Follow these 3 simple steps to enroll in the MBO:
Step 1. Complete the Modified Benefit Option (MBO) Election Form
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.
FSA Enrollment Form- If you chose the Blue Shield Bronze PPO plan, you may also enroll in the FSA plan to receive your County match by completing the FSA Enrollment Form.
Step 3. Submit your forms
by 5pm on Friday, March 29, 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: firstname.lastname@example.org
Interoffice mail to: Mail Code – 0440
Fax to: (909) 387-5566
If you have questions regarding this Special Open Enrollment period, please contact:
Karama Roberson, Benefits Analyst at e-mail: KaramaN.Roberson@hr.sbcounty.gov or phone: (909) 387-5578
Sara Girgis, Benefits Analyst at e-mail: Sara.Girgis@hr.sbcounty.gov or phone: (909) 387-5856
You may also contact the EBSD at e-mail: email@example.com or phone: (909) 387-5787