The CalPERS HBD-12 form is the paper enrollment form active state and public-agency employees use to sign up for CalPERS health coverage, switch plans, add or drop a dependent, or formally decline coverage. You complete sections A through E, attach any required dependent documents, and submit the form to your employer’s Health Benefits Officer, who verifies it and forwards it to CalPERS.1California Public Employees’ Retirement System. Health Benefits Plan Enrollment for Active Employees (HBD-12) Instructions Retirees use a different enrollment form through the retiree portal, not the HBD-12.2CalPERS. Eligibility and Enrollment (Retirees)
When You Can Submit the Form
The HBD-12 only works inside an open enrollment window. There are three.
If you’re a new hire, you have 60 calendar days from your appointment date to request enrollment.3CalPERS. Eligibility and Enrollment (Active Members) Coverage generally begins the first day of the month after your employer processes the form.
Open Enrollment is the yearly window when any active employee can switch plans, add or remove dependents, or cancel coverage with no qualifying event required. The 2026 period runs from September 14 through October 9, with changes effective January 1.4CalPERS. Open Enrollment for Active Members A straightforward plan change during Open Enrollment needs no supporting documentation.5CalPERS. Online Health Enrollment for Active Employees
Outside those windows, a qualifying life event opens a 60-day window.6New York Codes, Rules and Regulations. California Code of Regulations Title 2 Section 599.502 – Enrollment Marriage, divorce, birth or adoption, a spouse losing other group coverage, and a change in employment status all qualify. For births and adoptions, coverage can be made retroactive to the event date if you file within 60 days. For other events, coverage usually starts the first of the month after CalPERS processes the change. CalPERS does not grant extensions, so get the event date right on the form and submit quickly.
Filling Out the Form, Section by Section
The HBD-12 has eight sections, A through H. You handle A through E; your employer handles H. F and G are privacy notices to review.1California Public Employees’ Retirement System. Health Benefits Plan Enrollment for Active Employees (HBD-12) Instructions
Section A: Applicant Information
Full legal name, Social Security number, date of birth, mailing address, phone number. If you want to use your work ZIP code to determine plan availability rather than your home ZIP, enter it in the designated field. The ZIP code controls which plans you can choose, because CalPERS plans are organized by geographic region.7CalPERS. Plans and Rates (Active Members)
Section B: Type of Action
Check the box matching what you’re doing: new enrollment, plan change, adding a dependent, removing a dependent, or cancellation.
Section C: Permitting Event
Check the event that authorizes the action in Section B: new hire, Open Enrollment, marriage, birth, loss of other coverage, and so on. The event must match a current open window. A mismatch between Sections B and C is one of the most common reasons forms are returned.
Section D: Subscriber and Dependent Information
List yourself first. Then list each dependent you want to add or remove, with full legal name, Social Security number, date of birth, and the relationship code identifying them as a spouse, domestic partner, or child. Mark each line as an add or a delete. Names and Social Security numbers must match Social Security Administration records. Nicknames or shortened names will cause processing delays.
Eligible dependents include a legal spouse, a registered domestic partner, natural, adopted, and stepchildren up to age 26, and the children of a registered domestic partner.8CalPERS. Enroll Family Members A child in a parent-child relationship can qualify when you’re the primary care parent, though documentation is stricter.
Section E: Enrollment Decision
Check the enrollment box in Part 16 to enroll, or the declination box in Part 17 to decline coverage. If enrolling, enter the plan code. Use the Health Plan Search by ZIP Code tool on the CalPERS website or log into myCalPERS to see which plans are available in your area and compare premiums.7CalPERS. Plans and Rates (Active Members) Sign and date the form in Parts 18 and 19.
Section H: Employer Use Only
Leave blank. Your personnel office fills in the agency code, employment details, and payroll contribution information.
Dependent Documents to Attach
Listing dependents on the form is not enough. CalPERS requires proof of each relationship, and missing paperwork is the fastest way to stall an enrollment. Pull these together before you start the form, not after.
- Spouse: a government-issued marriage certificate, plus either the first page of your most recent federal or state tax return showing your spouse, or a household bill or account statement listing both names at the same address dated within the last 60 days.
- Registered domestic partner: a copy of the Declaration of Domestic Partnership from the California Secretary of State or equivalent, plus the same financial documentation options as for a spouse.
- Children under 26: a birth certificate or adoption certificate naming you, your spouse, or your domestic partner as a parent. For stepchildren or a partner’s children, include the spouse or partner documentation as well.
Financial documentation is not required when your spouse or domestic partner is also a CalPERS retiree receiving their own allowance and shares your address.9CalPERS. Dependent Eligibility Verification (Retirees) For everyone else, assume you’ll need to produce the full set.10CalPERS. Dependent Eligibility Verification
A Warning About Dual and Split Enrollment
You cannot be enrolled in a CalPERS health plan as both a subscriber and a dependent, and you cannot appear as a dependent on two separate CalPERS enrollments. If two CalPERS members are married or in a domestic partnership, each may carry a separate enrollment, but all children must sit on one parent’s plan. CalPERS retroactively cancels duplicate enrollments and bills the member for costs incurred from the date the overlap started.8CalPERS. Enroll Family Members If both spouses are filling out an HBD-12, decide ahead of time which parent carries the kids and make sure the two forms agree.
Where to Send the Form
Turn the completed HBD-12 and supporting documents in to your employer’s Health Benefits Officer. Do not mail the form directly to CalPERS. HR reviews it, verifies eligibility, calculates your payroll deduction, and enters the enrollment in CalPERS’s administrative system.1California Public Employees’ Retirement System. Health Benefits Plan Enrollment for Active Employees (HBD-12) Instructions
For many changes you don’t need the paper form at all. With your employer’s approval, active employees can submit enrollment changes online through myCalPERS. When you file online, your employer no longer needs to collect the HBD-12; everything goes electronically.5CalPERS. Online Health Enrollment for Active Employees HR still reviews changes that require supporting documents, but Open Enrollment plan switches go through without employer review. The online path is faster than paper and less likely to get lost in transit.
After You Submit
Watch for a Health Enrollment Confirmation letter from CalPERS. That letter is your proof the change went through. Processing generally takes two to four weeks, longer during Open Enrollment season when volume spikes. If the confirmation doesn’t arrive, follow up with your Health Benefits Officer before assuming the enrollment landed.
Situations the HBD-12 Doesn’t Cover
A few common enrollment scenarios use a different form or process, so don’t try to force them onto the HBD-12.
Keeping a disabled child on your plan past age 26 uses the Disabled Dependent Member Questionnaire and Medical Report, form HBD-34, not the HBD-12. The request must be submitted between 90 days before and 60 days after the dependent’s 26th birthday, and the medical sections must be completed by a physician who specializes in the dependent’s disability. Missing the window means the removal is permanent.11CalPERS PERSpective. Tips to Enroll Disabled Dependents and Certify Parent-Child Relationships
Retirees do not use the HBD-12 to enroll or make changes. Retiree enrollment forms are available on the CalPERS retiree portal, and many changes can be made through myCalPERS or by calling 888-CalPERS (888-225-7377).2CalPERS. Eligibility and Enrollment (Retirees)
Transferring from a basic plan to a CalPERS Medicare plan at age 65 is handled through CalPERS’s coordination with the Centers for Medicare and Medicaid Services, with a separate Certification of Medicare Status or Ineligibility of Medicare Certification form if CalPERS cannot verify your status.12CalPERS. Medicare
Continuing coverage after you leave the job runs through COBRA, elected within 60 days of losing eligibility, not through the HBD-12.3CalPERS. Eligibility and Enrollment (Active Members) Keep your CalPERS coverage active through your last day of employment; canceling before you separate makes you ineligible for COBRA.