Benefits Information

Log in to your my|CalPERS participant account to view:

1. Specific health benefit changes that may impact you in the coming year
2. Your current monthly premium rate
3. Health plans and monthly premium rates available based on your health eligibility ZIP code
4. Which health plans your doctor participates in
5. Your enrolled dependents

Dropping Dependents at Age 26 Limit:  REMEMBER that if your dependent is dropped by CalPERS for reaching age 26 and that reduces your plan tier, you MUST notify HR to change to the lower tier/deduction on your paycheck.  CalPERS does not automatically notify HR.

Visit your health plan’s website to learn how benefits, claims, and payment of claims are covered, as well as the service limitations and exclusions that may apply. You can also log in to myCalPERS to use the Search Health Plans tool to research the health plan coverage and benefits most important to you and your family.

You can view the Summary of Coverage and Evidence of Coverage documents for all health plans on the CalPERS website here: https://www.calpers.ca.gov/page/forms-publications&d=29

• CalPERS Enrollment Form (HBD-12) & Cafeteria Plan Forms – Required to enroll in/cancel health – along with Cafeteria Plan Form
• Opt-Out (Waiver) Attestation– Required annually if you are already waiving City medical coverage (new cancellations must submit CalPERS Enrollment Form (HBD-12) & Cafeteria Plan Form)

• Health Program Guide
• Marriage or Domestic Partnership Affidavit
• HBD-12a CalPERS Declaration of Health Coverage
• Parent-Child Relationship FAQs
• Parent-Child Relationship Affidavit

Commuter benefits give employees the opportunity through their employer to use tax-free dollars on commuting costs and keep more of what they earn in every paycheck. Companies that offer commuter benefits also save money by reducing payroll taxes.

Commuter benefits allow employers to support their employees when it comes to their daily commute. Commuter benefits include parking benefits and transit benefits, as well as benefits for vanpool and bicycle commuting.

When an employee enrolls in a commuter benefits program, they can pay for their commuting costs with pre-tax money, up to the current IRS tax limit.

Sign up today at  Commuter Benefits.

Additioal resources:

• Commuter Benefits Portal login instructions
• Commuter Benefits 101 Guide
• What are commuter benefits?

MissionSquare- 457 Plans

• 457 Plan Enrollment Portal
• 457 Plan Beneficiary Designation Form
• 457 Plan Contribution Change Form
• 457 Plan Catch-Up Brochure

MissionSquare- Roth IRA

• MissionSquare ROTH IRA Enrollment Form

MissionSquare- Informational Flyers

• Another Way to Save- 457 Plan vs Roth IRA
• ICMA Name Change to MissionSquare
• ICMA Name Change FAQ
• MissionSquare Video Clips
• Choose your contribution 
• Saving More Matters 
• MissionSquare Retirement Education Center
• How to Rollover Your Money to your New MissionSqaure Account 
• Retirement Health Savings Program (RHS) (see corresponding MOU to determine eligibility)

Nationwide

• Nationwide Enrollment Portal
• Nationwide Contribution Change Form
• Nationwide Beneficiary Change Form Deferred Plan
• Nationwide Rollover Request Form 

Nationwide- Informational Flyers

• Nationwide Online Enrollment Flyer
• Nationwide Retirement Resources

This benefit is fully paid by the City of San Rafael (pro-rated for part-time employees) and includes any eligible dependents.  Employees can log-in to the United Concordia website to view their covered dependents and search providers.  If you don’t have your member #, which is needed to log-in, please call UCCI at 1-800-332-0366.  You can print an ID card once you’re logged on to the website.

Please review the Summary of Benefits provided below to learn more about your deductibles and services covered.

Complete the UCCI Enrollment Form to sign up or add eligible dependents (up to age 19, or age 23 if a full-time student).

• UCCI Dental Enrollment Form
• Dependent Certification Form (ages 19-23)
• Additional Resources:
  • Dental Benefit Summary
  • Summary Plan Description – City of San Rafael – 50UXB
  • Frequently Asked Questions
  • Detailed Benefits Summary
  • Fast Facts
  • UCCI College Tuition Benefit
  • UCCI Advantage PLUS Network

Please visit & create an account at www.MagellanAscend.com to access well-being services including coaching, counseling self-care mobile apps and more.

Make sure to create a profile to:

1. Explore articles and webinars on topics from parenting to stress and anxiety
2. Research providers in your area
3. Browse apps to help with insomnia, depression, OCD and more

• • EAP Member e-brochure & EAP Benefits  brochure
    • List of all providers in Northern CA (includes First Responder providers)
  • Magellan Health Key Features
  • EAP Work-Life Services Overview
  • EAP Discount Center Flyer
  • EAP  Discount Center Flyer
  • Legal-Financial-ID Theft Flyer
  • Employee Assistance Program Combined Evidence of Coverage and Disclosure Form
  • FAQs for Magellan Ascend Launch

Effective January 1, 2022, City of San Rafael is providing a new employee emotional and mental wellness benefit service through Concern for first responders.

• EAP Concern Introduction
• EAP Concern Registration Instructions
• EAP First Responder Program
• First Responders Benefit Summary

Please note: Admin staff & Fixed-Term employees are covered through Magellan EAP. Please visit https://magellanascend.com/ccid=hpZiwITni%2FVKNrZqvUQNBw61jCVbxkAKZPYgqIIdcrY%3D or call 800-523-5668 for assistance.

The Employee Commute Program is for the sole use of employees and volunteers of the City of San Rafael. Certain incentives will be reported as income. Carpool and vanpool startup incentives are issued one-time only. Below are the incentives/services available. For more information, or to sign up, visit: https://www.cityofsanrafael.org/city-commuter-program/.

Enrollment in FSA Health Care Reimbursement and the Dependent Care program requires an annual election. This means you must submit a new enrollment form even if you are setting aside the same amount as previous years.

• 2024 FSA Enrollment Form (required annually) 

• FSA Medical Brochure
• FSA Dependent Care Brochure
• Common FSA eligible/ineligible expenses

Learn more about Flex Spending Accounts.

• What is Health Care FSA?
• What is Dependent Care FSA?

Need additional assistance? Check out the Optum Financial Resources Library to learn more on how to upload a receipt, submitting a claim & spending your FSA $.

Long-Term Disability (LTD) insurance is a supplemental insurance that helps people who can’t work because of an injury, illness or disability. If you have LTD insurance, it will replace some of the income you lose when you can’t work because of an injury, illness or disability.

• How to File a Disability Claim & Process
• Long Term Disability Claim Form – NYL

All employees are automatically enrolled in the city-paid Basic Life insurance benefit, as designated in the appropriate MOU, upon hire.  Employees should maintain an updated Basic Life Beneficiary Designation form on file.

There is no formal open enrollment period to purchase Voluntary Life insurance for yourself and/or your eligible dependents. Please note that in order to purchase life insurance for your spouse and/or child(ren), you are required to purchase voluntary life insurance for yourself. Evidence of Insurability is required for all new elections (outside of the 30-day window from date of hire); see form below. This optional benefit is fully paid for by the employee.

Cigna Life Insuarance Forms

• Basic Life and ADD Beneficiary Designation Form
• Voluntary Life Insurance Application
• Voluntary Life Insurance brochure
• Voluntary Life Insurance Sample Rate Sheet
• How To File A Disability Claim & Process
• Financial Legal & Estate Support Flyer
• Employee Assistance & Wellness Support Flyer

Certificates of Coverage:

• LTD
  • Class 1 All Employees – lk960715c01
  • Class 2 Safety Management – lk960715c02
  • Class 4 Executive Management – lk960715c04
  • Class 5 Mid-Management – lk960715c05
  • Class 6 City Manager – lk960715c06
  • LTD, ERISA Amendment 
• Life Insurance
  • Open Enrollment Jan – June 2015 – FLX960830a02rei1013
  • Class 1 All Employees – FLX960830c01rei1013
  • Class 2 Safety Mid-Management – FLX960830c02rei1013
  • Class 3 Councilmembers – FLX960830c03rei1013
  • Class 4 Executive Management – FLX960830c04rei1013
  • Class 5 Mid-Management – FLX960830c05rei1013
  • Class 6 City Manager – FLX960830c06rei1013
  • Continuation of coverage – FLX960830a03rei1013
  • Life Insurance, ERISA Amendment

LTD – Benefit Summary Flyers ( LK960715)

• Class 1 All Employees – City-of-San-Rafael-BLTD-Benefit-Highlight-Sheet-C1
• Class 2 Represented Management – City-of-San-Rafael-BLTD-Benefit-Highlight-Sheet-C2
• Class 4 Executive Management – City-of-San-Rafael-BLTD-Benefit-Highlight-Sheet-C4
• Class 5 Mid-Management – City-of-San-Rafael-BLTD-Benefit-Highlight-Sheet-C5
• Class 6 City Manager – City-of-San-Rafael-BLTD-Benefit-Highlight-Sheet-C6

Basic Life Benefit Summary Flyers (LK960715)

• Class 1 All Employees
• Class 2 Safety (Rep) Mgmt
• Class 3 Councilmembers
• Class 4 Management
• Class 5 Mid-Management
• Class 6 City Manager

*The Employee Retirement Income Security Act of 1974 (ERISA) is a federal law that sets minimum standards for most voluntarily established retirement and health plans in private industry to provide protection for individuals in these plans.*

PARS is a retirement account for part-time, seasonal, and temporary employees who work for public agencies. The federal government requires that all public agency employees are put in some type of retirement plan.  Learn more here: https://www.pars.org/view-agency-minisite/?agencyid=395

• Beneficiary Designation Form
• Plan Information Sheet

• MCERA Welcome Guide 
  • Classic Tier Member Handbook
  • PEPRA Tier Member Handbook
• CalPERS Reciprocity Form

Members in certain bargaining groups are eligible for vision coverage through EyeMed.  This benefit is fully paid by the City for Employee Only coverage (pro-rated for part-time employees).  Employees may enroll all eligible dependents for an out-of-pocket cost of $7.39 per month.  The City picks up the cost to enroll eligible dependents for Executive and Mid-Management employees.  Employees can log-in to the EyeMed website to view their coverage details, covered dependents, search providers and print an ID card (you will not receive anything in the mail).

Please review the Summary of Benefits provided below to learn more about your coverage and copay’s.

Complete the EyeMed Enrollment Form to sign up or add eligible dependents (up to age 19, or age 25 if a full-time student).

EyeMed Vision Forms

• EyeMed Enrolllment & Change Form

Additional Resources:

• EyeMed Mobile App
• EyeMed_Member_FAQs
• How to Access & Use Benefits Member Flyer
• EyeMed Benefit Summary City Of San Rafael