District Benefits: Administrators, CMS Employees & Trustees
Note: If you need to make changes to your health plan due to a qualifying event please contact Jim Firth, Human Resources Technician Benefits at ext. 6101 or email@example.com.
2020/2021 Online Open Enrollment:
Your Open Enrollment window is August 8, through August 25.
We are encouraging every employee to use the new online Open Enrollment Form this year. This form is a quick and easy way for you to select your benefits for the 2020/2021 benefit year. Most employees will not need to submit other documentation.
Health Plan Election Form:
- 2020-2021 CMSA Health Plan Election Form
- 2020-2021 CMSA Couples Rate Health Plan Election Form: Both spouses or Domestic Partners must be on SISC Composite rates to qualify.
- For your reference only: 2019-2020 CMSA Health Plan Election Form
- SISC Membership Change Form
- SISC III Enrollment Form
- SISC Kaiser Enrollment Form
- SISC WABE Waiver of Coverage Form
- SISC Digital Signature Instructions
- SISC HIPPA Notice of Privacy
- SISC Cobra Notice
- Notice: Medical Insurance Benefits provided to Domestic Partners as Taxable Income
- Domestic Partnership Affidavit Termination
CMSA SISC Health Matrix:
CMSA Benefit Plans:
- Blue Shield PPO: P021000: 100-A 20 Rx 7-25
- Blue Shield PPO: P041000: 100-C 20 Rx 200/10-35
- Blue Shield PPO: P011000: 90-C 20 Rx 9-35
- Blue Shield PPO: P031000: 80-G 30 Rx 9-35
- Kaiser HMO: 225543-0845 - OV 10 Rx 10
- Kaiser HMO: 225543-1017 - OV 30 Rx 10-30
- Navitus Plan Information
- Delta Dental: 7079 1390: DD 2000; C 100/1500
- VSP: 2978534A: Signature Plan C 0
- Mutual Of Omaha Group Life Insurance: G000AMP6-A001: Term and AD&D