PLAN YEAR 2020 ENROLLMENT/CHANGE FORM
MEDICAL SPENDING CONVERSION (MSC)
HEALTH BENEFITS BUY-OUT WAIVER PROGRAM
(212) 306-7760 nyc.gov/fsa
Employee (Participant) return completed form to:
Agency Benets Oce, NYCAPS Central or HR Shared Ser-
vices Oce. See information in Section V and instructions on
reverse side.
INSTRUCTIONS:
Please review the MSC Health Benets Buy-Out Waiver section in the Flexible Spending Accounts (FSA) Program Brochure, which is on the
FSA website at nyc.gov/fsa. Also, see instructions on reverse side of this form before completing.
ENROLLMENT
(Check one):
q Open Enrollment (October 1 - November 15, 2019; eective January 1, 2020) Complete Sections I, II, and IV.
q Mid-Year Enrollment (January 1 - November 9, 2020; eective Qualifying Event date) Complete Sections I, II, III, and IV.
I. EMPLOYEE (PARTICIPANT) INFORMATION (Please Print)
LAST NAME FIRST NAME M.I. SOCIAL SECURITY NUMBER
HOME ADDRESS - NUMBER AND STREET APT
CITY STATE ZIP CODE + FOUR
-
HOME PHONE NUMBER WORK PHONE NUMBER MOBILE PHONE NUMBER E-MAIL
( ) - ( ) - ( ) -
AGENCY NAME (NOT DIVISION):CUNY AND H+H EMPLOYEES PLEASE SPECIFY THE NAME OF COLLEGE OR HOSPITAL
II. MSC HEALTH BENEFITS BUY-OUT WAIVER PROGRAM SECTION: If completing this section during mid-year, you must also complete Section III below.
A)
To participate in the Buy-Out Waiver Program, complete this form and a Health Benets Application. Return both forms to your agency’s Human Resources
Department/NYCAPS (if applicable) for approval and completion.
q I wish to participate in the Buy-Out Waiver Program. Check one
Non-City group health plan provider (company name)
q Individual Coverage ($500) q Domestic Partner/Civil Union Coverage ($500) q Family Coverage ($1,000)
Please note: You must attach proof of non-City group health coverage (letter or health insurance card).
B)
To terminate your participation in the Buy-Out Waiver Program, you must complete this form and a Health Benets Application for reinstating City health ben-
ets. Return both forms to your agency’s Human Resources Department/NYCAPS (if applicable) for approval and completion.
q I wish to withdraw from the Buy-Out Waiver Program.
III. MID-YEAR QUALIFYING EVENT: Newly eligible employees or current employees changing their status during mid-year must complete this section.
This is to certify that I incurred the Qualifying Event indicated below and, therefore, wish to modify my benets as indicated. I understand that the change(s)
requested must be consistent with the Qualifying Event and that I must submit this form with legal/supporting documentation of all changes to my agency’s Human
Resources Department/NYCAPS (if applicable) and they must be received by the MSC Administrative Oce within 30 days after the Qualifying Event to take eect.
Date of Qualifying Event: / / 2020 Today’s Date: / / 2020
If Today’s Date is more than 30 days from the Date of Qualifying Event, please note that you are not eligible for Plan Year 2020.
Please check one of the following:
Employment Status: Documentation must be provided by employer/agency Family Status Change: Legal documentation must be provided by participant
q Beginning/termination of employment (q self q spouse)
q Unpaid leave of absence (q self q spouse)
q Return from unpaid leave of absence (q self q spouse)
q Change from P/T to F/T employment or vice versa (q self q spouse)
q Increase in health plan deductions by more than 20%
q Marriage/domestic partner
q Birth or adoption of child
q Divorce
q Ineligibility of dependent (q age q marriage)
IV. Employee Signature
I have read the MSC Program materials and instructions and I attest that I meet the qualications to enroll or withdraw from the MSC Health Benets Buy-Out
Waiver Program.
Signature:__________________________________________________________________________________________________ Date: _____/ _____/____
V. FOR COMPLETION BY EMPLOYING AGENCY’S HUMAN RESOURCES DEPARTMENT/NYCAPS/HR SHARED PERSONNEL ONLY:
Please review the above information and submitted documentation from employee before completing the information below.
Note to Benets/Payroll/NYCAPS/HR Shared Ocer: Send this MSC Form and the Health Benets Application, along with any legal/supporting documentation,
to: MSC Administrative Oce, Bowling Green Station, P.O. Box 707, New York, NY 10274. You should retain a copy of this form for your records.
If your agency is a centralized agency - send directly to: NYCAPS Central, 1 Centre Street, New York, NY 10006
DOE Employee/Payroll/Secretary - send directly to: DOE MSC Unit, 65 Court Street, Rm. 406, Brooklyn, NY 11201
H+H Centralized Agency - send directly to: H.R. Shared Services, 55 Water Street, 26
th
Floor, New York, NY 10041
1) For the Health Benets Buy-Out Waiver Program (Section II), I have reviewed and processed the Health Benets Application and certify that the employee
has listed a non-City group health insurance policy under which he/she is covered. I have notied the appropriate health insurance carrier of this change.
2) For mid-year changes, I certify that a Qualifying Event listed in Section III has occurred within 30 days after this request and this form, along with legal/
supporting documentation, have been submitted.
Employee’s Agency Appointment Date: / / Eective Date of Health Benets: / /
A)
MSC Buy-Out Waiver Eective Date: (Check one)
q Open Enrollment: (October 1 - November 15, 2019: eective January 1, 2020)
q Mid-Year Enrollment: / / 2020 (January 1, 2020 - November 9, 2020)
(June 1- June 30, eective July 1, 2020) (December 1- December 31, eective January 1, 2021)
B)
MSC Buy-Out Waiver Withdrawal Date: (Check one)
q Open Enrollment: (October 1 - November 15, 2019: eective January 1, 2020)
q Mid-Year Withdrawal: / / 2020 (January 1, 2020 - November 9, 2020)
AGENCY BENEFITS MANAGER/NYCAPS/HR SHARED PERSONNEL SIGNATURE EFFECTIVE DATE WORK PHONE NUMBER
/ / ( ) -
EMPLOYEE AGENCY CODE CUNY STATE I.D. NUMBER E-MAIL ADDRESS
MSC ADMINISTRATIVE OFFICE USE ONLY
ENROLLMENT EFFECTIVE DATE WITHDRAWAL EFFECTIVE DATE PROCESSING DATE PROCESSOR AGENCY PAYROLL CODE
/ / / / / /
J:FSA\PLYR2019\MSC\MSC_FORM_2018.INDD 9/19 1K
Reset Fields
Print Form
MEDICAL SPENDING CONVERSION (MSC)
PLAN YEAR 2020
INSTRUCTIONS:
HEALTH BENEFITS BUY-OUT WAIVER PROGRAM - SECTION II:
TheMedicalSpendingConversion(MSC)HealthBenetsBuy-OutWaiverProgramallowsyoutoreceiveanincentive
paymentforwaivingyourCityhealthbenets.RefertotheMSCHealthBenetsBuy-OutWaiverProgramsectioninthe
FlexibleSpendingAccountsProgramBrochurefordetailedinformation.
A. Enrolling:
Please Note: TheInternalRevenueServicedoesnotpermitanyretroactiveparticipationfromapreviousPlanYear.
Ifyouarecoveredunderyourspouse’s/domesticpartner’sorparent(s)’non-Citygrouphealthinsurance,oragrouphealth
planavailablethroughotheremployment,youmaywaiveNewYorkCityhealthbenets.Onceyourenrollmentformhas
beenprocessedandapproved,youwillreceiveaconrmationletterfromtheMSCAdministrativeOce.Pleasecontact
youragency’sHumanResourcesDepartment/NYCAPS/HRSharedpersonnelifyoudonotreceiveaconrmationletter.
Currentemployees:YoumayenrollintheProgramduringtheOpenEnrollmentPeriod(October1,2019-November15,
2019) foraneectivedateofJanuary1,2020.YoumustcompleteSectionsI,II,andIV.SectionVistobecompleted
byyouragency’sHumanResourcesDepartment/NYCAPS/HRSharedpersonnel.
Newlyeligibleemployees:YoumayenrollintheProgramwithinthirty(30)daysafterbecomingeligibleforCityhealth
benets.YoumustcompleteSectionsI,II,III,andIV.SectionVistobecompletedbyyouragency’sHumanResources
Department/NYCAPS/HRSharedpersonnel.
Duringmid-year:IfyouincuraQualifyingEvent,youmustnotifytheMSCProgramAdministrativeOcewithinthirty
(30)daysaftertheQualifyingEventinordertoparticipate.YoumustcompleteSectionsI,II,III,andIVandattachlegal/
supportingdocumentation.SectionVistobecompletedbyyouragency’sHumanResourcesDepartment/NYCAPS/HR
Sharedpersonnel.
AnyMSCFormreceivedinJunewillbeeectiveJuly1
st
ofthatPlanYear.AnyMSCFormreceivedinDecemberwillbe
eectiveJanuary1
st
ofthefollowingPlanYear.
BysigningtheMSCHealthBenetsBuy-OutWaiverProgramEnrollment/ChangeForm,youelecttoreceive$1,000(family
coveragewaived),$500(individualcoveragewaived),or$500(domesticpartner/civilunioncoveragewaived)annually
inlieuofNewYorkCityhealthbenets.Youwillreceive$500forfamilycoverage,$250forindividualcoverage,or$250
fordomesticpartner/civilunioncoveragewaivedattheendofeverysix-monthcalendarperiod.Pleasenotethatsame
sexmarriagewillbetreatedasfamilycoverage(This amount will be pro-rated for any period less than six months
by the number of days you are in the Health Benets Buy-Out Waiver Program.)
AnemployeeparticipatingintheCity’sDeferredCompensationPlan(DCP)inlieuofFICAandparticipatingintheHealth
BenefitsBuy-OutWaiverProgram(taxableincome),mayneedtoincreasehis/hersalarydeferralpercentagetoanamount
higherthan7.5%ofannualsalaryinordertoaccountfortheincreaseinincomeduetothe“Buy-OutWaiverIncentive
Payment.”Ifthe7.5%oftotalsalaryincomerequirementisnotmet,theparticipantwhoisenrolledintheDCPmayhave
tocontinuetopayFICAtaxesuntilthatrequirementismet.
B. Terminating:
YourwaiverwillremainineectduringthePlanYearunlessa)youexperienceanapprovedmid-yearQualifyingEventor,
b)youreinstateyourCityhealthcoverageduringtheHealthBenetsProgramFallTransferPeriod.Duringthemid-year,
yourformmustbereceivedbytheMSCAdministrativeOcewithinthirty(30)daysaftertheQualifyingEventinorderfor
thechangetobeeective.IfyouarereturningfromanapprovedleaveofabsenceortransferringtoanewCityagency,
youmustcompletetheMSCHealthBenetsBuy-OutWaiverProgramEnrollment/ChangeFormandtheHealthBenets
Applicationwithinthirty(30)daysaftersucheventtobereinstated,ortoreceiveapro-ratedincentivepayment.
IfyouwishtoterminateyourparticipationintheHealthBenetsBuy-OutWaiverProgramandreinstateyourCityhealth
benetscoverage,completeSectionII,byindicatingyourrequestedchange.Ifyouareterminatingyourparticipation
mid-year,youmustalsocompleteSectionIII.
Please Note:IfyouwaiveCityhealthcoverage,youmusthaveothernon-Citygrouphealthcoverageavailabletoyou.
TheHealthBenetsApplicationmustaccompanythisMSCFormsothatyouragency’sbenets/payrollmanagerisable
toverifythatyouhaveothercoverage.Youragency’sHumanResourcesDepartment/NYCAPS/HRSharedpersonnel
mayrequestadditionaldocumentation.
ThisformisnotvalidifyouhavenotcompletedSectionsI,II,III(formid-yearQualifyingEvent)andIV.
ThisformisnotvalidifSectionVhasnotbeencompletedbyyouragency’sHumanResourcesDepartment/NYCAPS/HRShared
personnel.
Please return the completed form and documentation to:
Ifyouragencyisanon-centralizedagency-senddirectlytoyouragencybenetsoce.
Ifyouragencyisacentralizedagency-senddirectlyto:NYCAPSCentral,1CentreStreet,NewYork,NY10007.
DOEEmployee/Payroll/Secretary-senddirectlyto:DOEMSCUnit,65CourtStreet,Rm.406,Brooklyn,NY11201.
H+HCentralizedAgency-senddirectlyto:H.R.SharedServices,55WaterStreet,26
th
Floor,NewYork,NY10041.