Benefits Resource Library Current Plan Year
Plan Year July 1, 2021 – June 30, 2022
Important links
2021-2022 PCCD Employee Benefits Guide with Monthly Contribution Rate Matrix
Open Enrollment 2021-2022 Virtual Presentations, Videos & Materials
Registration and login online instructions for BenefitBridge
BenefitBridge Secure Enrollment Portal
PCCD Required Documentation Matrix
403 (b) & 457 (b) Plan Information
Medical Plans
Kaiser HMO Plans
2021-2022 Kaiser Traditional Plans Summary of Benefits & Coverage
Peralta-Community-College-Kaiser-HMO-10 SBC
Peralta-Community-College-Kaiser-HMO-15 SBC
Peralta-Community-College-Kaiser-HMO-0 SBC
Click here for additional information
2021-2022 Kaiser Senior Advantage Plans Summary of Benefits & Coverage
Peralta Community College 65 HMO $0 SR ADV Benefit Summary
Peralta Community College 65 HMO $10 SR ADV Benefit Summary
Peralta Community College 65 HMO $15 SR ADV Benefit Summary
Kaiser Permanente Senior Advantage (HMO) Enrollment Form
Click here for additional information
2021-2022 Kaiser Senior Advantage HMO Delta Dental Plan Summary of Benefits & Coverage
KPSA HMO Delta Dental Plan Summary
Universal Benefit Enrollment Form – Retiree & Exceptional Processing
Universal Benefit Enrollment Form – Retiree & Exceptional Processing
*Retirees enrolling in a Kaiser Permanente Senior Advantage Plan must complete the Kaiser Permanente Senior Advantage Enrollment form (above) and mail to the address on the form. If you are changing your medical plan during open enrollment also complete the Universal Benefit Enrollment Form (above) and mail to the PCCD Benefits Office at the address on the form along with any required dependent documents if applicable. Remember to enclose a copy of the Kaiser Permanente Senior Advantage Form mailed directly to Kaiser.
PCCD Kaiser Permanente Reimbursement Form
Anthem PPO Traditional & PPO Lite Self-funded Plans Administered by Trustmark
2021-2022 Summary of Benefits & Coverage
Peralta Self Funded Traditional PPO SBC $15 Plan (Local 1021 & Confidentials)
Peralta Self Funded Traditional PPO SBC $10 Plan (PFT, Management & Trustees)
Peralta Self Funded Traditional PPO SBC $15 Plan (Local 39)
Peralta Self Funded Lite PPO SBC $15 Plan (Local 1021 & Confidentials)
Peralta Self Funded Lite PPO SBC $10 Plan (PFT, Management & Trustees)
Peralta Self Funded Lite PPO SBC $15 Plan (Local 39)
Click here for additional information
Universal Benefit Enrollment Form – Retiree & Exceptional Processing
*Retirees changing medical plans during open enrollment must complete the Universal Benefit Enrollment Form (above) and mail to the PCCD Benefits Office at the address on the form along with any required dependent documents if applicable.
CASH IN-LIEU OF MEDICAL & DENTAL BENEFITS FORM
If you are an active employee waiving medical and dental benefits please uploaded the completed form with all required insurance verifications during your BenefitBridge online enrollment.
Dental
Dental PPO
Delta Dental PPO Plan – Plan Summary
Click here for additional information
UHC Dental DHMO – Direct Compensation Dental Plan
UHC DHMO – Direct Compensation Dental Plan Evidence of Coverage
UHC DHMO – Direct Compensation (DC) Contributory CA250/covered dental services CA D1065
Click here for additional information
Vision (Bundled With Medical Plans)
Kaiser Vision Plan & UHC Vision Plans – Benefits Summary
Voluntary Vision
VSP (Voluntary Vision) – Benefits Summary
Click here for additional information
District-Paid Life Insurance
District-Paid Disability Insurance
Long Term Disability Certificate
Employee Assistance Program (EAP) Administered by MHN
Click here for additional information
Flexible Spending Medical and Dependent Day Care Expenses under IRS Code 125
*Open enrollment occurs annually November 1-30 for the following plan year (January – December).
CBIZ Open Enrollment 2021 Presentation
Current year forms & Documents:
CBIZ FSA Handbook with Enrollment Form- 2021
Flexible Spending SPD: 2014-spd-003
CBIZ FSA Claim-form Plan Year 2021
CBIZ Direct-deposit-authorization
CBIZ FSA Change in Status or Termination Form
CBIZ CONTACT INFORMATION
EMAIL: cbizflex@cbiz.com
TELEPHONE: 1-925-956-0514
Pre-tax Commuter Expense under IRS Code 132
CBIZ Open Enrollment 2021 Presentation
The maximum amount you may contribute to each account cannot exceed the maximum amount specified in Code Section 132(f).
The maximum amounts are:
Parking Expenses $270/month
Transportation Expenses $270/month (Public transportation/vanpool)
CBIZ COMMUTER – Transition Guide
CBIZ Pre-Tax Commuter Handbook with Enrollment Form – 2021
Pre-Tax Commuter SPD: peralta-132-doc
CBIZ PRE-TAX COMMUTER (PARKING ONLY) Claim-form Plan Year 2021
*CBIZ debit card must be used for eligible transit expenses starting 1/1/2021.
CBIZ Direct-deposit-authorization
CBIZ CONTACT INFORMATION
EMAIL: cbizflex@cbiz.com
TELEPHONE: 1-925-956-0514
Medicare Downloads
Medicare A, B & D Premium Reimbursement Plan Summary Plan Description (SPD) 2015
Medicare-A-and-B-and-D-Premium-Claim-Form-Revised-11-24-20
Medicare Reimbursement Plan Policy Statement 10.2015
CBIZ Direct-deposit-authorization
For BenefitBridge technical assistance only, please contact BenefitBridge Customer Care at 800.814.1862;
Mon – Fri, 8:00 AM – 5:00 PM, PST or email benefitberidge@keenan.com
For assistance with your benefits questions, please contact the District, Benefits office at 510.466.7229;
Mon – Fri, 8:30 AM – 5:00 PM, PST or email benefits@peralta.edu
PDF files