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2021-2022 Kaiser Senior Advantage Plans Summary of Benefits & Coverage

Universal Benefit Enrollment Form – Retiree & Exceptional Processing

Universal Benefit Enrollment Form – Retiree & Exceptional Processing

*Retirees enrolling in a Kaiser Permanente Senior Advantage Plan must complete the Kaiser Permanente Senior Advantage Enrollment form (above) and mail to the address on the form. If you are changing your medical plan during open enrollment also complete the Universal Benefit Enrollment Form (above) and mail to the PCCD Benefits Office at the address on the form along with any required dependent documents if applicable. Remember to enclose a copy of the Kaiser Permanente Senior Advantage Form mailed directly to Kaiser.

2021-2022 Kaiser Senior Advantage HMO Delta Dental Plan Summary of Benefits & Coverage
PCCD Kaiser Permanente Reimbursement Form

Anthem PPO Traditional & PPO Lite
Self-funded Plans Administered by Trustmark

2021-2022 Summary of Benefits & Coverage

Click here for additional information

Universal Benefit Enrollment Form – Retiree & Exceptional Processing

*Retirees changing medical plans during open enrollment must complete the Universal Benefit Enrollment Form (above) and mail to the PCCD Benefits Office at the address on the form along with any required dependent documents if applicable. 

CASH IN-LIEU OF MEDICAL & DENTAL BENEFITS FORM

If you are an active employee waiving medical and dental benefits please uploaded the completed form with all required insurance verifications during your BenefitBridge online enrollment.

Dental / Vision / District-paid insurance

Additional Documents

Employee Assistance Program (EAP) Administered by MHN
Flexible Spending Medical and Dependent Day Care Expenses under IRS Code 125

*Open enrollment occurs annually November 1-30 for the following plan year (January – December).

CBIZ Open Enrollment 2021 Presentation

Current year forms & Documents:

CBIZ FSA – Transition Guide

CBIZ FSA Handbook

CBIZ FSA Enrollment Form

Flexible Spending SPD: 2014-spd-003

CBIZ FSA Claim-form

CBIZ Direct-deposit-authorization

CBIZ FSA Change in Status or Termination Form

My Plans by CBIZ Direct Deposit Instructions

CBIZ CONTACT INFORMATION

EMAIL: cbizflex@cbiz.com

TELEPHONE: 1-925-956-0514

Pre-tax Commuter Expense under IRS Code 132

CBIZ Open Enrollment 2021 Presentation

The maximum amount you may contribute to each account cannot exceed the maximum amount specified in Code Section 132(f).

 The maximum amounts are:

 Parking Expenses $280/month

Transportation Expenses $280/month (Public transportation/vanpool)

CBIZ COMMUTER – Transition Guide

CBIZ Pre-Tax Commuter Handbook

CBIZ Pre-Tax Commuter Enrollment Form

Pre-Tax Commuter SPD: peralta-132-doc

CBIZ PRE-TAX COMMUTER (PARKING ONLY) Claim-form

*CBIZ debit card must be used for eligible transit expenses starting 1/1/2021.

CBIZ Direct-deposit-authorization

My Plans by CBIZ Direct Deposit Instructions

CBIZ CONTACT INFORMATION

EMAIL: cbizflex@cbiz.com

TELEPHONE: 1-925-956-0514

Medicare Reimbursement Direct Deposit and Downloads

Medicare Reimbursement Direct Deposit

If you are currently receiving direct deposits from CBIZ for your Medicare Premium Reimbursements and are not registered online on the CBIZ platform, click on the link below. Once registered you will be able to manage your direct deposit information.

CBIZ Online Registration

 If you are already registered on the CBIZ platform and would like to update your direct deposit information you can click on the link below.

https://myplans.cbiz.com/

My Plans by CBIZ Direct Deposit Instructions

Medicare Downloads

Medicare A, B & D Premium Reimbursement Plan Summary Plan Description (SPD) 2015

Medicare-A-and-B-and-D-Premium-Claim-Form-Revised-11-24-21

Medicare Reimbursement Plan Policy Statement 10.2015

CBIZ Direct-deposit-authorization