10-08-2025, 08:40 AM
Form Completion
In cases of two married or two domestic partner State employees, where more than one employing department is involved and both employees are making changes in their medical and/or dental insurance for purposes of enrolling in FlexElect, the departmental Personnel Office staff with the employee enrolling in FlexElect, should assume the responsibility of coordinating all forms.
Health Benefits Enrollment (HBD-) or Health Benefit and Enrollment History page after confirmation from my|CalPERS and/or the Dental Plan Enrollment Authorization (STD. ) forms. All forms must be submitted as a package to SCO with the FlexElect job function email database Enrollment Forms(s) (STD. C and/or STD. R). In the event both employees enroll in FlexElect, one departmental Personnel Office should assume responsibility to coordinate all the enrollment documents and send them to the SCO as a package. When applicable include the spouse's or domestic partner's SSN on all forms.
![[Image: job-function-email-database-4.png]](https://i.postimg.cc/FRDXPVJk/job-function-email-database-4.png)
The Personnel Office is responsible for confirming with the employee the accuracy of all information provided on the FlexElect Enrollment Authorization forms.
STD C - Cash Option Enrollment Form
Instructions to assist employees in completing Sections - are contained in the FlexElect Handook on pages - The Personnel Office should review each enrollment form to ensure it has been completed correctly. The Personnel Office should then complete the remainder of the form, Sections - Specific instructions for completion of the document are outlined below:
Section - Enrollment: - If employees are:
enrolling during the annual enrollment period, check Item A.
enrolling as "newly eligible" (i.e. enrolling outside an open enrollment period due to a permitting event), check Item B.
changing their FlexElect enrollment because they have experienced a valid change in status event (permitting event), check Item C.
cancelling their enrollment as the result of a valid change in status event, check Item D.
Section - Cash Option:
Medical Coverage - If employees are electing to receive the Cash Option in lieu of their medical coverage, then enter $ in Item A. If they do not want to receive the cash and wish to keep their State-sponsored health plan, they must enter "N/A" in Item A.
Dental Coverage - If employees are electing to receive the Cash Option in lieu of their dental coverage, then enter $ in Item B. If they do not want to receive the cash and wish to keep their State-sponsored dental plan, they must enter "N/A" in Item B.
Total Cash - Employees enter the total Cash Option amount (sum of Items A & B) in Item C.
Section - SCO Use Only: Do Not Complete
Section - Statement of Other Medical and/or Dental Coverage: Must be completed when enrolling into a Cash Option.
Item A and/or B: Indicate the carrier name for the other medical and/or dental insurance.
Item C: Check the appropriate box showing through whom is the other coverage.
Item D: Complete this section only if the medical and/or dental insurance is through a parent, spouse or domestic partner. Indicate the parent, spouse's/domestic partner's social security number.
Section - Important Program Information and Employee Signature/Date: This section contains important information that employees should be aware of when enrolling in FlexElect. Their signature certifies they have other medical and/or dental coverage and they have read the information and agree to the terms and conditions of the Program as outlined on the Cash Option Enrollment Authorization (STD. C) and in the FlexElect Handbook.
Section - Effective Date of Action: The effective date of action during open enrollment is January For documents processed outside the open enrollment period refer to the effective date rule for the appropriate permitting event.
Section - Employee CBID: Indicate the employee's Collective Bargaining Designation and Unit.
Section - Permitting Event Date: Complete this section for newly eligible enrollments or allowable change requests due to a permitting event. The Permitting Event Date is the date when an employee experienced a valid change in status event (permitting event). Do not complete this area for open enrollment requests.
Section - Permitting Event Code: Indicate the appropriate code as provided on Appendix A of this manual. The Permitting Event Code refers to an allowable enrollment change during the plan year due to a valid change in status event (permitting event). Do not complete this section for open enrollment requests.
In cases of two married or two domestic partner State employees, where more than one employing department is involved and both employees are making changes in their medical and/or dental insurance for purposes of enrolling in FlexElect, the departmental Personnel Office staff with the employee enrolling in FlexElect, should assume the responsibility of coordinating all forms.
Health Benefits Enrollment (HBD-) or Health Benefit and Enrollment History page after confirmation from my|CalPERS and/or the Dental Plan Enrollment Authorization (STD. ) forms. All forms must be submitted as a package to SCO with the FlexElect job function email database Enrollment Forms(s) (STD. C and/or STD. R). In the event both employees enroll in FlexElect, one departmental Personnel Office should assume responsibility to coordinate all the enrollment documents and send them to the SCO as a package. When applicable include the spouse's or domestic partner's SSN on all forms.
The Personnel Office is responsible for confirming with the employee the accuracy of all information provided on the FlexElect Enrollment Authorization forms.
STD C - Cash Option Enrollment Form
Instructions to assist employees in completing Sections - are contained in the FlexElect Handook on pages - The Personnel Office should review each enrollment form to ensure it has been completed correctly. The Personnel Office should then complete the remainder of the form, Sections - Specific instructions for completion of the document are outlined below:
Section - Enrollment: - If employees are:
enrolling during the annual enrollment period, check Item A.
enrolling as "newly eligible" (i.e. enrolling outside an open enrollment period due to a permitting event), check Item B.
changing their FlexElect enrollment because they have experienced a valid change in status event (permitting event), check Item C.
cancelling their enrollment as the result of a valid change in status event, check Item D.
Section - Cash Option:
Medical Coverage - If employees are electing to receive the Cash Option in lieu of their medical coverage, then enter $ in Item A. If they do not want to receive the cash and wish to keep their State-sponsored health plan, they must enter "N/A" in Item A.
Dental Coverage - If employees are electing to receive the Cash Option in lieu of their dental coverage, then enter $ in Item B. If they do not want to receive the cash and wish to keep their State-sponsored dental plan, they must enter "N/A" in Item B.
Total Cash - Employees enter the total Cash Option amount (sum of Items A & B) in Item C.
Section - SCO Use Only: Do Not Complete
Section - Statement of Other Medical and/or Dental Coverage: Must be completed when enrolling into a Cash Option.
Item A and/or B: Indicate the carrier name for the other medical and/or dental insurance.
Item C: Check the appropriate box showing through whom is the other coverage.
Item D: Complete this section only if the medical and/or dental insurance is through a parent, spouse or domestic partner. Indicate the parent, spouse's/domestic partner's social security number.
Section - Important Program Information and Employee Signature/Date: This section contains important information that employees should be aware of when enrolling in FlexElect. Their signature certifies they have other medical and/or dental coverage and they have read the information and agree to the terms and conditions of the Program as outlined on the Cash Option Enrollment Authorization (STD. C) and in the FlexElect Handbook.
Section - Effective Date of Action: The effective date of action during open enrollment is January For documents processed outside the open enrollment period refer to the effective date rule for the appropriate permitting event.
Section - Employee CBID: Indicate the employee's Collective Bargaining Designation and Unit.
Section - Permitting Event Date: Complete this section for newly eligible enrollments or allowable change requests due to a permitting event. The Permitting Event Date is the date when an employee experienced a valid change in status event (permitting event). Do not complete this area for open enrollment requests.
Section - Permitting Event Code: Indicate the appropriate code as provided on Appendix A of this manual. The Permitting Event Code refers to an allowable enrollment change during the plan year due to a valid change in status event (permitting event). Do not complete this section for open enrollment requests.