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
3. MARITAL STATUS
Married Single
5. PLAN ELECTIONS – Refer to the FlexCash Brochure for cash option election information.
Instructions for Completing Cash Option Elections
A. Cash in lieu of medical insurance
If you are electing the cash option in lieu of medical insurance, enter the
monthly cash amount in item A, otherwise enter “none.”
B. Cash in lieu of dental insurance
If you are electing the cash option in lieu of dental insurance, enter the
monthly cash amount in item B, otherwise enter “none.”
In Item C enter the total monthly cash option amount (sum of the
amounts entered in items A and B).
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.
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
B. Dental insurance carrier’s name
I underst
and 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 under
stand 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 Field” as defined in IRS Code Section 125 or other
permitting events.
I have r
ead and agree to the terms and conditions of the FlexCash Program as outlined on this form and in the FlexCash Brochure.
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7. Effective Date of Action
10. Permitting Event Code
11. Health Form Attached? (HBD12)
□ Yes □ No
12. Dental Form Attached? (STD 692)
□ Yes □ No
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:
*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
