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2. 
3. 2026 Benefits - Retiree Enrollment Election and Change Form

5. All retirees on Campbell County’s health plan must complete and sign a form for 2026 to select or waive benefits. All enrollment changes are effective January 1, 2026. 

   Submittal of this form replaces all other benefit elections made for 2025. 

   Allocations for benefits will be pulled from VRS in January 2026 for 2026 coverage. 

   All retirees must submit enrollment forms (through online link, email or hard copy) to the Campbell County Department of Management Services for processing by 5 p.m. on Friday, November 7.

    Payroll and Benefits, 47 Courthouse Lane - Suite 3,  Rustburg, VA 24588  

   payrollbenefits@campbellcountyva.gov 

   
   

7. Summaries of Benefits

   Anthem KeyCare HDHP with HSA/Vision

   
   

   Anthem's HealthKeepers Plan with HSA and Vision

   
   

   Anthem KeyCare - No HSA/No RX

   
   

   Anthem HealthKeepers - No HSA/No RX

   
   

   
   

   
   

   
   

   
   

9. 
13. First Name*
14. Last Name*
16. Address*
18. City*
19. State*
20. Zip Code*
22. Phone Number*
23. Cell Phone Number*
25. Email Address*
27. Section 1: Selection or Waiver of Health Benefits

    
    

    Please read all options below and check the box to reflect your choice.  Premiums are deducted monthly, starting in December for January 2025.  Please note that you must fill-out Section 3 to include any covered individuals on your plan.

29. Please select one option for 2026:

    1. Anthem's HDHP with HSA and Vision (KeyCare)
    2. Anthem's HealthKeepers Plan with HSA and Vision.
    3. Cancel/Waive Participation in Campbell County's Offered Health Benefits, effective December 31, 2025.
31. Section 2: Dependents on Plan

    Please list all depends, including yourself, covered by the plan. 

    Please note: A spouse or dependent not already covered by the plan cannot be added, unless confirmed as a new addition to the family.  

33. 1. Your Name*
34. Add or Drop*

    1. Add Health Coverage
    2. Drop Health Coverage
36. Your Birthday *
    Your Birthday

    Please enter the dependent's birthday.

37. Your Sex

    1. Male
    2. Female
39. Last Four Digits of Your Social Security Number *
41. 2. Spouse's Name:
42. Add or Drop

    1. Add Health Coverage
    2. Drop Health Coverage
44. Spouse's Birthday
    Spouse's Birthday
45. Spouse's Sex

    1. Male
    2. Female
47. Last Four Digits of Spouse's Social Security Number
49. 3. Child's Name
50. Add or Drop

    1. Add Health Coverage
    2. Drop Health Coverage
52. Child's Birthday
    Child's Birthday
53. Child's Sex

    1. Male
    2. Female
55. Last Four Digits of Child's Social Security Number
57. 4. Child's Name
58. Add or Drop

    1. Add Health Coverage
    2. Drop Health Coverage
60. Child's Birthday
    Child's Birthday
61. Child's Sex

    1. Male
    2. Female
63. Last Four Digits of Child's Social Security Number
65. Section 3: Health Savings Account

    Per federal IRS laws, you must meet all the following requirements to open/contribute to an HSA account:

    • Covered under a qualified high deductible health plan;
    • Not covered by any other health plan, including your spouse’s health insurance;
    • Not covered by spouse’s Medical Flexible Spending Account (FSA);
    • Not enrolled in any part of Medicare or Tricare;
    • Not claimed as a dependent on another person’s tax return. 

    PLEASE NOTE: If turning 65 in 2026, you must notify Payroll and Benefits staff at least 6 months prior to your 65th birthday. 

    The 2026 IRS Maximum Limits are as follows:

    Employee Only - $4,400

    Employee +1 - $8,750

    Employee +Family - $8,750

    Family - (Both spouses employed by County) - $8,750

    *If you are over age 55, an additional $1,000 may be contributed until your effective Medicare date.

67. Confirmation of Eligibility *

    1. I confirm that I meet federal eligibility standards for HSA participation and contributions.
    2. I do not meet federal eligibility standards for HSA participation and contributions.

    I understand my responsibility to ensure all IRS guidelines and applicable regulations are followed as it relates to my HSA account.  By checking the confirmation box I confirm that I meet all the criteria listed in this section.

    
    

      

69. Special Notice

    Please note: If you did not select benefits at the time of retirement, you are not eligible to participate in current plan offerings. 

71. Terms and Conditions

    By signing below I understand and agree to the following:

    I cannot change or revoke any of my elections or this compensation reduction agreement at any time during the plan year unless I have a qualified change in family status.

    The Plan Administrator/VRS may reduce or cancel my compensation reduction or otherwise modify this agreement in the event it advisable in order to satisfy certain provisions of the Internal Revenue Code;

    The reduction in my cash compensation under this agreement shall be in addition to any reductions under other agreements or benefit programs maintained by Campbell County/VRS. 

    It is my responsibility to contact Campbell County Management Services three months before becoming Medicare eligible.

    I give Campbell County permission to adjust payment of my insurance premiums through VRS, based on the plan I select. 

73. Section 4: RETIREE SIGNATURE and DATE

    I hereby authorize Campbell County to coordinate the necessary payments of premiums from my VRS account. I cannot change or revoke any of my elections at any time during the plan year unless I have a qualifying life event. Changes to HSA contributions for those under 65 are allowed at open enrollment and mid-year open enrollment in June to be effective July 1 of each year. 

    If canceling coverage, I certify I have been given the opportunity to continue coverage for myself and eligible dependents per Campbell County's handbook. I understand I am canceling enrollment for myself and, if applicable, my eligible dependents. 

75. Electronic Signature Agreement*

    By checking the "I agree" box below, you agree and acknowledge that 1) your submission will not be signed in the sense of a traditional paper document, 2) by signing in this alternate manner, you authorize your electronic signature to be valid and binding upon you to the same force and effect as a handwritten signature, and 3) you may still be required to provide a traditional signature at a later date.

    1. I agree.
77. Electronic Signature
Leave This Blank:


79. 1. Receive an email copy of this form.
80. Email address

    This field is not part of the form submission.

81. Submit

* indicates a required field