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Member Eligibility

Eligibility Rules

The San Francisco Health Service System (SFHSS) Rules govern enrollment eligibility for employee and retiree members and their families.

MEMBER ELIGIBILITY

SFHSS administers health benefits for eligible San Francisco City and County Employees (including the San Francisco Superior Court), Retirees, San Francisco Unified School District employees, and City College of San Francisco employees.

City and County of San Francisco Employee Members

The following City employees are eligible to participate in the San Francisco Health Service System (SFHSS) as defined in San Francisco Administrative Code Section 16.700:

  • All permanent employees of the City and County of San Francisco whose normal work week is not less than 20 hours.
  • All regularly scheduled provisional employees of the City and County of San Francisco whose normal work week is not less than 20 hours.
  • All other employees of the City and County of San Francisco, including temporary exempt “as needed” employees,who have worked more than 1040 hours in any consecutive 12 month period and whose normal work week is not less than 20 hours.
  • Elected Officials.
  • All members of designated boards and commissions during their time in service to the City and County of San Francisco as defined in San Francisco Administrative Code Section 16.700(c).
  • All officers and employees as determined eligible by the governing bodies of the San Francisco Transportation Authority, San Francisco Parking Authority, and Treasure Island Development Authority, San Francisco Superior Court and any other employees as determined eligible by ordinance.
  • All other employees who are deemed 'full-time employees' under the federal Patient Protection and Affordable Care Act (section 498OH).

San Francisco Unified School District Employee Members

Employee eligibility for SFHSS healthcare coverage is determined by the San Francisco Unified School District (SFUSD). Please confirm your eligibility with the SFUSD Benefits Office. The following SFUSD employees may be eligible for healthcare coverage administered by the Health Service System. Please note that temporary Exempt or “As Needed” SFUSD employees are not eligible for SFHSS administered healthcare coverage.

  • All full-time Permanent Civil Service and Permanent Exempt SFUSD employees whose normal work week is not less than twenty (20) hours.
  • All part-time Permanent Civil Service and Permanent Exempt SFUSD employees who work less than 20 hours per week will be eligible upon completion of 1,040 hours in a 12-month period.
  • All Provisional SFUSD employees will be eligible upon completion of 1,040 hours in a 12 month period unless otherwise approved by the SFUSD Board.
  • All other employees who are deemed 'full-time employees' under the federal Patient Protection and Affordable Care Act (section 498OH).

City College of San Francisco Employee Members

City College of San Francisco employee eligibility for SFHSS healthcare coverage is determined by the Governing Board of the San Francisco Community College District. Please refer to the City College of San Francisco Benefits Guide or contact the City College Benefits Unit for more information at (415) 487-2445 or the City College Human Resources office at (415) 241-2246, benefits@ccsf.edu or visit their website ccsf.edu/hr.

Retiree Members

Newly eligible retirees must enroll in an available medical and/or dental plan within 30 days of their retirement effective date. You must provide the SFHSS with a completed Retiree Enrollment Application and all required documentation within this initial 30 day enrollment period. SFHSS Rules requires that to be eligible for retiree healthcare coverage the retiree must have been a member of SFHSS at some time during their active employment. Other restrictions may apply.

DEPENDENT ELIGIBILITY

SFHSS member employees and retirees may enroll eligible dependents on their health coverage. Dependent eligibility and enrollment deadlines are outlined below.

Spouses and Domestic Partners

A member’s legal spouse or domestic partner may be eligible for HSS healthcare coverage. Proof of marriage or registered domestic partnership is required, as well as the dependent’s Social Security number. Proof of Medicare enrollment must also be provided for a same-sex spouse or domestic partner (of either gender) who is age 65 or older, or who is Medicare-eligible due to a disability. Enrollment in SFHSS benefits must be completed within 30 days of the date of marriage or partnership. In that case, coverage begins on the first day of the coverage period after a completed application and eligibility documentation is filed with SFHSS. Legal spouses and domestic partners can also be added to a member’s coverage during annual Open Enrollment.

Natural Children, Step-Children, Adopted Children

A member’s natural child, stepchild, adopted child (including child placed for adoption), and the natural or adopted child of a member’s enrolled domestic partner are eligible for coverage up to 26 years of age. Coverage terminates at the end of the coverage period in which the child turns 26. Eligibility documentation is required upon initial enrollment.

Legal Guardianships and Court Orders

Children under 19 years old who are placed under the legal guardianship of an enrolled member, a member’s spouse, or domestic partner are eligible. If a member is required by a court’s judgement, decree or order to provide health coverage for a child, that child is eligible up to age 19. Coverage terminates at the end of the coverage period in which the child turns 19. The member must provide SFHSS with proof of guardianship

Disabled Children

Children who are disabled may be covered beyond the age limits stated previously, provided all of the following criteria are met. (A newly hired employee who enrolls an adult disabled child age 26 or older must meet all requirements below except 1 and 2.)

  • 1. Adult child was enrolled in an SFHSS medical plan on the child’s 19th birthday and continuously for at least one year prior to the child’s 19th birthday;
  • 2. Adult child was continuously enrolled in an SFHSS- administered medical plan from age 19 to 26;
  • 3. Adult child is incapable of self-sustaining employment due to the disability;
  • 4. Adult child is unmarried.
  • 5. Adult child permanently resides with the employee member;
  • 6. Adult child is dependent on the member for substantially all of his economic support, and is declared as an exemption on the member’s federal income tax;
  • 7. Member submits to SFHSS acceptable medical documentation–a certification that an adult child is enrolled in Medicare due to a Social Security-qualifying disability, or SFHSS disabled dependent forms completed and signed by a physician–at least 60 days prior to child’s attainment of age 26 and every year thereafter as requested;
  • 8. All enrolled dependents who qualify for Medicare due to a disability are required to enroll in Medicare. Members must notify SFHSS of any dependent’s eligibility for, and enrollment in, Medicare;
  • 9. Once enrolled, the member must continuously enroll the disabled adult child in SFHSS coverage and Medicare (if eligible) to maintain future eligibility.

Social Security Numbers Required

Members and dependents who do not have a Social Security number on file at HSS risk having benefits terminated. Social Security numbers for newborns must be provided within 6 months of the date of birth. Visit ssa.gov for more information. If your dependent does not qualify for a Social Security number, please contact SFHSS at (415) 554-1750.

Financial Penalties for Failing to Disenroll Ineligible Dependents

Members must notify SFHSS within 30 days and cancel coverage for a dependent who becomes ineligible. If a member fails to notify SFHSS, the member may be held responsible for the costs of ineligible dependent health premiums and any medical service provided.