Follow these 3 simple steps to enroll in the MBO:
Step 1. Complete the Modified Benefit Option (MBO) Election Form:
Supervising Attorney (to be used by Supervising Attorneys) OR
Nurse Supervisory and Management (to be used by employees in the Supervisory Nurses & Mgmt Unit) OR
Teamsters (except Nurse Supervisory-Management)
(MBO eligible classifications except Sup Nurses & Mgmt Unit)
Step 2. Choose your benefit options:
If you are satisfied with your current health plan, no other forms are needed other than the MBO Election form. If you want to make changes to your medical plan elections you will need to complete the following forms (as applicable).
Premium Deduction Election Form- Required if you chose to enroll in the MBO and are making changes to your medical insurance plan.
Medical Plan Enrollment/Change Form- Required if making changes to your medical insurance to any plan except Blue Shield Bronze PPO plan.
Essential Health Plan Coverage Enrollment /Change Form- (AKA Blue Shield Bronze PPO Plan)- Required if you chose to enroll in the MBO and enroll in the Blue Shield Bronze PPO Plan.
Step 3. Submit your forms
by 5pm on Friday, October 4, 2019
Send your completed forms to the Employee Benefits and Services Division (EBSD)
in one of the following ways:
In person: 157 W. 5th Street, First Floor, San Bernardino, CA 92415-0440
Scan and e-mail to: email@example.com
Interoffice mail to: Mail Code – 0440
Fax to: (909) 387-5566
If you have questions regarding this Special Open Enrollment period, please contact:
Jose Mancilla, Benefits Analyst at e-mail: Jose.Mancilla@hr.sbcounty.gov or phone: (909) 387-5578
Khristin Vargas, Benefits Analyst at e-mail: Khristin.Vargas@hr.sbcounty.gov or phone: (909) 387-5812
You may also contact the EBSD at e-mail: firstname.lastname@example.org or phone: (909) 387-5787