THE CALIFORNIA STATE UNIVERSITY FLEXCASH PROGRAM ENROLLMENT AUTHORIZATION
Please type or use ball point pen, print clearly. Return completed form to campus Benefits Officer.
SEE PRIVACY NOTICE ON REVERSE OF EMPLOYEE COPY
1. TYPE OF ENROLLMENT (
Check appropriate box)
ANNUAL/OPEN ENROLLMENT NEWLY
NEWLY ELIGIBLE ENROLLMENT
CHANGE DUE TO PERMITTING EVENT
CANCELLATION
2. SOCIAL SECURITY NO.
3. MARITAL STATUS
Married Single
4. NAME
(first)
(initial)
(last)
5. PLAN ELECTIONS Refer to the FlexCash Brochure for cash option election information.
Cash Option Type
Monthly Payment
A. Cash in lieu of medical insurance
$
B. Cash in lieu of dental insurance
$
C. Plan Code 381-001
Monthly Total
$
6. ATTESTATION OF OTHER QUALIFYING GROUP HEALTH COVERAGE
This section must be completed if you choose cash instead of your own CSU medical and/or dental insurance plans.
I certify that I am covered by another qualifying group health plan that conforms to the Affordable Care Act’s (ACA’s) minimum value standards (see next
page). I certify that I will maintain coverage in a quali fyin g gro up health plan on an ongoing basis and I agree to notify my campus Benefits Officer
within 60 days if I lose coverage under the medical and/or dental insurance plan(s). I understand than an individual health insurance policy (for example,
from Covered California or another insurance marketplace) and coverage under Tricare, Medicare and Medi-Cal are not qualifying group health plan
coverage for purposes of the FlexCash Benefit Program.
Alternative Coverage
Complete this section ONLY if your “other” non-CSU medical and/or
dental insurance coverage is through your spouse’s (or domestic
partner’s*) plan(s).
Spouse’s (or domestic partner’s*) SSN:
A. Medical insurance carrier’s name
Policy Number
B. Dental insurance carrier’s name
Policy Number
I understand
that my FlexCash election in lieu of Health Coverage will continue from year to year until I take action to change or cancel my enrollment.
I understand that my benefit elections are regulated under Section 125 of the Internal Revenue Service (IRS) Code. I understand that regulations under the IRS Code require that my
benefit choices authorized by this election are irrevocable until the next scheduled open enrollment unless I have a valid “Change in Status Eventas defined in IRS Code Section
125 or other permitting events.
I have rea
d and agree to the terms and conditions of the FlexCash Program as outlined on this form and in the FlexCash Brochure.
Employee’s Signature:
Date Signed:
FOR CAMPUS USE ONLY
7. Effective Date of Action
8. Employee CBID
9. Permitting Event Date
10. Permitting Event Code
Mo
Day
-1-
Year
Mo
Day
Year
11. Health Form Attached? (HBD12)
Yes No
12. Dental Form Attached? (STD 692)
Yes No
13. Agency Code
14. Unit Code
15. Campus Name
16. Remarks:
17. Authorized Campus Signature
I hereby certify under penalty of perjury as follows: That I am the duly appointed,
qualified
and acting officer of the herein named agency and that I am authorized to
make this
certification; that the employee named herein is eligible for enrollment in
the CSU FlexCash
Program.
Signature:
18. E-MAIL ADDRESS OF AUTHORIZED CAMPUS BENEFITS OFFICER SIGNER:
19. Date Received:
20. Telephone Number:
*Employees who obtain “alternative non-CSU coverage through a domestic partner are not required to submit proof of registration through the Secretary of State process to
enroll in the
FlexCash Program.
DISTRIBUTION: ORIGINAL - State Controller’s Office COPY Campus COPY- Employee (with privacy notice)
Revised October 2015
Print
Clear Form
01
2019
Select
09
10
2019
Select
213
Fresno State University
lphelps@csufresno.edu
(559) 278-2032
The Affordable Care Act (ACA) establishes a minimum value standard of a benefits of health plan. For a qualifying
group health plan to meet the ACA’s minimum value standards, the plan must cover at least 60 percent of the total
allowed costs of benefits provided under the plan. Employees may refer to their plan’s Summary of Benefits and
Coverage document to determine if their coverage meets the law’s minimum value standards. For more information on
qualifying group coverage refer to the FlexCash brochure located on CSU’s website at http://calstate.edu/Benefits/
flexible/tapp.page.shtml.
PRIVACY NOTICE
The Information Practice Act of 1977 (Civil Code Section 1798.17) and the
Federal
Privacy Act (Public Law 93-579) require that this notice be provided
when collecting
personal information from individuals.
Information requested on this form is used by the State Controller’s Office and
the
program administrator for the purposes of identification and account
processing.
It is mandatory to furnish all information requested on this form except for marital
status,
which may be furnished on a voluntary basis. Failure to provide the
mandatory information
may result in the enrollment elections not being processed or being processed incorrectly.
The State Controller’s Office requires the employee’s social security number and
name for
identification purposes. Legal references authorizing maintenance of this information
include Government Code Sections 1151 and 1153, Sections
6011 and 6051 of the
Internal Revenue Code, and Regulation 4, Section
404.1256, Code of Federal
Regulations, under Section 218, Title II of the Social
Security Act.
Copies of the FlexCash Enrollment Authorization are maintained in confidential
files of the
State Controller’s Office for five years. Employees have the right of access to copies of
their Enrollment Authorization forms upon request. The
official responsible for the
maintenance of the forms is: Chief of Personnel/Payroll Services Division, State
Controller’s Office, Post Office Box
94250, Sacramento, California 94250-5878.