Associate Faculty Medical Insurance
The medical enrollment period for the Associate Faculty Medical Benefits Program (AMBP) happens twice per year in September and March.
You must re-confirm your enrollment during every enrollment period by submitting the Declaration of Eligibility form to Human Resources.
The current enrollment period is happening now (March 1 to March 31, 2022) and the medical insurance starts 4/1/22 and lasts until 9/30/22. If you resign your position or retire, then your medical insurance ends at the end of the month that you last work. All forms and required documents are due to Human Resources by 5 p.m. on March 31, 2022.
The forms on this page are all fillable and signable electronically. Once you've opened the form, please click "Download" and "Save" to access the signable version.
Eligibility requirements for those CONTINUING their medical insurance in Spring 2022:
Due to the covid side letter dated 10/28/21, Associate Faculty members who are currently participating in the Associate Faculty Medical Benefits Program (AMBP) will maintain eligibility for the program even if the faculty member's load drops below the 40% threshold required by the state-funded program. In order to continue to be eligible to receive medical insurance, associate faculty members must have an assignment in the District or be on an approved leave during the Spring 2022 enrollment period.
CLICK HERE for the Declaration of Eligibility form to complete if you are continuing your Associate Faculty medical insurance.
All enrollees must submit this semester’s Declaration of Eligibility Form to Human Resources by 3/31/2022 or your current medical insurance will end 3/31/2022.
Eligibility requirements for NEW enrollees in Spring 2022:
- You must be employed by SRJC as an Associate Faculty member and have a cumulative assignment of 40% or greater from all California Community College Districts for which you work. 20% of that must be from SRJC.
- No portion of your medical benefits premium is paid by any other employer, or by any employer of your spouse or domestic partner, or by any businesses owned by yourself, spouse or domestic partner, including another California Community College District.
- You do not receive reimbursement for retirement medical benefits or stipends, from any source.
- You do not receive a payment in lieu of medical benefits from another employer, nor does your spouse or domestic partner from any of their employers.
CLICK HERE for more information about the Associate Faculty Medical Benefits Program such as eligibility requirements, types of medical plans that are offered and the required forms to complete if you are enrolling for the first time.
Medical Plan Offerings
The District offers a choice of five medical plans through our membership in Self-Insured Schools of California (SISC). Please click on the links below to view the Benefit Summaries of these five plans:
- Kaiser Permanente HMO
- Kaiser Permanente Account Based Health Plan with a Health Savings Account (HSA). This is a deductible plan.
- Blue Shield of California HMO
- Blue Shield of California PPO
- Blue Shield of California Account Based Health Plan with a Health Savings Account (HSA). This is a PPO deductible plan.
New! Please click below for plan features and member benefits for:
Medical Plan Rates
Your portion of the monthly medical premium will come out of your paycheck.
Enrollment Form Instructions
All enrollment forms should be submitted to Christie Colón in Human Resources
- Blue Shield Enrollment Form – use this form to enroll for the first time and follow these instructions:
* Blue Shield PPO or HSA – you must write HSA or PPO in the top margin on the enrollment form
**Blue Shield HMO – you must select a doctor when enrolling in this plan and include the doctor's IPA & PCP numbers on the enrollment form:
IPA is the Group Name
PCP is the Primary Care Physician #
Here’s how to search on Blue Shield's website for that information and to select a Blue Shield HMO doctor in your area:
Click on “Primary Care Physician”
Type in your location
Select Specialty, like “Family Practice”, “Internal Medicine”, etc.
- Kaiser Enrollment Form – use this form to enroll for the first time and follow these instructions:
* Be sure to check HMO or Deductible plan in Section A on enrollment form
- Membership Change Form - making changes to your current medical plan (like adding or deleting a dependent)? Please fill out the Membership Change form and include the required dependent documentation.
- Premium Payment Voucher – use this form to pay for your medical insurance during a month that you don’t have a paycheck, like during the summer.
- Verification of Teaching Load - If you are working at least 40% load at SRJC, you don’t need to complete this form. You only need your other college to complete this form if you have less than a 40% load at SRJC, but are working at least 20% at SRJC and the other % at another California Community College during Spring 2022 as long as the total % equals 40%.
REQUIRED DEPENDENT DOCUMENTS
To enroll a spouse:
• Copy of your Marriage Certificate
• Copy of page 1 of your most recent 1040 Federal Tax Return that shows Married filing status
To enroll a domestic partner:
• Copy of the State of California Certificate of Registration of Domestic Partnership
• Copy of page 1 of both partner’s most recent 1040 Federal Tax Returns
To enroll a child:
• Copy of birth certificates for children up to age 26. OR, if child is adopted or you are the legal guardian: legal adoption documentation. If you have legal guardianship or legal court documentation establishing guardianship the child can be covered up to age 18.
Dependents can be enrolled at your time of hire or within 30 days after experiencing a qualifying event.