Eligibility Criteria for Dependents in a Parent-Child Relationship and Updated Affidavit

The purpose of this Circular Letter (CL) is to inform you of approved regulatory language that clarifies the requirements to enroll a child under a Parent-Child Relationship (PCR). It also announces changes the California Public Employees’ Retirement System (CalPERS) made to the Affidavit of Parent-Child Relationship (Affidavit) form (CalPERS-HBD-40) effective July 1, 2023. This letter supersedes CL 600-037-20 and CL 600-008-15.

Background

Government Code section 22775, which is part of the Public Employees’ Medical and Hospital Care Act defines the term “family member.” Title 2 of the California Code of Regulations, section 599.500(o) further clarifies this definition to include dependents in a PCR. The regulation has been updated to clarify the documentation needed to confirm the subscriber’s assumed parental duties. Additionally, the regulation now provides guidance for individuals who are not required to file an income tax return.

New Affidavit of Parent-Child Relationship Form (CalPERS-HBD-40)

The CalPERS-HBD-40 (PDF) has been updated to reflect the amended regulation and the affidavit now only requires the signature of the health benefits officer and no longer requires a second signature of a manager. You can download the new form from the Forms & Publications section of the CalPERS website. The new form has a revision date of July 2023. CalPERS will notify subscribers of the new requirements beginning in December 2023 for the March 2024 recertifications. CalPERS will continue to accept the older version of the HBD-40 form and required documents for recertifications through March 31, 2024.

Supporting Documentation for PCR Dependent Age 18 or Under

A copy of the first page of the subscriber’s federal or state income tax return such as IRS Form 1040 from the previous tax year listing the child as a tax dependent
In lieu of a tax return, for a time not to exceed one tax filing year and only during the child's initial enrollment as a PCR, the subscriber must provide the supporting documentation listed in section 4 below.

Supporting Documentation for PCR Dependent Age 19 to 26

A copy of the first page of the subscriber’s federal or state income tax return such as IRS Form 1040 from the previous tax year listing the child as a tax dependent
The child must live with the subscriber more than fifty percent (50%) of the time or be a full-time student, and the subscriber will have to provide the supporting documentation listed in the Affidavit section 4 (review Section 4: Supporting PCR Documentation below) to substantiate the child is dependent on the subscriber for more than fifty percent (50%) of their financial support.

Supporting PCR Documentation Requirements and Categories

All supporting documents must have the child’s name printed on them by the issuer. Supporting documents may not be older than sixty (60) calendar days from the date of signature on the Affidavit by the subscriber. However, the regulation exempts current legal judgements, court documents, driver’s licenses, state identification, vehicle registrations, and rental/lease agreements from the sixty (60) calendar day requirement.

Section 4: Supporting PCR Documentation

For the scenarios listed in the affidavit where a tax return is not required, the subscriber will need to provide two or three documents from the list below depending on if the PCR dependent lives with the subscriber or not, as indicated on the affidavit. At least one document must be from category A, the remaining required documents can be from category A or B.

Category A – Primary Supporting PCR Documentation

Current legal judgments or court documents showing the subscriber's legal parental status or duties/guardianship over the child
Current child’s driver’s license or state identification showing common residency
Current rental or lease agreements
School or college records listing the subscriber as the child’s guardian or indicating common residency
Other verifiable documents showing common residency
Bank statements or other financial documentation reflecting rent payment(s) for the child who does not reside with the subscriber, along with proof of payment made by the subscriber

Category B - Secondary Supporting PCR Documentation

Tuition payment(s), car insurance, vehicle registration, credit card statements, or other billing statements along with proof of payment(s) made by the subscriber
Joint or child’s bank statement showing recurring deposits along with proof that deposits were made by the subscriber
Medical and dental bills for the child along with proof of payment(s) made by the subscriber

Additional Requirements for Subscribers Who Are Not Required to File Taxes

If subscribers are not required to file taxes, they must submit confirmation from the Internal Revenue Service, Franchise Tax Board, certified public accountant, tax preparer, or other tax professional indicating a tax return is not required.

Additional Resources

Public Agency & Schools Health Benefits Guide (PDF, 1.2 MB)
State Health Benefits Guide (PDF, 1.3 MB)
Affidavit of Parent-Child Relationship (CalPERS-HBD-40) (PDF)

Questions

If you have questions, call our CalPERS Customer Contact Center at 888 CalPERS (or 888-225-7377 888-225-7377 ).

Yesenia Croft, Chief
Health Account Management Division

Updated: December 1, 2023

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