PLAN YEAR 2022 ENROLLMENT/CHANGE FORM
MEDICAL SPENDING CONVERSION (MSC)
HEALTH BENEFITS BUY-OUT WAIVER PROGRAM
nyc.gov/fsa
Employee (Participant) return completed form to:
Agency Benets Oce, NYCAPS Central or HR Shared
Services Oce. See instructions on reverse side.
INSTRUCTIONS:
Please review the MSC Health Benets 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 12 - November 19, 2021; eective January 1, 2022) Complete Sections I, II, and IV.
q Mid-Year Enrollment (January 1 - November 11, 2021; eective 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 EMPLOYEES PLEASE SPECIFY THE NAME OF COLLEGE
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 Benets Application or submit through ESS. 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 Benets Application, or submit through ESS, for
reinstating City health benets. 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 benets 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 Oce within 30 days after the Qualifying Event to take eect.
Date of Qualifying Event: / / 2022 Today’s Date: / / 2022
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 2022.
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 qualications to enroll or withdraw from the MSC Health Benets 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 Benets/Payroll/NYCAPS/HR Shared Ocer:
• Send this MSC Form and the Health Benets Application, along with any legal/supporting documentation, electronically to: https://nyc-fsa.leaple.net
• You should retain a copy of this form for your records.
1) For the Health Benets Buy-Out Waiver Program (Section II), I have reviewed and processed the Health Benets Application and certify that the employee
has listed a non-City group health insurance policy under which he/she is covered. I have notied 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: / / Eective Date of Health Benets: / /
A)
MSC Buy-Out Waiver Eective Date: (Check one)
q Open Enrollment: (October 12 - November 19, 2021: eective January 1, 2022)
q Mid-Year Enrollment: / / 2022 (January 1, 2022 - November 11, 2022)
(June 1- June 30, eective July 1, 2022) (December 1- December 31, eective January 1, 2023)
B)
MSC Buy-Out Waiver Withdrawal Date: (Check one)
q Open Enrollment: (October 12 - November 19, 2021: eective January 1, 2022)
q Mid-Year Withdrawal: / / 2022 (January 1, 2022 - November 11, 2022)
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\PLYR2022\MSC\MSC_FORM_2022.INDD 10/21 1K
