Fillable New Employee HIP HMO Opt-Out Request Form (NYC Health & Hospitals)

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New Employee HIP HMO Opt-Out Request Form (NYC Health & Hospitals)

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0 | Page- Updated 11/19/19
Group 12
BENEFITS OVERVIEW
• Health Insurance Plans
• Flexible Spending Account Programs
• Union Benefits*
• Family & Medical Leave (FMLA)
• Special Leave of Absence Coverage (SLOAC)
• Other Types of Leave
• Retirement Savings Plans
(NYCERS,TDA - 403B, 401k & 457, NYCE)
• Additional Savings Plan
• Transit Benefit
• Direct Deposits
• Municipal Credit Union (MCU)
You may receive a
dditional information on how to enroll during your New Employee
Orientation.
For additional information, please log in to ESS.nychhc.org
1 | Page- Updated 11/19/19
Newly – Hired Eligible Employees on or after November 1, 2019
Per NYC Office of Labor Relations (OLR) a new health benefit requirement has been implemented for
all new employees (Group 11 & 12) hired on or after November 1, 2019.
New employees hired during this period who are electing City Health Coverage will be able to
choose from the following options:
• HIP HMO Basic or
• HIP HMO Carved-Out (Those Unions who offer the Prescription Coverages) or
• HIP HMO Standard Rx plan (For Group 11 and unions who do not provide Prescription
Coverage)
HIP HMO Gold Preferred Grandfathered Rx plan (For Group 11 and unions who do not
provide Prescription Coverage and are hired between 7/1/2019-10/31/2019)
Important Note:
• If you were hired between 7/1/2019 – 10/31/2019 and elected the HIP HMO GOLD Preferred
(Grandfathered) Optional Rider you may only change to the HIP HMO Standard Rx during 2020
Open Enrollment.
• New employees hired on or after July 1, 2019 will be able to transfer out of the HIP HMO within
30 days beginning on the 366th day of employment.
Exception:
An employee who needs to request an exemption from the required enrollment in the HIP HMO
Preferred Plan can do so by submitting an HIP HMO Opt-Out Request Form to EmblemHealth.
Once the employee completes and submits the HIP HMO Opt-Out Request Form, Emblem Health will
notify the employee of the decision within 7-10 days, based on the information provided by the
employee. The employee will submit this notice from Emblem, along with other necessary
documentation, when they are applying for the City Health Benefits Program.
*For further instructions, please visit ESS.nychhc.org or the Employee Resource Center at
http://hhcinsider.nychhc.org/corpoffices/erc/Pages/Index.aspx
Excluded:
• New Employees who are classified as Rehires
• Agency/participating employer transfers who were originally hired prior to July 1, 2019
• New Employees who reside outside of the service area (as identified by designated Zip Codes)
2 | Page- Updated 11/19/19
Health Insurance
* You may select from up to 11 Health Insurance Plans, all offering individual coverage and family coverage
(which includes current spouse, registered domestic partner and children/young adults up to age 26).
The following are HMOs (Health Maintenance Organizations) that provide managed, pre-paid hospital and
medical services to its members. Members choose a Primary Care Physician (PCP) from the HMO network, and
the PCP manages all medical services, provides referrals, and is responsible for non-emergency admissions:
•
CIGNA Healthcare
•
Empire Gated
•
GHI HMO
•
HIP Prime HMO (Basic Plan has No employee cost)
•
Vytra Health Plan
•
MetroPlus Health Plan(Basic Plan has No employee cost) -MetroPlus Gold has been available since
January 1, 2016 to all NYC employees, non-Medicare eligible retirees, their spouses or qualified
domestic partners, and eligible dependents. MetroPlus Gold’s basic plan is offered at no cost to the
employee. There are no copays for most in-network services including PCPs, specialists, lab, and x-
rays. No pre-authorizations are required for any outpatient services, and there are no written referrals
to an in-network specialist. A low-cost optional prescription drug rider is available, prescription dru
g
r
ider is available. MetroPlus Gold has an extensive network of participating physicians and hospitals,
with providers in over 22,000 sites in all five boroughs.
T
he following is an EPO (Exclusive Provider Organization) that provides a higher level of choice and flexibility
than many other managed care plans. Members can see any provider in the EPO network, no need to choose a
primary care physician and no referrals are necessary to see a specialist. There is no out-of-network coverage:
•
Empire EPO
•
Aetna EPO
T
he following is a POS (Point-of-Service) that provide the freedom to use either a network provider or an out-of-
network provider for medical and hospital care. With the usage of a network provider there is prepaid
comprehensive coverage and little out-of-pocket costs for services. With the usage of an out-of-network provider
there is less comprehensive coverage and employees are subject to deductibles and/or coinsurance:
•
HIP Prime POS
T
he following is a PPOs (Participating Provider Organizations) / Indemnity plans that provide the freedom to use
either a network provider or an out-of-network provider for medical and hospital care. PPO/Indemnity Plans
contract with health care providers who agree to accept a negotiated lower payment from the health plan, with co-
payments from the subscribers as payment in full for medical services. When the subscriber uses a non-
participating provider, they are subject to deductibles and/or coinsurance:
•
GHI-CBP/Empire BlueCross BlueShield (Basic Plan has No employee cost)
•
* I
f hired before July 1, 2019 you are able to enroll into any of the 11 Health Plans Offered. If you were hired
post July 1, 2019 you may change your coverage 365 days after your date of hire.
Vis
it www.nyc.gov/olr
, Health Benefits Program for additional information.
3 | Page
Below is a list of all dependent eligibility documentation requirements for health benefits coverage for
dependents.
For a Spouse
• married one year or less – Government Issued Marriage Certificate
• married more than one year – Government Issued Marriage Certificate and one of the following:
o Federal tax return filed within last two years and listing spouse as joint or individual
o Proof of joint ownership (bank account, auto, home, etc.) issued within last six months
o Proof of cohabitation (two separate documents – one in your name and one in your spouse’s
name
– at the same address, such as utility bills, bank statements or credit card statements)
For a Domestic Partner
• partnership of one year or less – Domestic Partnership Certificate of Registration
• partnership of more than one year – Domestic Partnership Certificate of Registration and
one of the following:
o Proof of joint ownership (bank account, auto, home, etc.) issued within last six months
o Proof of cohabitation (two separate documents – one in your name and one in your
domestic partner’s name – at the same address, such as utility bills, bank statements
or credit card statements)
For a Child
NOTE: Disabled status for any child still requires current medical certification from the health plan in
addition to the documents listed below.
• B
iological Child
o Government Issued Birth Certificate (including parent’s names)
• Step Child – Must be spouse’s child. One of the following combinations of documents is required:
o Government Issued Birth Certificate (including parent’s names) and Government Issued
Marriage Certificate if married one year or less
o Government Issued Birth Certificate (including parent’s names) and Government Issued
Marriage Certificate and Federal tax return filed within last two years listing spouse
as
joint or individual
o Government Issued Birth Certificate (including parent’s names) and Government Issued
Marriage Certificate and proof of joint ownership (bank account, auto, home, etc.) issued
within last six months
• Domestic Partner’s child – Must be registered domestic partner’s child. One of the following
combinations of documents is required:
o Government Issued Birth Certificate (including parent’s names) and Domestic
Partnership Certificate of Registration if partnership of one year or less
o Government Issued Birth Certificate (including parent’s names) and Domestic
Partnership Certificate of Registration and proof of joint ownership (bank account,
auto, home, etc.) issued within last six months
• L
egal Ward
o G
overnment Issued Birth Certificate and the court ordered document of legal custody
• Tax Dependent Child
o Government Issued Birth Certificate and the federal tax return filed in the previous
year listing child as dependent
4 | Page- Updated 11/19/19
Flexible Spending Account Programs
Medical Spending Conversion (MSC) Health Benefits Buy-out Waiver Program: Allows eligible employees
who can obtain non-City group health benefits (proof required) to waive their New York City health benefits in
return for a cash incentive payment (taxable) made semi-annually (June and December). Annual amount for
waived family coverage is $1,000 and waived individual coverage is $500. Employees who enroll remain in the
Buy-out Waiver program until they have a qualifying event or during open enrollment when a City health plan
can be elected. Re-enrollment is not required every year.
Medical Spending Conversion (MSC) Premium Conversion Program: Allows employees who have payroll
deductions for health insurance premiums and optional riders to increase their take-home pay. Payments are made
on a pre-tax basis effectively reducing the salary on which your taxes are computed by the amount of the health
plan deduction. Enrollment remains in effect during the Plan Year and your status cannot change unless an
approved Qualifying Event occurs mid-year. Enrollment in the Premium Conversion Program is automatic.
Health Care Flexible Spending Account Program (HCFSA): Allows employees to pay for eligible out-of-
pocket health care expenses on a pre-tax basis, with deductions taken directly from salary. This reduces your gross
salary for federal and Social Security tax, resulting in tax savings. HCFSA is designed to help employees pay
for necessary out-of-pocket medical, dental, vision, and hearing expenses not covered by health insurance.
The minimum annual contribution is $260 and maximum annual contribution is $2,750. Any unused balances
will be forfeited, If you don’t use it, you lose it! (see website below for more information*)
Grace Period.
There is a Grace Period offered following the end of a Plan Year. During this Grace Period, you may submit
claims for eligible medical expenses incurred from January 1st through March 15
th
, using the remaining
balance in your Plan Year account, if any. However, in the event that you are unable to submit HCFSA
Program claims by the end of the Plan Year or accompanying Grace Period, a Claims Run-Out Period is
provided, during which you may submit claims for services performed during the previous Plan Year or
accompanying Grace Period.
Plan Year: January 1st, – December 31st
Grace Period: January 1st, – March 15th
Claims Run-Out Period: January 1st– May 31st
(If you do not submit claims for eligible expenses incurred during the Plan Year or the Grace
Period by May 31st, you will forfeit any money remaining in your HCFSA for Plan Year).
E
nrollment in HCFSA remains in effect during the Plan Year and your status cannot change unless an
approved Qualifying Event occurs mid-year. Enrollment is not automatic from year to year. You must re-
enroll each year during the annual Open Enrollment Period.
Dependent Care Assistance Program (DeCAP): Employees are able to pay for eligible dependent care expenses
on a pre-tax basis, with deductions taken directly from paychecks. These deductions reduce your gross income on
your W-2 Form for federal and Social Security tax purposes. The minimum annual contribution is $500 and
maximum annual contribution is $5,000 (reduced to $2,500 if you are married and file a separate federal income
tax return). Any unused balances will be forfeited. Enrollment remains in effect during the Plan Year and your
status cannot change unless an approved Qualifying Event occurs mid-year. Enrollment is not automatic from
year to year. Employee must re-enroll each year during the annual Open Enrollment Period.
Plan Year: January 1st – December 31
st
Claim Run-Out Period: January 1st – February 28th
*Visit www.nyc.gov/olr , Flex Spending Account Programs for additional information.*
5 | Page- Updated 11/19/19
Union Benefits (Employees covered by Collective Bargaining Agreements)
P
rovides supplemental benefits to employees covered by a union. Once an employee becomes employed with
the City of New York, they must reach out to their union to obtain a summary/explanation of benefits offered
through their Union, including vacation and sick leave accrual rates
Union Description
Website
Committee of Interns and Residents
http://www.cirseiu.org/
Communications Workers of America
http://cwa1180.org/
District Council 37
http://dc37.net/
District Council 9, International Union of Painters & Allied
Trades Local 1968 (IUPAT)
http://www.dc9.net
Doctor's Council
http://doctorscouncil.com/
1199 SEIU
http://www.1199seiu.org/
International Brotherhood of Electrical Workers
http://www.ibew.org/
International Brotherhood of Teamsters Local 237
http://www.local237.org
http://www.iuoe.org/
Local 371 (SSEU)
http://www.sseu371.org/
New York State Nurses Association
http://www.nysna.org
Organization of Staff Analysts
http://www.osaunion.org
Plumbers of New York City
http://www.ualocal1.org/
Service Employees International Union
http://www.seiu.org/
United Brotherhood of Carpenters
https://www.carpenters.org/Home.aspx
6 | Page- Updated 11/19/19
T
he following are regular holidays with pay:
New Year’s Day Columbus Day
Martin Luther King, Jr. Day Election Day
President’s Day Veteran’s Day
Memorial Day Thanksgiving Day
Independence Day Christmas Day
Labor Day
Family & Medical Leave Act (FMLA)
•
FMLA entitles eligible employees up to a maximum of 12 weeks of paid/unpaid leave in a 12 month
p
eriod to care for an immediate family member (spouse, domestic partner, child and parent) or for th
e
ser
ious illness of the employee.
•
During this period, benefits remain intact (health insurance and MBF).
Special Leave of Absence Coverage (SLOAC)
• SLOAC entitles eligible employees on an active approved unpaid leave up to a maximum of 18 weeks
or 4 months of continued benefits (health insurance and MBF) coverage in a 12 month period during a
n
u
npaid Leave resulting from a disability or serious illness of the employee.
Other Types of Leave
• Child Care Leave
• P
arental Leav
e
• Mi
litary Leave
• Paid Family Medical Leave (Please check with your welfare fund if you qualify)
Retirement Savings Plans
Pension: New York City Employees’ Retirement System (NYCERS).
•
Membership is available to all New York City employees.
•
Employee holding a permanent civil service position in the competitive or labor class are
required to b
ecome members of NYCERS six months after their date of appointment, but may
voluntarily el
ect to join the system prior to their mandated membership date. All other eligible
employees h
ave the option of joining the system upon appointment or at any time thereafter. After
joining NYC
ERS, membership is irrevocable until you leave city service.
•
Tiers and Plans ~ Your Tier is generally determined by the date you joined NYCERS.
•
NYCERS is a defined benefit plan, which means the amount of your benefit is defined by law.
•
Buy-Back Option ~ Employees are eligible to buy back full or part-time New York City service
rendered pr
ior to your NYCERS membership.
•
NYCERS member has an option to take a loan from the plan (qualification required).Visit
www.nycers.org
for additional information.
7 | Page- Updated 11/19/19
Taxed Deferred Arrangement Program - TDA 403B: The NYC Health + Hospitals TDA Program is a
retirement program that has been available to all employees for more than 40 years. This 403(b) program gives
you the opportunity to save for retirement on a tax-deferred basis.
•
Immediate eligibility and anytime enrollment for NYC Health + Hospitals’ employees.
•
Employees choose the percentage they want to contribute to the TDA. Deductions are taken from your
paycheck. You may start with as little as 1% and up to a max of 70% of your salary a year (subject to ma
x
dol
lar amount a year by IRS regulations). This is an employee contributed only program
.
•
The federal maximum limits for elective deferrals in 2020 for employees under age 50 is $19,500 and for
employees 50 + is $26,000.
•
You can rollover another employers’ qualified retirement plan or pre-tax IRA into the TDA.
•
The TDA is one way to help you save for retirement. That’s because you have two ways to contribute:
1)
T
raditional pre-tax contributions, and 2) Roth after-tax contributions. You can choose to make either
one or both types of contributions based on what’s best for your tax situation.
•
You can change or stop your contribution rate at any time.
•
You may borrow (loan) up to 50% of your vested balance. Options to take out a loan are available to all
TDA members.
•
A 10% federal income tax penalty may apply for any withdrawals made before age 59 ½.
•
Hardship withdrawals are available that provide for situations that require emergency access to your
money, i.e. unforeseen medical expenses, purchase of primary residence, higher education expenses
,
thr
eat of eviction from primary residence, or funeral expenses.
*Visit www.prudential.com/nychealthandhospitals for additional information.*
Deferred Compensation Plan: An employee benefit available to New York City employees. The Plan is
comprised of two programs: a 457 Plan and a 401(k) Plan. Employees may choose to join either the 457, the
401(k), or both.
•
It is recommended that participants choose to invest in either one of the pre-arranged portfolios or create
their own portfolio from the core investment funds offered.
•
The Deferred Compensation Plan has an option to contribute on both a pre-tax and post-tax (Roth) basis.
.
*Visit www.nyc.gov/olr
, Deferred Compensation for additional information.*
The New York City Employee Individual Retirement Account - NYCE IRA: A tax-favored retirement savings
account. Includes both a traditional IRA and a Roth IRA for the exclusive benefit of employees and former
employees of the City of New York and their respective spouses.
• You can continue to make contributions while you work or after you leave City service. As long as you
r
eceive taxable compensation, even after you retire or leave City service, you are eligible to contribute to
the Traditional NYCE IRA until age 70½. There is no age limit for making contributions to the Rot
h
NYC
E IRA.
• You can rollover all your retirement plans into an IRA.
*
Visit www.nyc.gov/olr
, NYCE IRA for additional information.*
8 | Page- Updated 11/19/19
Additional Savings Plan
NY 529 College Savings Program: Direct Plan provides a flexible, convenient, and low-cost way to save for
college. The Program features a wide range of investment choices, tax-free withdrawals when used for qualified
higher education expenses, and contributions that are tax-deductible (up to certain limits) for New York State
residents.
•
You can save for a child, grandchild, friend — or even yourself.
•
You can start with as little as $15 and can contribute by check, automatic investment, electronic bank
t
ransfer, payroll deduction, or by moving assets from other college savings accounts.
•
Your assets grow tax-deferred and earnings on your withdrawals are exempt from federal income tax
when used for qualified higher education expenses.
-
*Visit www.nysaves.org
for additional information.*
Transit Benefit
TransitChek: The Premium TransitChek MetroCard (Premium Card) is a special annual, unlimited ride
MetroCard offered to eligible employees of the City of New York.
• Y
ou receive a MetroCard that can be used for a continuous twelve-month period for unlimited rides o
n
t
he subway and local buses (MTA NYC Transit subway and local buses, MTA Staten Island Railroad
,
MTA Bus Company (not for Express buses).
• Y
ou will have a set pre-tax monthly deduction, which is equal to the cost of the MTA NYCT 30-Da
y
unlimited Ride MetroCard.
• You can purchase your Premium Card with pre-tax dollars through payroll deductions. As a result, y
ou
do not
pay federal, state, city, social security, or Medicare taxes on payments for the card.
Wage Work Account (Transportation Spending Account – TSA): NYC Health + Hospitals offer employees
the opportunity to deduct pre-tax dollars to cover certain public transportation costs.
• Is a
voluntary benefit providing you with flexibility and control over your purchases of Metrocards used
for commuting to and from work
.
• Upon enrollment, a special bank account is established and then issues you a PIN-based debit card
linked to that account. Your Transportation Spending Account (TSA) is funded each payday with pre-
tax deductions taken from your paycheck. You then use the TSA debit card to purchase your MetroCar
d
o
r pay for parking.
• You can select a deduction plan to suit your personal transportation needs; Occasional Rides, Frequent
Rides, or Express Bus Rides
.
• You can save money per month in taxes.
• You can suspend deductions for short periods, i.e. while on vacation or on paid leave of absence.
• Your funds are protected; a lost TSA debit card does not mean lost funds.
9 | Page- Updated 11/19/19
Direct Deposit
-
Your paycheck can be conveniently deposited (bi-weekly) into a checking or savings account.
-
Enroll into direct deposit through Employee Self Service. Payroll Shared Services can assist if needed.
MCU (Municipal Credit Union)
• MCU offers the convenience of direct deposit and automatic payroll deductions into your savings,
checking, IRA and even to a high dividend earning Certificate Account all without taking a single step
once you've filled out the appropriate forms.
• MCU offers excellent rates on Savings Accounts, Mortgages, Auto Loans, Credit Cards, Personal Loans,
etc.
• MCU offers special accounts like a Holiday or Vacation Account which earn a dividend rate and help you
save for those special occasions. At the end of the one year term, your funds will be automatically
deposited into your Checking or Share account for easy ATM access.
• Not everyone can be a member at MCU, but NYC Health + Hospitals employees are qualified, so tak
e
ad
vantage of the exceptional offerings.
*
Visit www.nymcu.org
for additional information.*
Premium MetroCard Program
Wage Work
•
Provides unlimited MetroCards only.
•
Provides the employee with an actual
card.
•
Requires continuous deductions for card
a
ctivation.
•
Provides an actual replacement card, if
the original is lost, damaged, or stolen,
but may result in loss of use (and
therefore dollars) while the Card is being
replaced.
•
Provides 4 different deduction plans, including an
express bus plan and an unlimited ride plan.
•
Provides the means to purchase a Metrocard
•
Provides the option to suspend deductions without
termination of program.
•
Debit cards are PIN protected. If card is lost or
stolen the funds are secure. Your old card will b
e
d
eactivated and a new card will be issued.
City of New York
New Employee HIP HMO Opt-Out Request Form
Pursuant to the New York City Health Benefits Summary Program Description, all City of New York employees, and employees of
Participating Employers, hired on or after July 1, 2019 will only be eligible to enroll in the EmblemHealth HIP HMO Preferred Plan and
must remain in the HIP HMO Preferred Plan for the first 365 days of employment.
An employee who needs to request an exemption to this requirement can do so by submitting this completed Opt-Out Request Form
to EmblemHealth, via the email address provided below. An employee or eligible dependent must meet the criteria outlined below,
and the request must be approved by EmblemHealth before the exemption is granted.
Criteria for Opt-Out (Check box below):
If the new employee or eligible dependent is being treated by a non-network provider for a life-threatening or disabling
disease or condition and is receiving ongoing treatment for a catastrophic or terminal illness or has a condition that
requires complex case management (such as ventilator dependence or trauma). Please provide treating physicians name,
address and phone number on the back of this form.
Process:
New employees need to complete and submit this New Employee HIP HMO Opt-Out Request Form immediately. Please email
completed forms to: cityagencies@emblemhealth.com or fax to 212-510-5445. You can also mail the completed form to:
EmblemHealth Attn: Opt-Out Form Processing Department, 55 Water Street New York, NY 10041.
Once your Opt-Out Request Form has been reviewed and a determination has been made, you will be notified by EmblemHealth via
the email address you have provided on the back of this form. If you are approved, you must submit the approval notification to
NYCAPS or your agency benefits representative.
Please complete the following:
Employee Information
Employee Last Name:
Employee First Name:
Date of Birth:
Phone:
Email Address:
Home Address:
Home Zip:
Agency:
Date of Hire:
Dependent Information:
(If the request for exemption is due to an eligible dependent, please also provide the following.)
Dependent’s Last Name:
Dependent’s First Name:
Dependent’s Date of Birth:
Group Health Incorporated (GHI), Health Insurance Plan of Greater New York (HIP), HIP Insurance Company of New York and EmblemHealth Services Company, LLC are EmblemHealth
companies. EmblemHealth Services Company, LLC provides administrative services to the EmblemHealth companies.
EMB_MB_FRM_46011_NewMember_HMO-OptOutPolicy_Form 6/19
(Continued)
Medical Information
Please check one: Self Dependent
Treating Physician’s Name:
Physician’s Phone:
Physician’s Address:
Diagnosis/Condition:
EMPLOYEE/DEPENDENT’S SIGNATURE AND RELEASE (This form must be signed to be processed)
I hereby request exemption from the above City Health Benefits Program requirement and certify that the above information is complete,
true and correct. I authorize above listed physicians and other medical professionals to provide EmblemHealth with information concerning
medical care, advice, treatment or supplies provided to the Employee or eligible dependent. I understand that this authorization will be
used only for the purpose of obtaining information, and the duration of the authorization will be limited, to determine whether the
employee or eligible dependent meets the criteria outlined above. I agree that a photostatic copy of this authorization is as valid as the
original.
Employee Signature:
Date:
Dependent’s Signature (if dependent is not a minor)
Date:
FOR OFFICIAL USE ONLY
Approval
Denial – does not meet criteria
Date:
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