SISC Medicare-Eligible Retiree Benefits

Auxiliary, Classified, Confidential, Management

Welcome to the retiree benefits page for Medicare-eligible (65+) employees. Here you will find information about the health and wellness benefits available to you in retirement. Our goal is to help you navigate your options and make informed choices that support your well-being in this new chapter of life.

When a retiree or spouse or registered domestic partner of record becomes eligible for Medicare, the eligible person must apply for Medicare Part A and B prior to the month they turn 65. Failure to enroll in Medicare Part A and B and provide Human Resources proof of enrollment prior to the month they turn 65 may be billed a surcharge in the amount of $1,250 per month until proof of enrollment is received.

Open Enrollment Period: July 1, 2026 - August 1, 2026

Open Enrollment is your annual opportunity to review your current benefit elections and make changes to your medical, dental, and vision coverage for the upcoming plan year. Any changes made during Open Enrollment will be effective October 1, 2026.

Outside of the open enrollment period, changes to an election plan can only be made if an employee experiences a qualifying life event. The employee must notify the Benefits Department at HRbenefits@mtsac.edu within 30 days of the life event date.

Key Enrollment Information

If you take no action during the open enrollment period, your current enrollment will remain in effect; however, the new premium rates will apply.
If you would like to make a change to your current medical, dental, and/or vision plans during the open enrollment period, you may do so either by completing and submitting the information described below.
If you are newly enrolling a dependent in your benefit plans, you must provide proof of dependent eligibility (Filed tax return showing joint filing for spouse or domestic partner).

Enrollment Change Process

Schedule an appointment with Jose Garcia, Benefits Specialist.
- Online: book an appointment
- Email: jf.garcia@mtsac.edu
- Phone: 909-274-4119
Complete the Mt. SAC Election Form and Carrier Enrollment Form (available below under Medical Plans and Election Forms)
Submit forms and dependent documentation (if applicable) to Human Resources:
- Email: hrbenefits@mtsac.edu or jf.garcia@mtsac.edu
- Mail:
  - Mt. San Antonio College Attention: Human Resources
  - 1100 N. Grand Avenue
  - Walnut, CA 91789

Medical Plans and Election Forms

Mt. SAC Election Form

All benefit enrollment changes begin with the completion of the required Mt. SAC Retiree Election Form. This form initiates your request. Depending on the type of change, you may also be required to complete the applicable insurance carrier enrollment form before your request can be processed.

2026-2027 Retiree Plan Election Form: Medicare Eligible

HMO Medical Plans

Carrier	Benefit Plan Summaries	Enrollment Form
Kaiser	Kaiser Permanente Senior Advantage $15 (1 person with Medicare) (2025-26) Kaiser Permanente Senior Advantage $0 (1 person with Medicare) - Classified Only (2025-26) Kaiser Permanente Senior Advantage $10 (2 persons with Medicare) (2025-26)	Kaiser Permanente Senior Advantage Enrollment Form
Blue Shield	Blue Shield of California 65 (HMO) $10 Blue Shield 65 Plus (HMO) Medicare Advantage $20 (2025-26)	Enrollment Request For Blue Shield 65 (HMO) Employer Group Enrollment Form SISC III Enrollment Form for Blue Shield HMO Full Network

PPO Medical Plans

Carrier	Benefit Plan Summaries	Enrollment Form
Blue Shield	Blue Shield - Employer Group Waiver Plan (EGWP) 100A ($0; Rx 0-20) (2025-26) Companion Care - Medicare Supplement (2025-26)	SISC CompanionCare/PPO EGWP Rx Enrollment Form

Prescription Coverage

Navitus Medicare Rx Information

HIPAA Privacy Notice

HIPAA Notice of Privacy Practices

Dental Plans (Optional)
HMO Dental Plan
- Delta Care HMO
PPO Dental Plans
- Delta Dental 1500
- Delta Dental Incentive Unlimited
Vision Plan (Optional)
- VSP Signature Plan C $0
Additional Forms
- Dependent Eligibility Documentation Checklist

Gym Discount Programs:

Sliver & Fit Program – Blue Shield Companion Care, Blue Shield Medicare Advantage
Fitness Your Way by Tivity Health – Blue Shield 100A EGWP
Medicare Members One Pass - Kaiser Permanente Senior Advantage 65+