Flexible Benefits Program Enrollment And Change Form
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County of Ventura Human Resources/Benefits
Flexible Benefits Program
800 S. Victoria Ave., #1970, Ventura, CA 93009-1970
(805) 654-2570 ∙ FAX (805) 654-2665
Enrollment & Change Form
Email:
Intranet:
Plan Year 2016
Internet:
Type of Enrollment
Instructions: After completion, please return this form, along
New Enrollment
with any required back-up documentation, to your
Add Dependent/Date & Reason
agency/department’s Benefits Representative.
Cancel Dependent/Date & Reason
Other
1.
Employee Data
(please print)
NAME (LAST, FIRST, M.I.)
EMPLOYEE ID NUMBER
SOCIAL SECURITY NUMBER
DATE OF BIRTH
ADDRESS (NUMBER & STREET)
CITY
STATE
ZIP CODE
HOME PHONE
WORK PHONE
GENDER (M/F)
HIRE DATE
AGENCY/DEPARTMENT NAME
BARGAINING UNIT
EMAIL ADDRESS
2. Medical Plan Coverage
(pre-tax composite rates; see last page of this form for your biweekly flexible credit amount)
Ventura County Health Care Plan HMO ($352.95/biweek)
UnitedHealthcare HMO – Network 1 ($540.08/biweek)
UnitedHealthcare HMO – Network 2 ($696.94/biweek)
UnitedHealthcare HMO – Network 3 ($813.40/biweek)
UnitedHealthcare High Deductible Health Plan/PPO ($652.54/biweek)
Medical Plan Opt Out - must submit Opt Out Certification Form with proof of eligibility ($214.38/biweek)
VCDSA Only (supplemental enrollment forms must be submitted to VCDSA):
VCDSA Ventura County Health Care Plan ($351.91/biweek)
VCDSA Kaiser HMO ($398.64/biweek)
VCDSA Anthem Blue Cross HMO ($622.48/biweek)
VCDSA Kaiser CDHP ($244.41/biweek)
VCDSA Anthem Blue Cross PPO/HRA ($1,155.57/biweek)
Medical Plan Opt Out - must submit Opt Out Certification
Form with proof of eligibility ($214.38/biweek)
VCDSA Anthem Blue Cross CDHP ($473.00/biweek)
VCPFA Only (supplemental enrollment forms must be submitted to VCPFA):
VCPFA UnitedHealthcare HMO High ($518.41/biweek)
VCPFA UnitedHealthcare HMO Low ($406.48/biweek)
VCPFA UnitedHealthcare PPO ($887.13/biweek)
VCPFA UnitedHealthcare HDHP/PPO ($600.89/biweek)
VCPFA UnitedHealthcare HMO Bronze (EE Only = $136.50/biweek, EE + 1 = $306.72/biweek, EE + 2 or more = $446.27/biweek)
Medical Plan Opt Out - must submit Opt Out Certification Form with proof of eligibility ($214.38/biweek)
3. Dental Plan Coverage
(pre-tax tiered rates)
MetLife Dental PPO (EE only = $19.40/biweek, EE + 1 = $36.98/biweek, EE + 2 or more = $55.93/biweek)
4. Vision Plan Coverage
(pre-tax)
MES Vision ($4.60/biweek)
5. Flexible Spending Accounts
(pre-tax; annual re-election is required)
Health Care Account (not available if enrolled or enrolling in a High Deductible Health Plan):
I elect a Health Care Flexible Spending Account with a semi-monthly pledge of $
($10.00 - $106.25/semi-monthly).
I understand that annual re-election is necessary if I wish to participate in future plan years.
Dependent Care Account:
I elect a Dependent Care Flexible Spending Account with a semi-monthly pledge of $
($10.00 - $208.33/semi-monthly).
I understand that annual re-election is necessary if I wish to participate in future plan years.
PY 2016 – revised 10/23/15
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