Dependent’s eligibility; Dependent Eligibility – Events that cause a Dependent to satisfy or cease to satisfy eligibility requirements

for coverage on account of attainment of age, student status, or any similar circumstances;

The events listed above qualify as a change in status event only if the change causes a gain or loss of eligibility for coverage under the CSU or other plan. Other change in status events include: Entitlement to Medicare or Medicaid – Employee, Spouse or Dependent gains or loses eligibility for

Medicare or Medicaid; or Judgment, decree, court order, or Qualified Medical Child Support Order (QMCSO).

Pre-paid – The effective date of this benefit is the 1st of the month following the pay period that the first

deduction is taken.

Staff and Non-AY Faculty example: 1. August appointment effective date 2. Enrollment form received and processed during August pay period 3. Deduction appears on September 1 pay warrant



Additional example: 1. August appointment effective date 2. Employee decides in October to enroll 3. Enrollment form received and processed during October pay period 4. Deduction appears on employee’s November 1 pay warrant

AY example: 1. August appointment effective date 2. Deduction taken 1st pay period of AY calendar (September) 3. Deduction appears on employee’s October 1 pay warrant

Enrollment End Date

Actives: The first day of the month following the pay period that the employee has a qualifying change in status

event that is processed by the SCO by the tenth of the month. The last day of the month of the plan year (December 31) if the participant chooses not to re-enroll. The last day of month following the pay period of the last deduction, i.e., unpaid leave of absence – if

employee chooses not to direct pay while on leave. For example, if the employee separates on February 20 and the HCRA deduction appears on the final warrant, enrollment in the plan ends March 31.

Separated Employees/Retirees: Last day of the month following the pay period of the last deduction in which an active employee retires or

separates from the campus. Specific Eligibility Criteria Enrollment in HCRA is specifically tied to classification. Exclusions are listed by classification code as noted

below. Regular Eligibility Criteria Employee Group Eligible: All represented and unrepresented employee groups Eligible: All active positions Eligible: Employees concurrently appointed in an eligible and ineligible classification with a time base Eligible: Employees on an unpaid leave of absence, including FMLA IF employee chooses direct payment.

While on unpaid status, direct payments will be made on an AFTER-tax basis. Ineligible: Rehired annuitants, FERPS, hourly intermittent employees and employees appointed in any

classification excluded from benefits (refer to TL HR/Benefits 2004-09, Attachment F) including the following: Student classifications (0100, 1870, 1871, 1872, 1874, 1875, 1876), Graduate Assistants (2355), Instructional Faculty, Designated Discipline - Extra Quarter Assignment (2367), Instructional Faculty, Extra Quarter Assignment – QSYRO (2368), Instructional Faculty, Executive Committee, Academic Senate (2394), Trade rate employees, Special pay classifications (2322, 2322, 2356, 2357, 2363, 2365, 2974, 4660), Employees appointed without a time base, in any classification (e.g., intermittent, indeterminate),

and/or Any person who performs service for the CSU solely as an independent contractor

FTE Requirements (Time Base) Position must have a time base, but there is no minimum time base requirement.

Appointment Duration – does not apply to HCRA



Multiple Positions The appointment with the eligible classification is used to determine eligibility for HCRA.


2308, 2358, 2375, 2378, 2381, and 2384. Eligible: Employees on an unpaid leave of absence, including FMLA IF employee chooses direct payment.

While on unpaid status, direct payments will be made on an AFTER-tax basis. FTE Requirements (Time Base) Position must have a time base, however, there is no minimum time base requirement.

Appointment Duration – does not apply to HCRA eligibility



meet the regular eligibility criteria. Eligible: Employees on an unpaid leave of absence, including FMLA IF employee chooses direct payment.

While on unpaid status, direct payments will be made on an AFTER-tax basis.

FTE Requirements (Time Base) Position must have a time base, however, there is no minimum time base requirement

Appointment Duration – does not apply to HCRA eligibility


Enrollment Form and Codes The HCRA enrollment form and the corresponding change in status codes appear after the Dependent Care Reimbursement Account Plan (DCRA) benefits eligibility section.



Dependent Care Reimbursement Account Plan (DCRA) Deduction Code: 380-017 (Code changes annually)

Administrative Fee Deduction Code: 375-001 Effective Date of Benefit: July 1, 1988

Plan Year Period: January 1 – December 31 Pre-tax Benefit: Yes

Enrollment Method: HCRA/DCRA Enrollment Form Description of Benefit The Dependent Care Reimbursement Account Plan (DCRA) allows eligible CSU employees to pay for eligible out-of-pocket household, child and/or Dependent care expenses with pre-tax payroll deductions pursuant to Internal Revenue Service (IRS) Code 125. The payroll deductions are taken in equal monthly installments based on an annual amount chosen by the employee. Yearly contributions to this plan can be a minimum of $240 up to a maximum of $5,000, which equates to a minimum monthly payroll deduction of $20 up to a maximum of $416.66. The maximum amount of $5,000 is reduced to $2,500 if the employee is married and files an income tax return separately from the Spouse. Participation in this plan automatically prompts the State Controller’s Office to apply an administrative fee for each contribution through deduction code 375-001. Currently, the administrative fee for this plan is $2.00 per month. Once enrolled in the plan, the employee’s participation is “locked” for the 12-month plan period unless the employee separates from the campus or has a qualifying change in status event. Newly hired eligible employees have sixty days in which to enroll in the benefit. After the sixty-day limit, enrollment is allowable only in the occurrence of a change in status (as defined), or during the annual benefits open enrollment period (dates announced in benefits technical letter). Enrollment Periods First 60 days of employment Annual open enrollment (required to continue or start enrollment from plan year to plan year) Within 60 days of an allowable change in status (see Appendix C in HCRA/DCRA Administrative Guide)


Change in status events are defined by the IRS regulations and allow eligible participants to stop, start, cancel or enroll in the plan outside of the standard initial enrollment and/or annual open enrollment period. Allowable change in status events include: Change in Legal Marital Status – Marriage, divorce, death of Spouse, legal separation or annulment; Change in Number of Dependents – The birth, death, adoption, loss or gain of domestic partner or loss or

gain of legal custody or placement for adoption of a child; Change In Work Hours – Change in work schedule including a decrease or increase in hours, full-time/part-

time switch, start/stop or unpaid leave of absence or a strike or lockout of employee, Spouse or Dependent. Termination/Commencement of Employment – The beginning or the end of employment of the Employee,

Spouse or Dependent that impacts the Employee’s, Spouse’s, or Dependent’s eligibility; or Dependent Eligibility – Events that cause a Dependent to satisfy or cease to satisfy eligibility requirements

for coverage on account of attainment of age, student status, or any similar circumstances.

The events listed above qualify as a change in status event only if the change causes a gain or loss of eligibility for coverage under the CSU or other plan. Other change in status events include: Dependent Care Provider Cost/Coverage Change – Significant change in cost and/or coverage of

Dependent care provided as long as provider is not a relative. Judgment, decree, court order, or Qualified Medical Child Support Order (QMCSO).



Pre-paid – The effective date of this benefit is the 1st of the month following the pay period that the first

deduction is taken.




Enrollment End Date

Actives: The first day of the month following the pay period that the employee has a qualifying change in status

event that is processed by the SCO by the tenth of the month. The last day of the month of the plan year (December 31) if the participant chooses not to re-enroll. The last day of month following the pay period of the last deduction, i.e., unpaid leave of absence.

Separated Employees/Retirees: Last day of the month following the pay period of the last deduction in which an active employee retires or

separates from the campus. Specific Eligibility Criteria Enrollment in DCRA is specifically tied to classification. Exclusions are listed by classification code and are

noted below: Regular Eligibility Criteria Employee Group Eligible: All represented and non-represented employee groups Eligible: All active positions Eligible: Employees concurrently appointed in an eligible and ineligible classification and time base. Ineligible: Employees on an unpaid leave of absence, including FMLA. Direct Payment is not an option for

DCRA participants. Ineligible: Rehired annuitants, FERPS, hourly intermittent employees and employees appointed in any

classification excluded from benefits (refer to TL HR/Benefits 2004-09, Attachment F) including the following: Student classifications (0100, 1870, 1871, 1872, 1874, 1875, 1876), Graduate Assistants (2355), Instructional Faculty, Designated Discipline - Extra Quarter Assignment (2367), Instructional Faculty, Extra Quarter Assignment – QSYRO (2368), Instructional Faculty, Executive Committee, Academic Senate (2394), Trade rate employees, Special pay classifications (2322, 2322, 2356, 2357, 2363, 2365, 2974, 4660), Employees appointed without a time base, in any classification (e.g., intermittent, indeterminate), and/or Any person who performs service for the CSU solely as an independent contractor



FTE Requirements (Time Base) Position must have a time base, however there is no minimum time base requirement.

Appointment Duration – does not apply to DCRA

Multiple Positions The appointment with the eligible classification is used to determine eligibility for DCRA.


2308, 2358, 2375, 2378, 2381, and 2384. Ineligible: Employees on unpaid leaves of absence, including FMLA. Direct payment is not an option for

DCRA participants. FTE Requirements (Time Base) Position must have a time base, however, there is no minimum time base requirement.

Appointment Duration – does not apply to DCRA eligibility


“Grandfathered” Eligibility Criteria

Employee Group Eligible: Part-time lecturers and coaches in class codes 2308, 2358, 2375, 2378, 2381, or 2384 who do not

meet the regular eligibility criteria. Ineligible: Employees on an unpaid leave of absence, including FMLA. Direct payment is not an option for

DCRA participants.

FTE Requirements (Time Base) Position must have a time base, however, there is no minimum time base requirement

Appointment Duration – does not apply to DCRA eligibility


Enrollment Form and Codes The DCRA enrollment form and the corresponding change in status codes appear on the following pages.



RThe California State University DEPENDENT CARE/HEALTH CARE REIMBURSEMENT ACCOUNT PLANS ENROLLMENT AUTHORIZATION Please type or print clearly with ballpoint pen. Return completed form to campus Benefits Officer.

SEE PRIVACY NOTICE ON REVERSE OF EMPLOYEE COPY 2. SOCIAL SECURITY NO.

3. MARITAL STATUS Married Single

1. TYPE OF ENROLLMENT (Check appropriate box)

OPEN ENROLLMENT NEWLY ELIGIBLE ENROLLMENT CHANGE DUE TO PERMITTING EVENT CANCELLATION

4. NAME (first) (initial) (last)

5. REIMBURSEMENT PLAN ELECTIONS: To establish a Health Care and/or Dependent Care Reimbursement Account, enter the amount you want to have deducted EACH month from your pay warrant: The minimum monthly deduction amount for each account is $20.00, up to a maximum of $416.66, as allowed by the Plan.

Benefit Deduction Item (Pre-Tax) 6. DED/ORG

Code 7. Monthly Deduction

Amount SCO Use Only

Health Care Reimbursement Account (HCRA)

378- ____ A. $ ________. ___

Dependent Care Reimbursement Account (DCRA) 380- ____

B. $ ________. ___

8. Coverage Statement

I UNDERSTAND THAT MY ENROLLMENT INTO THE HEALTH CARE AND/OR DEPENDENT CARE REIMBURSEMENT ACCOUNT PLAN(S) IS FOR THE CURRENT PLAN YEAR ONLY. IF I WISH TO CONTINUE ENROLLMENT FOR THE NEXT PLAN YEAR, I MUST RE-ENROLL ANNUALLY DURING OPEN ENROLLMENT. I hereby agree to have my monthly pay reduced by the amount(s) specified above. I understand that IRS regulations require that my monthly deductions authorized by this form are irrevocable during this plan year, unless I experience an allowable “status change event,” as defined in these regulations and described in the Health Care and/or Dependent Care Reimbursement Account brochure(s). This reduction in pay is effective with the December pay period (unless this is a mid-year enrollment), and will continue for each succeeding pay period until the end of the Plan Year. My agreement to have my pay reduced is made on the condition that the CSU contribute the amounts to the Reimbursement Account(s) that I have specified on this document. I also agree to pay the $2.00 monthly administrative fee through payroll deduction on a post-tax basis. The $2.00 administrative fee is charged per Plan. I understand that requests for reimbursement must be for eligible services/supplies incurred between the effective dates of my participation in the Plan(s) through the end of the Plan Year. Each Plan Year begins on January 1 and ends December 31. All reimbursement requests for the current Plan Year must be postmarked by June 30 of the following Plan Year in order to be reimbursed. I further understand that any unclaimed amount remaining in my Health Care or Dependent Care Reimbursement Account(s) after that date will be forfeited. I have read the above statements and agree to the terms and conditions of the Health Care and/or the Dependent Care Reimbursement Account Plan(s) as outlined on this form. Employee’s Signature: ►

Date Signed: ►

FOR CAMPUS USE ONLY 9. Effective Date of Action 11. Permitting Event Date

Mo Day -1-

Year

10. Employee CBID Mo Day Year

12. Permitting Event Code

14. Agency Code 15. Unit Code 16. Campus Name

17. Authorized Campus Signature I hereby certify under penalty of perjury as follows: That I am the duly appointed, qualified and acting officer of the herein named agency and that I am authorized to make this certification; that the employee named herein is eligible for enrollment in the CSU Health Care and/or Dependent Care Reimbursement Plan(s). Signature: ►

13. Remarks:

18. Date Received:

19. Telephone Number:

DISTRIBUTION: ORIGINAL - State Controller’s Office COPY – Campus COPY W/PRIVACY NOTICE – Employee



This chart describes the election changes permitted during a period of coverage. Events may fall into more than one election category. Exceptions are permissible only to the extent that such change or revocation is on account of and consistent with these Change in Status Events. The following events qualify as a change in status event only if they result in a gain or loss of eligibility under the CSU or another plan: Please note that “Change in Cost and Coverage” (DCRA only), “Entitlement or loss of entitlement to Medicare or Medicaid” (HCRA only), “Judgment, decree, court order”, or “Qualified Medical Child Support Order (QMCSO)” are not subject to the gain or loss of eligibility requirement.

TYPES OF ALLOWABLE CHANGES

Event DCRA HCRA Change in Legal Marital Status Marriage Enroll as newly eligible or cancel, increase,

decrease contributions Enroll as newly eligible or cancel, increase, decrease contributions

Divorce, legal separation, annulment Enroll as newly eligible or cancel, increase, decrease contributions

Enroll as newly eligible or cancel, increase, decrease contributions

Spouse’s death Enroll as newly eligible or cancel, increase, decrease contributions


Change in Number of Dependents Increase in number of employee’s eligible tax Dependents (e.g., by birth, legal custody, adoption, domestic partner, or placement for adoption)

Enroll as newly eligible or increase contributions


Decrease in number of employee’s eligible tax Dependents (e.g., by death, loss of legal custody, loss of domestic partner as a tax Dependent or because child becomes self supporting)

Cancel or decrease contributions Cancel or decrease contributions

Termination/Commencement of Employment

A. Employee

Employee begins employment Enroll as newly eligible Enroll as newly eligible

Employee terminates employment Cancel contributions (contributions will cancel automatically)

Cancel contributions (contributions will cancel automatically) or Increase contributions on an after-tax basis (for administrative fee only) to pay for HCRA COBRA coverage (see Section 8 of Administrative Guide for additional information)

Employee is rehired less than 30 days after termination of employment

Reinstate prior election unless intervening status change event

Reinstate prior election unless intervening status change event

Employee is rehired more than 30 days after termination of employment

Enroll as newly eligible Enroll as newly eligible

Change in employee’s employment status that causes a significant change in cost or coverage

See Change in Cost or Change in Coverage rules None

Other change in employee’s employment status that causes employee to lose eligibility for coverage under plan

Cancel contributions Cancel contributions or Increase contributions on an after-tax basis (for administrative fee only) to pay for HCRA COBRA coverage (see Section 8 of Administrative Guide for additional information)



Event DCRA HCRA

Other change in employee’s employment status that causes employee to gain eligibility for coverage under plan

Enroll as newly eligible Enroll as newly eligible

B. Spouse or Dependent Spouse or Dependent terminates employment

Enroll as newly eligible or cancel, increase, decrease contributions (i.e., in order to enroll or increase, Spouse must attend school full-time or become an eligible tax Dependent)


Spouse or Dependent commences employment


Cancel or decrease contributions

Other change in Spouse’s or Dependent’s employment status that causes Spouse or Dependent to cease to be eligible for coverage under his/her plan

Enroll as newly eligible or increase contributions Enroll as newly eligible or increase contributions

Other change in employment status that causes Spouse or Dependent to gain eligibility for coverage under his/her plan

Cancel or decrease contributions Cancel or decrease contributions

Change in Work Hours A. Employee Employee commences unpaid leave (including FMLA)

Cancel contributions Cancel contributions Increase contributions on an after-tax basis (See Section 8 for additional information)

Employee returns less than 30 days after beginning of unpaid leave

Prior election will automatically resume

Prior election will automatically resume

Employee returns more than 30 days after beginning of unpaid leave

Prior election will automatically resume or Make election to same extent permitted as new hires

Prior election will automatically resume or Make election to same extent permitted as new hires

Employee commences paid leave Cancel or decrease contributions No change

Employee returns from paid leave Enroll as newly eligible or increase contributions No change

B. Spouse or Dependent Spouse or Dependent commences unpaid leave



Spouse or Dependent returns from unpaid leave


Cancel or decrease contributions

Change in Dependent Eligibility Dependent ceases to satisfy CSU’s plan eligibility requirements on account of age, student status, or any similar circumstance (i.e., no longer a tax Dependent)

Cancel coverage or decrease contributions Cancel coverage or decrease contributions – only if Dependent no longer is an eligible tax Dependent. (Also see Change in Number of Eligible Tax Dependents)

Dependent satisfies CSU’s plan eligibility requirement on account of age, student status, or any similar circumstance (i.e., new tax Dependent)

Enroll as newly eligible or increase contributions (also see Change in Number of Eligible Tax Dependents)

Enroll as newly eligible or increase contributions – only if Dependent becomes an eligible tax Dependent. (also see Change in Number of Eligible Tax Dependents)



Event DCRA HCRA Change in Cost – Employer’s Plan (DCRA only) Significant decrease in cost in child care provided

Cancel or decrease election – only if cost imposed by provider who is not a relative of the employee

None

Significant increase in cost in child care provided

Enroll as newly eligible or increase election – only if cost imposed by provider who is not a relative of the employee

None

Change in Coverage – Employer’s Plan (DCRA only) Employee changes child care provider, or change in number of hours worked by child care provider


None

Election Change Under Another Employer Plan (DCRA only) Spouse or Dependent changes election during open enrollment period that differs from the open enrollment period under the CSU’s plan


None

Other Events (HCRA only) Judgment, decree, or order (including QMCSO) relating to accident/health coverage for child

None Enroll in coverage, increase or decrease contributions

Employee, Spouse, or Dependent becomes entitled to Medicare or Medicaid

None Cancel or decrease contributions

Employee, Spouse, or Dependent loses entitlement to Medicare or Medicaid

None Enroll in coverage or increase contributions


ATTACHMENT D Page 1 of 3

DPA Savings Plus Plan (401(k)/457) Deduction Codes: 029-401/029-457

Effective Date of Benefit: Approx. July 1, 1966 Tax Year Period: January 1 –December 31

Pre-tax Benefit: Yes Enrollment Method: Self-Service Enrollment

Description of Benefit The Savings Plus Plan (SPP) is a voluntary program offered by the Department of Personnel Administration (DPA) and administered by Nationwide Retirement Solutions. This program allows eligible state and CSU employees to save toward retirement by investing pre-tax contributions in tax-deferred investments, via two deferred compensation plans: a Thrift Plan (IRC 401(k)) and a Deferred Compensation Plan (IRC 457). These contributions are made through payroll deductions, prior to federal and state taxes being calculated.

Currently, the plan contribution limits that apply to the SPP are prescribed under Internal Revenue Code (IRC) Sections 401(k) and 457. As a result of the federally mandated Economic Growth Tax and Reconciliation Relief Act (EGTRRA), made effective January 1, 2002, contribution limits and provisions for 401(k) and 457 plans were significantly revised. For the 2004 tax year, the contribution limit is 100% of includible income, or a maximum of $13,000 per year.

After enrolling in the Savings Plus Programs, employees can start, stop, increase or decrease deductions once per pay period, via an automated system. Enrollment Period Anytime during employment

Special Enrollment Details: For Savings Plus to establish an account by the 25th of the month, an enrollment form must be processed by the 15th of the same month. Payroll deductions cannot be started until an account is established on behalf of the employee. After the account is established, employees can start payroll deductions for the next payroll cycle through an automated system. The cutoff period is 1:00 p.m. on the last business day of the month. For example, accounts that are opened by September 25th and establish payroll deductions by September 30 no later than 1:00 p.m. will be effective with the October pay period. The deduction will appear on the employee’s November pay warrant. Pre-paid – The effective date of the SPP contribution is the 1st of the month following the pay period that

the deduction was taken. Deductions are posted by SPP to the participants’ account based on when deductions are received from the State Controller’s Office (generally by the 5th of each month).

Staff and Non-AY Faculty example: 1. August appointment effective date 2. Enrollment form received and processed during August pay period 3. Deduction request processed during September pay period 4. Deduction appears on October 1 pay warrant

Additional example: 1. August appointment effective date 2. Employee decides in October to enroll 3. Enrollment form received and processed during October pay period 4. Deduction request processed during November pay period 5. Deduction appears on employee’s December 1 pay warrant



AY example: 1. August appointment effective date 2. Deduction request processed during 1st pay period of AY calendar (September) 3. Deduction appears on employee’s October 1 pay warrant

Enrollment End Date

Actives: The last date that a payroll deduction has posted to the employee’s account, i.e., employee decides to stop

deductions, unpaid leave of absence, not enough pay generated to maintain deduction, etc. Separated Employees/Retirees: The last date that a payroll deduction has posted to the employee’s account prior to retirement or separation.

Special Provisions Age 50 catch-up allowance; additional $3,000 contribution in excess of the $13,000 limit The 457 plan offers a traditional catch-up provision that allows eligible participants to contribute up to

twice the maximum contribution amount. In 2004, eligible participants can contribute up to another $13,000 for a total contribution of $26,000. Other restrictions apply.

Regular Eligibility Criteria Employee Group Eligible: All represented and non-represented employee groups Eligible: All active positions Eligible: Employees concurrently appointed in an eligible and ineligible classification Ineligible: Part-time, seasonal and temporary employees that are currently enrolled in the DPA

PST Programs and are not covered by CalPERS, retired/rehired annuitants including FERPS. Ineligible: Employees on unpaid leaves of absence, including FMLA Ineligible: Independent contractors

FTE Requirements (Time Base) 401(k) and 457 plan eligibility is not tied to time base

Appointment Duration Does not apply to 401(k) and 457 plan eligibility

Multiple Positions The appointment with the eligible classification is used to determine eligibility for 401(k) and 457 plan

enrollment. AB 211 Eligibility Criteria Employee Group Eligible: Part-time lecturers and coaches in class codes 0357, 0360, 0361, 0364, 0365, 0557, 0560, 0564,

2308, 2358, 2375, 2378, 2381, and 2384. Ineligible: Employees on unpaid leaves of absence, including FMLA




enrollment.




meet the regular eligibility criteria. Ineligible: Employees on unpaid leaves of absence, including FMLA




enrollment.

Enrollment Form and Codes The enrollment form and publications for the Savings Plus Program appear on their website at: http://www.dpa.ca.gov/spp/svplmain.shtm.

http://www.dpa.ca.gov/spp/svplmain.shtm


ATTACHMENT E Page 1 of 4

Tax Sheltered Annuity (TSA) 403(b) Plan Effective Date of Benefit: Approx. July 1, 1966

Tax Year Period: January 1 –December 31 Pre-tax Benefit: Yes

Enrollment Method: Miscellaneous Deduction Change Report Form Description of Benefit The Tax Sheltered Annuity (TSA) Program is a voluntary program that allows eligible CSU employees to save toward retirement by investing pre-tax contributions in tax-deferred investments. TSA contributions are made solely by the employee through payroll deductions, prior to federal and state taxes being calculated.

The Internal Revenue Code (IRC) establishes specific limits that govern the amounts an individual can contribute to a 403(b) plan. As a result of the federally mandated Economic Growth Tax and Reconciliation Relief Act (EGTRRA), effective January 1, 2002, contribution limits and provisions for 403(b) plans were significantly revised. Currently, two IRC limits apply: the IRC Section 402(g) "elective deferral limit" and the IRC Section 415(c) "percentage of compensation" limit. For the 2004 tax year, the contribution limit is 100% of adjusted gross income (up to $41,000), or a maximum of $13,000 per year.

Employees are allowed up to two (2) active TSA deductions, and can start, stop, increase or decrease deductions once per pay period. Enrollment Period Anytime during employment

Pre-paid – The effective date of the TSA contribution is the 1st of the month following the pay period that

the deduction was taken. Deductions are posted by the TSA company to the participants’ account based on when deductions are received from the State Controller’s Office (generally by the 5th of each month). Please note that the time frame specified may be delayed for those employees who are paid outside of the master payroll cycle.


Additional example: 1. August appointment effective date 2. Employee decides in October to enroll 3. Enrollment form received and processed during October pay period 4. Deduction appears on employee’s November 1 pay warrant AY example: 1. August appointment effective date 2. Deduction taken 1st pay period of AY calendar (September) 3. Deduction appears on employee’s October 1 pay warrant

Enrollment End Date

Actives: The last date that a payroll deduction has posted to employee’s account, i.e., employee decides to stop

deductions, unpaid leave of absence, not enough pay generated to maintain deduction, etc. Separated Employees/Retirees: The last date that a payroll deduction has posted to employee’s account prior to retirement or separation.



Specific Eligibility Criteria TSA eligibility is specifically tied to classification. Exclusions are listed by classification code, as noted

below (see TSA Administrative Guide): Resident Assistant (class code 1869) Student Assistant (class code 1870) Student Trainee, On-Campus Work Study (class code 1871) Student Trainee, Off-Campus Work Study (class code 1872) Graduate Assistant (class code 2355)

Special Provisions Age 50 catch-up allowance; additional $3,000 contribution in excess of the $13,000 limit 15 year catch-up allowance; additional $3,000 contribution in excess of $13,000 limit and age 50 catch-up

(limited to $15,000 total over 5 year period). Regular Eligibility Criteria Employee Group Eligible: All represented and unrepresented employee groups Eligible: All active positions Eligible: Employees concurrently appointed in an eligible and ineligible classification Eligible: FERPS, rehired annuitants, hourly intermittents Ineligible: Employees on unpaid leaves of absence, including FMLA Ineligible: Certain student classifications: Student classification (1869, 1870, 1871, 1872), Graduate Assistants (2355)

FTE Requirements (Time Base) TSA eligibility is not tied to time base

Appointment Duration Does not apply to TSA eligibility

Multiple Positions The appointment with the eligible classification is used to determine eligibility for TSA enrollment.


2308, 2358, 2375, 2378, 2381, and 2384. Ineligible: Employees on unpaid leaves of absence, including FMLA





meet the regular eligibility criteria. Ineligible: Employees on unpaid leaves of absence, including FMLA






Enrollment Form and Codes The Miscellaneous Deduction enrollment form appears on the following page.

STATE OF CALIFORNIA

MISCELLANEOUS DEDUCTION CHANGE REPORTDOCUMENT NUMBER

TO: STATE CONTROLLER—PPSD/PAYROLL SERVICES(1)

(2)

NAMESOCIAL SECURITY NUMBERPOSITION UMBER(4)

AGENCY UNIT CLASSIFICATION SERIAL

ORGANIZATION CODE

(5)DEDUCTION

CODE

(6)

(3)

(7) CHANGE TYPE (10) NUMBER OF TIMESDEDUCTION IS TO BE TAKEN

(IF APPLICABLE)DEDUCTION AMOUNT NEW DELETE CHANGE MONTH YEAR

REMARKS

(9)(8) PAY PERIOD

DATE SIGNED

Payroll information certified in accor-dance with Board of Control Rule 660.

AUTHORIZED SIGNATURE

FROM:

FORM COMPLETED BY

(Agency Name)

TELEPHONE NUMBER

DEDUCTIONAMOUNT

TYP

E

CH

AN

GE

PM

T.

TYP

E

PAYPERIOD

DOLLARS CENTS MONTH TYR MONTH YR

ARREARSPAY

PERIOD

NUMBEROF

DED.

POLICY NUMBERPREFIX

AGENCY 001, 012, 030

50

50

FORCONTROLLER'S

USE ONLY

DOC.TYPE

DED.CODE

ORG.CODE

1 2 3 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 33 34 35 36 37 38 39 40 41 42 43 44 45 46 47 48 49 50 51 52

STD. 650 (REV. 5-90)


ATTACHMENT F Page 1 of 2

Pre-Tax Parking Deduction Code: 360-XXX (X code varies by campus)

Effective Date of Benefit: January 1, 2002 Plan Year Period: Not Applicable

Pre-tax Benefit: Yes Enrollment Method: Automatic

Description of Benefit The Pre-Tax Parking Plan allows eligible CSU employees to pay for qualified campus parking deductions on a pre-tax basis under Internal Revenue Service (IRS) section 132f. Deductions are taken from an employee’s pay warrant before Federal, State, Social Security and Medicare taxes are applied. The monthly deduction limit is established by the IRS and usually increases in $5 increments each year. For 2004, the monthly limit is $195.00. Any amount in excess of $195 must be paid in AFTER-tax dollars. Employees can opt out of pre-tax parking at anytime by completing the CSU Pre-Tax Parking Enrollment Form. Enrollment Periods At time of employment, or anytime thereafter. Initial enrollment for all eligible employees is automatic; to cancel and/or re-enroll requires completion of form.

Pre-paid – Upon hire, campuses usually collect first month’s parking fee directly from employee.

Staff and Non-AY Faculty example: 1. August appointment effective date 2. Deduction taken during August pay period 3. Pre-tax deduction reflected on employee’s September 1 pay warrant

AY example:

1. August appointment effective date 2. Deduction taken 1st pay period of AY calendar (September) 3. Pre-tax deduction reflected on employee’s October 1 pay warrant

Enrollment End Date

Actives: The first day of the month following the pay period in which the employee cancels enrollment.

Separated Employees/Retirees: Last day of the month in which an active employee retires or separates from the campus.

Regular Eligibility Criteria Employee Group Eligible: All represented and non-represented employee groups, including AB 211 and “Grandfathered”

employees, as determined by campus policy. Eligible: All active positions Ineligible: FERP employees and rehired annuitants Ineligible: Employees on paid and/or unpaid leaves of absence, including FMLA. (Employees may wish to

cancel parking deductions during extended absences from the campus.) Ineligible: Retired or separated employees

FTE Requirements (Time Base) None

Appointment Duration None

Enrollment Form and Codes The CSU Pre-Tax Parking Election form (HR/Benefits 2001-20 Attachment C) appears on the following page.


ATTACHMENT F Page 2 of 2

The California State University
PRE-TAX PARKING DEDUCTION ELECTION AUTHORIZATION
Please type or use ballpoint pen, print clearly. Send completed form to campus Human Resources Office.

Employee Name: (first) (initial) (last)

Please check the appropriate box.

I decline to participate in the CSU Pre-Tax Parking Deduction Plan and wish to pay for parking expenses with after-tax earnings through payroll deduction.

I request to participate in the CSU Pre-Tax Parking Deduction Plan and pay for parking expenses with pre-tax earnings through payroll deduction. [Not for use during initial automatic enrollment]

I understand that enrollment in the Pre-Tax Parking Deduction Plan is automatic for

parking paid through payroll deduction. I also understand that participation in the Plan is optional and I may choose to start/stop participation at any time in the future pursuant to eligibility and Plan guidelines.

I understand that I must complete and return this form to the campus Human Resources

Office by the 5th day of the month in order for the change in participation to be effective the 1st day of the following month.

Employee Signature: __________________________________Date: ________________ Employee SSN: ______________________________________

- For Office Use Only - I have received notification of employee’s decision to start ____stop____ (check appropriate selection) participation in the CSU Pre-Tax Parking Deduction Plan. Benefits Officer Signature:_____________________________________Date:___________________ Campus:____________________________________________Phone No. ______________________ Mail completed form to:

State Controller’s Office Personnel/Payroll Services Division, Collective Bargaining Unit

P.O. Box 942850 Sacramento, CA 94250-5878

Distribution: White – State Controller’s Office Yellow – Campus Pink - Employee


ATTACHMENT G Page 1 of 3

Voluntary Life Insurance Enrollment Code: 075-117

Effective Date of Benefit with Current Carrier: January 1, 2000 Plan Year Period: Not Applicable

Pre-tax Benefit: No Enrollment Method: Voluntary Life Insurance Enrollment Form/Carrier Driven

Description of Benefit The CSU offers an employee-paid voluntary life insurance plan to eligible employees through The Standard Life Insurance Company (The Standard). Employees can purchase policies for themselves and eligible family members including spouse/ domestic partner and dependent children. Employee coverage ranges from a minimum of $10,000 to a maximum of $1,500,000. Coverage for an employee's spouse or domestic partner ranges from a minimum of $10,000 to a maximum of $750,000. Coverage for children can be purchased at $5,000, $10,000 and $20,000. Each child covered on the same policy must be insured for the same amount. The deduction amount is based upon premium per $1,000. Newly hired eligible employees have sixty days in which to enroll in the benefit. After the sixty-day limit, enrollment is allowable only with the submission of evidence of insurability. Enrollment Periods First 60 days of employment (without evidence of insurability) Anytime during employment, but employee must submit evidence of insurability even if a change in status

event occurs (newly acquired spouse, child, etc.) Effective Date of Coverage

The first of the month following the pay period that the deduction was taken Pre-paid




Enrollment End Date

Actives: The date that employment ends. The last day of month following the pay period of the last deduction, i.e., unpaid leave of absence – if

employee chooses not to direct pay while on leave. Separated Employees/Retirees: The date that employment ends.



Specific Eligibility Criteria Enrollment in Voluntary Life is tied to classification and time base. Specific classification exclusions apply.

Regular Eligibility Criteria Employee Group Eligible: All represented and unrepresented employee groups Eligible: All active positions Eligible: Employees concurrently appointed in an eligible and ineligible classification and time base Eligible: Employees on an unpaid leave of absence, including FMLA IF direct payment is chosen as an

option. While on unpaid status, employee must direct pay to carrier to continue coverage Ineligible: Rehired annuitants, FERPS, and including the following: Intermittent employees Graduate Assistants Faculty employed solely to teach summer session, extension, or intersession Any employee paid from funds not controlled by the California State University or from revolving or

similar funds from which a regular California State University premium payment cannot be made, or Employees who are full-time members of the armed forces of any country.

FTE Requirements (Time Base) Sum of FTE for all active positions must be > = 0.5 or greater

Appointment Duration – at least one position must qualify Permanent/probationary appointments (no appointment expiration date). Employee on a Pre-retirement Reduction in Time Base who was benefits eligible previously. Temporary appointment of at least 6 months and 1 day from appointment effective date to appointment

expiration date. Temporary appointment less than 6 months and 1 day continuous with no break in service between this

appointment and previous benefits-eligible appointment. A transaction such as a temporary promotion, reclassification, or reassignment for less than 6 months and 1



FTE > = 0.5 regardless of length of appointment.


duration.


2308, 2358, 2375, 2378, 2381, and 2384. Eligible: Employees on an unpaid leave of absence, including FMLA IF direct payment is chosen as an

option. While on unpaid status, employee must direct pay to carrier to continue coverage


Appointment Duration – at least one position must qualify Minimum of one semester or two consecutive quarters.



Mid appointment increases to FTE and the original effective date of the appointment (not the effective date

of the increase in FTE) and appointment expiration date is at the end of one semester, two consecutive quarters or the Academic Year (TL HR/Benefits 2003-06). Once an employee is benefits eligible, benefits continue in subsequent consecutive appointments as long as


duration. “Grandfathered” Eligibility Criteria Employee Group Eligible: Part-time lecturers and coaches in class codes 2308, 2358, 2375, 2378, 2381, or 2384 who do not

meet the regular eligibility criteria. Eligible: Employees on an unpaid leave of absence, including FMLA IF direct payment is chosen as an

option. While on unpaid status, employee must direct pay to carrier to continue coverage



expiration date. Mid appointment increases to FTE and the original effective date of the appointment (not the effective date


FTE is >= 0.4 but <= 0.49 regardless of length of appointment.


duration. Enrollment Form and Codes The enrollment form for voluntary life are at the following Web site: http://www.calstate.edu/Benefits/carrier.materials/VolLife_EnrollmentForm.pdf


ATTACHMENT H Page 1 of 2

Voluntary Auto and Homeowner Insurance Deduction Code: 075-105

Effective Date of Current Carrier: January 4, 1989 Plan Year Period: Not Applicable

Pre-tax Benefit: No Enrollment Method: Enrollment Form Via The Carrier

Description of Benefit The CSU allows eligible employees to obtain automobile and homeowner’s insurance policies through A+ Auto & Home Insurance Plus via direct payment, automatic payment (checking) or payroll deduction. All policies are written for a 12- month period. Enrollment Periods At time of employment, or anytime thereafter.

The effective date of coverage is the same date that coverage is actually bound, and is not tied to when the

payroll deduction starts. For new policies, a down payment is obtained from the participant and payroll deduction is started within 2 months of policy start date. Upon renewal, premium can be paid in 12 monthly installments of payroll deduction if chosen as an option. Staff and Non-AY Faculty example: 1. September appointment effective date 2. Auto and/or homeowner’s policy effective October 15 3. Deduction taken during December pay period 4. Deduction reflected on employee’s January 1 pay warrant

AY example: 1. August appointment effective date 2. Auto and/or homeowner’s policy effective November 11 3. Deduction taken during January pay period 4. Deduction reflected on employee’s February 1 pay warrant

Enrollment End Date

If employment ends prior to the end of the policy, the separated employee maintains current rate through end of policy and can direct pay. If payment agreement is not kept, policy is subject to cancellation date established by the carrier. However, if direct payment is chosen as an option, the separated employee is entitled to discounted rate through the end of the policy termination date. Actives: The date that the policy is scheduled to expire and is not renewed. The date that the policy ends through failure to direct pay.

Separated/Retirees: The date that the policy is scheduled to expire and is not renewed. The date that the policy ends through failure to direct pay.

Regular Eligibility Criteria Employee Group Eligible: All represented and unrepresented employee groups, including AB211 and “Grandfathered”

employees. Eligible: All active positions Eligible: Employees on unpaid leaves of absence, including FMLA if the employee

chooses to continue enrollment through direct payment. Ineligible: Retired or separated employees, after expiration date of policy that was in

force while an active employee.


ATTACHMENT H Page 2 of 2

FTE Requirements (Time Base) Not Applicable

Appointment Duration Not Applicable

Enrollment Form Enrollment forms A+ Auto and Home & Home Insurance Plus can be obtained by accessing their website at http://www.calcas.com. Forms are processed by carrier and then forwarded to the State Controller’s Office for payroll deduction implementation (if payroll deduction is chosen by employee).

http://www.calcas.com/


ATTACHMENT I Page 1 of 2

Voluntary Insurance Plans Deduction Code: 075-090

Effective Date of Current Carrier: January 4, 1989 Plan Year Period: Not Applicable

Pre-tax Benefit: No Enrollment Method: Enrollment Form(s) Via The Carrier

Description of Benefit CSU permits eligible employees to obtain supplemental insurance policies through Sanders & Associates via payroll deduction. Various insurance products are available to employees including: Accidental Death and Dismemberment (AD&D) Policy –

This policy pays a benefit for accidental death or dismemberment at a benefit level selected by the employee. Hospital Income Plan –

This policy pays a predetermined daily benefit amount for each qualified day (up to two (2) years) that the participant and/or covered family member is hospitalized. Participant may choose any amount between a minimum daily benefit of $30.00 and a maximum daily benefit of $250.00. Disability Insurance –

Disability insurance provides loss of income protection (up to 60% of earnings) due to a qualified disability. Travel Assistance Policy -

Provides worldwide assistance to participants that encounter emergencies while traveling. Cancer Medical Reimbursement Plan –

Provides 100% reimbursement for covered medical expenses of cancer and supplements participant’s existing health insurance plan. There is a lifetime maximum of $1,000,000.

Enrollment Period For all plans except for disability insurance, employees can apply at time of employment, or anytime thereafter.

Employees must apply for disability insurance within the first 31 days of employment. Pre-paid – Coverage for all plans except Travel Assistance is effective the 1st of the month following the

pay period that the deduction is taken. Payroll deduction is not available for Travel Assistance policy.

Staff and Non-AY Faculty example: 1. August appointment effective date 2. Deduction taken during August pay period 3. Deduction reflected on employee’s September 1 pay warrant 4. Coverage is effective September 1

Additional example: 1. August appointment effective date 2. Deduction taken during October pay period 3. Deduction reflected on employee’s November 1 pay warrant 4. Coverage is effective November 1

AY example: 1. August appointment effective date 2. Deduction taken 1st pay period of AY calendar (September) 3. Deduction reflected on employee’s October 1 pay warrant 4. Coverage is effective October 1


ATTACHMENT I Page 2 of 2

Enrollment End Date Actives: Last day of the month following the pay period of the last deduction, if employee fails to direct pay while

on leave of absence, or cancels policy. Separated Employees/Retirees: The date active employee retires or separates from the campus.

All plans, except for Travel Assistance and Disability Insurance are portable upon employee separation or retirement.

Specific Eligibility Criteria Enrollment in certain plans is restricted based on CBID, or other criteria specified by Sanders.

The following employee groups are not eligible to enroll in the disability insurance policy: Physicians (Unit 1) Faculty (Unit 3) Academic Support (Unit 4) Management Personnel Plan (MPP – M80) Executives (M98)

Employees are ineligible to enroll in the Hospital Income Plan if: Employee does not work a minimum of 30 hours per week Employee is on full time active duty in the armed forces.

Employees are ineligible to enroll in the Cancer Medical Reimbursement Plan if: Employee is not already covered by a primary health plan.

Please note: deduction code for Sander’s is used for all plans and doesn’t indicate the type of plan an employee is enrolled in. Regular Eligibility Criteria Employee Group Eligible: All represented and unrepresented employee groups, including AB 211, “Grandfathered,” and

hourly intermittent employees, etc. Eligible: All active positions Ineligible: Employees on unpaid leaves, including FMLA Ineligible: Retired or separated employees Ineligible: Any additional criteria expressed by Sanders

FTE Requirements (Time Base) Time base requirement does not apply to any policy except for the Hospital Income Plan.

Appointment Duration Not Applicable

Enrollment Form Enrollment forms can be obtained by contacting Sanders & Associates. Forms are processed by Sanders & Associates, and then forwarded to the State Controller’s Office for payroll deduction implementation.

pcos technical letter

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