Human Resources

Benefit Forms

 

Santa Barbara County Employee Medical Plans

  • Blue Shield of California
  Enrollment Form  (use for all EPO/PPO and HDHP additions/deletions/changes)
  Declaration of Disability for Over Age Dependent Child Form
  Transition of Care Request Form
  •
Kaiser Permanente (Eligible Zip Codes Only) 
  Enrollment Form (use for all additions/deletions/changes)
  Zip Code Listing of Eligible Enrollment Areas

Sterling Health Savings Account (HSA)

  All changes have to be submitted through the County's eBenefits website BenXcel at https://www.benxcel.com/cosb.htm

Delta Dental Plans

  Delta Dental Enrollment/Status Change Form (Used for both DeltaCare USA DHMO & Delta Dental Self-funded DPPO)

Vision Plan (stand-alone plan)

  VSP Benefits
  VSP Enroll Form
  VSP Provider Finders
  VSP Claim Form (for non-VSP providers)

Medical & Dental Waiver and Combined Coverage Forms
  Waiver of Medical/Dental Coverage
  Combined Coverage (complete if both Spouse and Dependent are County employees) 

Status Change

  Qualifying Event - Change in Status Form
  Detailed Description of Qualifying Events per HIPAA Special Enrolment rules and IRS Section 125 
  Declaration of Domestic Partnership

Flexible Benefits Enrollment, Commuter Benefits and FSA Forms

  Direct Deposit Form (for FSA and Commuter Benefits)
  FSA Health and/or Dependent Care Reimbursement Form
  Additional Flex Debit Card Request Form
  Commuter Benefit Reimbursement Form
  Parking Only Expense Reimbursement Request Form
  FSA Dependent and Healthcare Enrollment form

VOYA Forms (including Wellness Benefit Reimbursement Form)

  Compass Critical Illness Enrollment Form
  Compass Accident Insurance Enrollment Form
  Wellness Benefit Reimbursement Claim Form
  To obtain any other claim form please visit www.voya.com. Once on the site please click "Contact and Services, then click "Claims" and then click "Claim Forms Library". Scroll down and find the form you are looking for.
  Group Name: County of Santa Barbara
  Group Policy Number: 684911
 

IRS requirements to make a change to your Benefit enrollment levels outside of Open Enrollment

Pursuant to Section 125 of the Internal Revenue Code, premiums paid by the employee for health, dental, and life insurance coverage are tax-exempt. The tax exemption applies only to premiums that are payroll deducted. For plans that provide the tax-exempt premium, the Internal Revenue Code prohibits changes in the employee's deduction during the plan year unless there is a qualifying change in status.  If the County of Santa Barbara is not in compliance, the plan could lose its qualification and/or employees could be subject to an IRS audit and be required to pay additional taxes and possible penalties. The Irrevocability Rule applies to both increases and decreases in coverage, such as adding or dropping dependents from the health coverage or increasing or decreasing employee life insurance coverage.

To make any changes to you Health and Other Benefit plans outside of Open Enrollment you need to experience a Qualifying Event which are described in detail in the following 2 documents:

 

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