Welcome to Your Benefits Choices for 2019! · your benefits record by logging on to My MTA Portal...
Transcript of Welcome to Your Benefits Choices for 2019! · your benefits record by logging on to My MTA Portal...
November 1, 2018
Welcome to Your Benefits Choices for 2019!
The Open Enrollment period for NYSHIP members is November 1 – December 31, 2018. If you choose to continue your current health insurance plan, no action is necessary unless:
You will become eligible for Medicare in 2019. See page 3 of the Summary of Health
Benefits.
This Summary of Health Benefits packet provides the information you need to make the best decisions.
Information on the following will be available on My MTA Portal – www.mymta.info:
2019 NYSHIP Employee Contribution Rates available in December Medical Insurance Opt-Out Program Brochure from the MTA
Dates to remember … Open Enrollment - November 1 – December 31.
Opt-Out Program - November 1 – 30.
Flexible Spending Account (FSA) - November 1 – December 15.
The MTA Business Service Center is available to answer your questions and provide assistance.
MTA Business Service Center 646-376-0123, 8:30 to 5 p.m., Monday-Friday [email protected] www.mymta.info
Disclaimer
This Employee Benefits Summary contains information concerning some of the benefits you will
receive as a New York City Transit employee. This Employee Benefits Summary is for
informational purposes only and may be modified at any time. If a conflict exists between this
Employee Benefits Summary and an official written document setting forth the benefit, policy,
procedure, or rule, the official written document controls.
It is important to note that all benefits summarized herein are the benefits that are currently in
effect at New York City Transit. These benefits are all subject to change, including termination,
at any time in the sole discretion of New York City Transit, except to the extent that they have
been established by collective bargaining agreement or are required by law. Some benefit
programs, such as public retirement plans, are administered and interpreted outside of New York
City Transit. If the information contained in this Employee Benefits Summary conflicts with the
provisions of any benefit program, the program’s policies control.
2019 Open Enrollment
November 1 through December 31, 2018
1 MTA Business Service Center 2019 Open Enrollment
I. INTRODUCTION
A) 2019 Health Benefits Open Enrollment Period B) Sources of Information
II. HEALTH BENEFITS CHOICES A) Electing/Changing Medical/Dental Coverage B) Medical Opt-Out Program
III. HEALTHCARE REFORM & OTHER REQUIREMENTS A) Grandfathered Status B) Coverage for Children from Age 19 to 26 C) Social Security Number Requirement
IV. TAX-FAVORED PROGRAMS A) Flexible Spending Account (FSA) B) MTA Deferred Compensation Program C) New York’s 529 College Savings Program D) Premium TransitChek
V. IMPORTANT TELEPHONE NUMBERS & WEBSITES
2019 Open Enrollment November 1st through December 31st, 2018
Summary of Health Benefits
Active MTA NYCT – NYSHIP Employees
2 MTA Business Service Center 2019 Open Enrollment
I. INTRODUCTION
A) 2019 Health Benefits Open Enrollment Period
Your Open Enrollment Period for Benefit Plan Year 2019 is November 1 through December 31, 2018.
See the 2019 Open Enrollment Meeting Schedule enclosed.
B) Sources of Information
MTA Business Service Center (BSC) will be available at informational meetings that will be held at locations throughout the five boroughs to explain your benefit plan choices and answer questions. Watch for announcements that will be posted at your place of work and on My MTA Portal (www.mymta.info). My MTA Portal at www.mymta.info, provides information and links to providers’ websites. You can also check and update your personal information online and view your benefits and payroll information. The BSC Customer Management Center (CMC) provides assistance at:
o 646-376-0123, 8:30 a.m. to 5 p.m., Monday – Friday, or o you can send an email to [email protected].
The 180 Livingston Street Walk-in Center is open 8:30 a.m. to 5 p.m., Monday –
Friday.
Important telephone numbers, websites and contact information are in Section V.
3 MTA Business Service Center 2019 Open Enrollment
II. HEALTH BENEFITS CHOICES
A) Electing/Changing Medical/Dental Coverage
The BSC processes all medical/dental benefits enrollments and changes. You need to complete and submit the appropriate enrollment/change form(s) to the BSC to do the following:
Change plans and/or
Add/terminate dependents and/or
Provide a social security number for a covered dependent who is at least age 45, as required by federal legislation (see Section IIIB)
Members of the New York State Health Insurance Program (NYSHIP) include the following groups:
Managerial Non-Represented including DC37 with NR Benefits and TWU Local 100 with NR Benefits TWU Local 106 - Transit Supervisors Organization (TSO Operating and Queens Division) Subway Surface Supervisors Association (SSSA) Organization of Staff Analysts (OSA) Doctors Council (medical only) Special Inspectors represented by UFLEO hired on or after 01/30/08 Special Inspectors represented by SISEA
To assist with your decision making, see the 2019 NYSHIP Choices Guide listing your plan choices which will be available on My MTA Portal as soon as it is released by NYSHIP.
The 2019 Employee Contribution Rates will be available on My MTA Portal in December. These include the following options:
The Empire Plan Rates Preferred Provider Organization (PPO)
The NYSHIP-approved Health Maintenance Organizations Rates (HMO)
No action is required if you choose to continue your current health insurance plan.
If you opt to make a change, it is important that you choose carefully because you may not change your health insurance option after the December 31, 2018 deadline, except if the option you are enrolled in no longer services the area in which you live. In addition, you may change your enrollment status if you experience a qualifying event, such as marriage, divorce, birth or adoption of a child, loss of dependent child status, or loss of coverage. When you experience a qualifying event, it is important that you update your records by submitting the appropriate forms to the BSC within 30 days of the qualifying event date.
To change your health insurance plan effective January 1, 2019, complete and submit the 2019 NYSHIP Open Enrollment/Change Form (HR-BEN-060K) located in this package.
Note to employees planning to retire in 2019: If you and/or your covered dependent(s) are at least age 65 when you retire, Medicare will be your primary medical coverage on the first of the month coincident with your retirement date or the following month. Enrollment in Medicare generally takes about three months so please contact the Social Security Administration well enough in advance so that you will be enrolled in Medicare Part A (hospitalization) and Medicare Part B (medical) upon retirement.
4 MTA Business Service Center 2019 Open Enrollment
B) Opt-Out Program (Medical/Hospital and Prescription Drugs)
The MTA Opt-Out Program provides an incentive to employees who opt out of medical/prescription drug coverage.
Please note that your dental and vision coverage will remain in effect if you elect the Opt-Out Program.
You will find complete information on how the program works and the incentive payments in the 2019 Opt-Out Brochure, available on My MTA Portal; the brochure will also be mailed to you. Following are general guidelines for the opt-out process.
If you opted out for 2018 and wish to opt-out for 2019: DO NOTHING. Your opt-out status will remain in place for 2019 provided you remain eligible to participate in the program.
If you opted out for 2018 and wish to enroll for medical coverage for 2019:
Submit a NYSHIP Open Enrollment/Change Form, no later than the open enrollment deadline, December 31, 2018.
If you did not opt out for 2018 and wish to opt out for 2019:
Submit an Agreement to Decline (Opt-Out) Medical Coverage Form (HR-BEN-036) no later than the opt-out deadline, November 30, 2018. A lump sum incentive payment will be issued to you during the first quarter of 2020.
Please note that your election to opt-out remains in effect until you change your election during a
future Open Enrollment period or you experience a Qualified Family Status Change.
Information and forms are available on the BSC Self-Service website at www.mymta.info. You will also receive a brochure in the mail.
III. HEALTHCARE REFORM & OTHER REQUIREMENTS A) Grandfathered Status
NYC Transit’s health plans are “grandfathered health plans” under the Affordable Care Act (ACA). As permitted by the ACA, grandfathered health plans can preserve certain basic health plan benefits that were already in effect when the law was enacted. Grandfathered status also means that our plans may not include certain consumer protections of the ACA that apply to other plans. However, grandfathered health plans must comply with certain other consumer protections in the ACA, for example, the elimination of lifetime limits on benefits.
Questions regarding which protections apply and which protections do not apply to a grandfathered health plan and what might cause a plan to change from grandfathered health plan status can be directed to the BSC by
sending an email to [email protected] or calling the BSC Customer Management Center at 646-376-0123.
B) Coverage for Dependent Children from Ages 19 to 26 A dependent child age 19 to the end of the month of the 26th birthday is eligible for medical, hospital and prescription drug coverage, regardless of their student or marital status. If you wish to enroll a dependent child age 19 to 26, add the child’s name on the NYSHIP Open Enrollment/Change Form (HR-BEN-060K) and submit the required documentation listed on page 2 of the form.
Note: The extended dependent child coverage does not apply to dental and vision coverage. (For more information see the BSC Self-Service Portal, Benefits Section under “Full-time Student Verification.”)
C) Social Security Number Requirement The Medicare, Medicaid, and State Children’s Health Insurance Extension Act of 2007 (MMSEA) requires that the MTA report Social Security Numbers to the Federal Centers for Medicare and Medicaid Services (CMS) for all dependents who are at least age 45.
You can check to see if your covered dependent’s Social Security Number (SSN) is missing from your benefits record by logging on to My MTA Portal at www.mymta.info. Click the My Benefits ribbon to view your benefits information.
If your dependent’s Social Security Number is not shown under SSN (only the last four digits will show), please submit a copy of your dependent’s Social Security card with your name and BSC ID number noted on the copy, along with the 2019 NYSHIP Open Enrollment/Change Form (HR-BEN-060K) to the BSC.
MTA Business Service Center 6 2019 Open Enrollment
IV. TAX-FAVORED PROGRAMS
A) Flexible Spending Account (FSA) You may enroll in the FSA Program during the open enrollment period, November 1 – December 15, 2018, by contacting the P&A Group (see Section V and information posted on the BSC Self-Service Portal).
FSA is a program that allows you to set aside part of your paycheck on a pre-tax basis through automatic payroll deductions for eligible Health Care and Dependent Care expenses. This program allows you to reduce your taxable income thereby reducing your tax liability. Keep in mind that your FSA account cannot be used to pay for the cost of over-the-counter (OTC) medicines (such as ibuprofen and antacids), unless accompanied by a physician’s prescription.
The FSA Health Care Account limit is capped at $2,650 for 2019. The Dependent Care FSA annual maximum allowance per household is $5,000.
If you enrolled in FSA for 2018, please note that you will not be automatically re-enrolled in FSA for 2019. You must re-enroll by contacting the P&A Group during this Open Enrollment Period. See Section V.
Examples of Eligible Expenses
Health Care FSA o Medical, dental, vision and prescription drug deductibles and copayments o Eyeglasses, contact lenses, contact lens supplies, and prescription sunglasses
Dependent Care FSA o Child care costs o Elder care costs (dependent must meet the definition of a qualifying relative per the
IRS, based on a tax year) o Before-school and after-school programs o Summer day camp
B) MTA Deferred Compensation Program
You may enroll or make changes at any time by contacting Prudential (see Section V).
401(k)/457 Participating in the 401(k) and/or the 457 MTA Deferred Compensation Program may help you achieve a more comfortable and secure financial future. The program helps supplement your existing retirement/pension benefits by allowing you to save and invest before-tax dollars through the convenience of automatic payroll deductions. You are offered diversified investment options, access to local service representatives, financial education services, and planning tools that can help you better prepare for retirement. Contributions and any earnings are tax deferred until money is withdrawn, usually at retirement, when you may be receiving less income and are in a lower income tax bracket.
MTA Business Service Center 7 2019 Open Enrollment
401(k)/457 Roth In addition to the traditional pre-tax contributions, both the 401(k) Plan and 457 Plan now allow you to make after-tax contributions (also known as Roth contributions). The Roth contribution option combines the savings and investment features of a traditional retirement plan with the tax-free distribution features of a Roth IRA. While income taxes on pre-tax contribution amounts are deferred until your account is distributed (for example, at retirement), Roth contributions are made on an after-tax basis, so the amount contributed is included in your W-2, just like regular income, in the year you make the contribution. However, earnings on Roth contributions may be distributed tax-free in retirement if you meet certain requirements.
C) New York’s 529 College Savings Program
You may enroll at any time by contacting the College Savings Program (see Section V).
This program is designed to assist families saving for college. You can elect to contribute to a choice of funds on a post-tax basis through automatic payroll deductions. If you use the money for higher education, earnings will be distributed tax-free.
D) Premium TransitChek
You may enroll at any time by contacting the TransitChek Center (see Section V).
This program allows you to set aside money on a pre-tax basis through automatic payroll deductions for commuting expenses for you and your family, up to certain limits established by the IRS. Eligible expenses include using public transportation such as commuter trains, subways, buses, ferries, van-pool services, and/or commuter parking for travel to and from work.
MTA Business Service Center 8 2019 Open Enrollment
Submit Open Enrollment/Change Forms by email, fax, or mail: Email: [email protected]
Fax: 212-852-8700 Mail: MTA Business Service Center,
333 W. 34th Street, 9th Floor, New York, NY 10001-2402
Contact the MTA Business Service Center (BSC) for assistance: Email: [email protected]
Fax: 212-852-8700
Phone: 646-376-0123
Hours: 8:30 a.m. - 5 p.m., Monday - Friday
Website: www.mymta.info
All Open Enrollment information and documents can be accessed on the BSC Self-Service Portal: www.mymta.info
Please have your BSC ID ready when you contact us and be sure to include your full name
and BSC ID on all emails and documents you submit.
MTA Business Service Center 9 2019 Open Enrollment
V. IMPORTANT TELEPHONE NUMBERS & WEBSITES
Carriers Telephone Website
Medical/Hospital Options
NYSHIP 877-769-7447 www.cs.ny.gov
Dental Options
Healthplex/Dentcare 800-468-0600 www.healthplex.com
MetLife 800-942-0854 www.metlife.com
Plan A - American Dental Center 800-447-6453 www.americandental.com
Plan B - ProBenefits Administrators 888-683-3682 www.probenefitsadmin.com
Vision
EyeMed 800-334-7591 www.eyemedvisioncare.com
Savings Programs
P&A Group (FSA) 800-688-2611 www.padmin.com
Prudential (401k/457) 877-756-4682 www.prudential.com/mta
College Savings 800-420-8580 www.ny529atwork.com
TransitChek 866-618-2435 www.transitchek.com
COBRA & Government
P&A Group (COBRA Administrator) 800-688-2611 www.padmin.com
Medicare 800-633-4227 www.MyMedicare.gov
Social Security Administration 800-772-1213 www.ssa.gov
Railroad Retirement Board 877-772-5772 www.rrb.gov
2019 Open Enrollment Meeting Schedule
OCTOBER-NOVEMBER 2018
SUNDAY MONDAY TUESDAY WEDNESDAY THURSDAY FRIDAY SATURDAY
7 8 9 MNR Croton Harmon 1 Croton Point Ave. Bldg #4, Lunch Room Croton on Hudson, NY 10520 8am – 1pm
10 11 MNR White Plains 525 N. Broadway Conf. Room 2C & 2D North White Plains, NY 10603 1pm – 4pm
12 13
14 15 16 17 18 19 20
21 22 23 24 25 26 27
28 29 30 Bridges &Tunnels Randall's Island 10am – 12pm
Bridges &Tunnels Manhattan Plaza 1:30 pm – 3pm
Bridges &Tunnels Bronx Plaza 3:30 pm – 5pm
31 1 NOVEMBER 2 3
2019 Open Enrollment Meeting Schedule
NOVEMBER 2018
SUNDAY MONDAY TUESDAY WEDNESDAY THURSDAY FRIDAY SATURDAY
4 5 NYCT 2 Broadway 4th Floor, Conf. Rm. A4.02 New York, NY 10004 10am – 4pm
Bridges &Tunnels 2 Broadway 24th Floor, Conf. Rm. 24A New York, NY 10004 9am – 12pm
6
7 8 Bridges &Tunnels Verrazano Narrows Bridge 1 Verrazano Bridge Plaza Staten Island, NY 10305 10am – 12pm
9 10
11 12 13 MNR Graybar Building 420 Lexington Avenue 12th floor, Conf Rm 12A New York, NY 10170 10am – 4pm
MNR New Haven Line - Stamford 18 Cherry Street 2nd FL, Conf. Room Stamford, CT 06902 8am – 1pm
14 LIRR Hillside Support Facility (Cafeteria) 93-59 183rd St. Hollis, NY 11423 10am – 1pm
15 16 Bridges &Tunnels Queens Midtown Tunnel 10am – 12pm
17
18 19 20 LIRR Jamaica JCC location (Lobby) 144-41 94th Ave Jamaica, NY 11435 10am – 1pm
21 22 23 24
EMPLOYEE BENEFITS DIVISION
INSTRUCTIONS FOR THE PS-404
NYS HEALTH INSURANCE TRANSACTION FORM
State of New York
Department of Civil Service
Alfred E. Smith State Office Bldg.
Albany, NY 12239 PS-404 OE2019
Page 1
New Enrollees (also complete 10.G for family coverage)
Note: for new enrollments in a Health Maintenance Organization (HMO), complete an HMO form in
addition to this form.
10.A Request Enrollment – Individual Check box to enroll in individual coverage. Check Medical,
Dental and/or Vision boxes for coverage being enrolled.
10.B Request Enrollment – Family Check box to enroll in family coverage. Check Medical,
Dental and/or Vision boxes for coverage being enrolled.
10.C Elect Pre-Tax Status? New Enrollees choose to enroll in or decline the Pre-Tax
Contribution Program for medical coverage.
10.D Decline Coverage Check box to decline coverage. Check Medical, Dental
and/or Vision boxes for coverage being declined.
Cancellation or Change in Coverage
10.E Voluntarily Cancel
Coverage
The enrollee is entitled to make separate decisions regarding their
medical, dental and vision coverages. Enrollees may cancel or change
their dental and/or vision coverage(s) at any time during the year.
Pre-tax medical enrollees may only cancel coverage during the Pre-
Tax Open Enrollment Period, or with a qualifying event (enter the
qualifying event). If you are going on Leave Without Pay, also
complete Box 12.
10.F Change Coverage Check this box to change from Individual to Family, or from Family to
Individual coverage. Pre-tax medical enrollees may only change their
coverage from Family to Individual during the Pre-Tax Open
Enrollment Period, or with a qualifying event (check the qualifying
event and enter the Date of Event). Check Medical, Dental, and/or
Vision boxes for coverage being changed.
10.G Add/Change/Delete
Dependents
Check the box to add or delete dependents or to change dependent
information. Check Medical, Dental, and/or Vision boxes that apply.
Complete all dependent information including date of birth.
Additional documentation may be required to add the dependent.
10.H Change Medical
Benefit Plan
Complete during annual Option Transfer Period or with a qualifying
event (for example, change of address outside of HMO area.)
10.I Change Pre-Tax Status Existing enrollees can only change pre-tax status during the annual
Pre-Tax Open Enrollment Period in November.
Boxes 1 - 9 All enrollees must complete boxes 1 – 9 with their personal information.
Note: Marital Status Date is used to show date of marriage, separation or divorce when those marital
statuses are selected.
Box 10 (A – I) Complete appropriate sections. The employee is entitled to make separate choices regarding their
medical, dental and vision coverages. They may decline any of the three, all of the three, or none of the
three different coverage options. Also, they many enroll in family coverage in one benefit and
individual coverage in another.
Reminder: Enrollees with a Benefit Fund (CSEA, UUP and DC-37) receive their dental and vision
benefits through that Fund. Do not enter dental and vision information on NYBEAS for these
enrollees.
EMPLOYEE BENEFITS DIVISION
INSTRUCTIONS FOR THE PS-404
NYS HEALTH INSURANCE TRANSACTION FORM
State of New York
Department of Civil Service
Alfred E. Smith State Office Bldg.
Albany, NY 12239 PS-404 OE2019
Page 2
Box 12 LEAVE WITHOUT
PAY SECTION
Enrollees going on leave without pay who request cancellation of coverage at
the time they leave the payroll must complete this section. To request
permanent cancellation of coverage, check the appropriate box and cross out the
sentence which reads “I wish to resume my coverage upon return to the
payroll.”
RETIREMENT
SECTION
Enrollees leaving the payroll due to retirement must complete this section to
indicate their decision to either defer or continue health insurance coverage as a
retiree. A PS-406.2 must be completed for enrollees requesting deferment of
medical coverage, prior to retirement.
AGENCY/EBD USE ONLY This section is for Agency and/or EBD use only and is provided to assist in
updating the enrollee’s record on NYBEAS.
Action/Reason Transaction that will be inputted into NYBEAS by HBA.
Date of Event Date the event took place, which resulted in the enrollee requesting a change to
benefits. Example: first day worked, first day on leave, date of birth, date of
marriage.
Hire Date Original date of hire or rehire. (Only needed for new enrollment).
Date of 1st
Eligibility (PE only) The first day the enrollee is eligible for coverage.
Percentage Working Enrollee’s percentage on payroll.
Agency Code Enrollee’s agency code.
Neg. Unit Enrollee’s negotiating unit.
Ret. System The retirement system for the enrollee (ERS, TRS or PFS)
Retirement Tier Tier 1, 2, 3 or 4.
Sick Leave Information - # Hours Number of sick leave hours for enrollee at time of retirement.
Sick Leave Information - Hourly
Rate of Pay
Enrollee’s hourly rate of pay based on annual salary at the time of retirement.
(See Hourly Rate Calculation memo NY99-22).
Date Entered on NYBEAS Date HBA processes the transaction on NYBEAS.
Effective Date The effective date assigned to the transaction by NYBEAS.
Note: When updating NYBEAS, use Date in Authorization Box as Date of Request.
Legal changed
EXAMPLES OF DOCUMENTATION REQUIRED TO PROCESS YOUR TRANSACTION
Employees Spouse/Domestic Partner Children
Copy of Birth Certificate Copy of Birth Certificate Copy of Birth Certificate
Copy of Social Security Card Copy of Social Security Card Copy of Social Security Card
Copy of Marriage Certificate or Complete PS-425 series Domestic Partner, if Applicable
Completed PS-451 – Statement of
Disability and Required Documentation,
if Applicable
For Changes of Coverage, copy of Marriage
Certificate, Divorce Order, Death Certificate,
PS-425.4 (Domestic Partner), as appropriate
Completed PS-457 – Statement of
Dependence and Required
Documentation, if Applicable
Box 11 Complete previous coverage information, if applicable.
Box 13 Request for Empire Plan Cards Only – complete this section to order a duplicate or replacement Benefit
Card. Do not complete this section if requesting a change to your health insurance coverage. A new card
will be issued automatically.
AUTHORIZATION Employees must SIGN and DATE this form.
INSTRUCTIONS: READ AND COMPLETE BOTH SIDES/PAGES. PLEASE PRINT AND CHECK THE APPROPRIATE CHOICES.
EMPLOYEE INFORMATION (All employees must complete)
1. Last Name First Name MI 2. Social Security Number 3. Sex Male Female
4. Street Address City State
Zip
5. Date of Birth 6. Telephone Numbers
Home ( ) Work ( )
7. Work location and address
8. Marital Status
Single
Married
Widowed
Divorced
Separated Marital Status Date
9. Covered under Medicare? Self Yes No Spouse/Domestic Partner/Dependent? Yes No
10. ENTER REQUEST(S) BELOW
A. Request Enrollment-
Individual
(Select Empire Plan or HMO)
Empire Plan HMO* Code Name
B. Request Enrollment-
Family (Complete G)
(Select Empire Plan or HMO) Empire Plan HMO* Code Name
C. Elect Pre-Tax Status for
Premium deduction? Yes
No
Note: pretax deductions may not be offered by all
agencies. Verify eligibility with your agency.
D. Decline Coverage For Agency Use: (Process WAV/BEN transaction)
E. Voluntarily Cancel Coverage
F. Change Coverage
Date of Event
Change to FAMILY (Complete G)
Marriage
Domestic Partner
First dependent child acquired
Dependent returned to full-time student status Request coverage for dependents not previously covered
Newborn
Previous coverage terminated (Complete Section 11)
Other
Change to INDIVIDUAL I voluntarily cancel coverage for my dependents
I voluntarily cancel coverage for my domestic partner
Only dependent died
Only dependent married
Only dependent graduated
Divorce
Only dependent disqualified by age Termination of domestic partnership (Attach Completed PS-428.4)
Other
G. DEPENDENT INFORMATION (use additional sheets if necessary)
Check One: A (Add), D (Delete) or C (Change) Date of Event
Last Name First Name MI Relationship Date of Birth Sex Address (if different) Social Security
Number
A
D
C
A D
C
A D
C
A D
C
A D
C
* A completed HMO form must be attached.
State of New York
Department of Civil Service
Alfred E. Smith State Office Bldg.
Albany, NY 12239
EMPLOYEE BENEFITS DIVISION
NYS HEALTH INSURANCE TRANSACTION FORM
For Participating Employers PS-404 OE2019
NYS Department of Civil Service, Albany, NY 12239 Health Insurance Transaction Form For Participating Employers
PS-404 PE OE2019 Page 2
10. Continued. ENTER REQUEST(S) BELOW
H. Change Medical Benefit Plan Change to: Empire Plan HMO* Code HMO Name_______________
* A completed HMO form must be attached.
11. PREVIOUS COVERAGE INFORMATION
If you were previously covered under NYSHIP
or another health insurance plan (attach proof,
i.e. insurance bill or letter stating former
coverage), please complete this section.
Previous ID Number Date Coverage
Terminated
Enrollee’s Name Under
Which Previously Covered
Last First Middle Initial
12. LEAVE WITHOUT PAY AND RETIREMENT STATUS
LEAVE
WITHOUT PAY
I wish to continue coverage while I am on authorized leave.
I understand that I will be billed for this coverage.
I do not wish to continue coverage while I am on authorized leave.
I wish to resume my coverage upon return to the payroll.
I understand the requirements for continuing medical insurance coverage
as a retiree and wish to continue my coverage.
RETIREMENT I understand the requirements for continuing medical insurance coverage
as a retiree and wish to defer my coverage. (A completed PS-406.2 must be attached.)
13. REQUEST FOR EMPIRE PLAN CARD ONLY
For Health Maintenance Organization (HMO) cards, contact your HMO.
DUPLICATE CARD
(Previously issued card remains valid.)
REPLACEMENT CARD
(Previously issued card(s), lost or stolen, become invalid.)
FOR ENROLLEE
ENROLLEE AND ALL DEPENDENTS
INDIVIDUAL DEPENDENT
Name
Personal Privacy Protection Law Notification
This information you provide on this application is requested in accordance with Section 163 of the New York State Civil Service Law for the principal purpose of enabling
the Department of Civil Service to process your request concerning health insurance coverage. This information will be used in accordance with Section 96 (1) of the
Personal Privacy Protection Law, particularly subdivisions (b), (e) and (f). Failure to provide the information requested may interfere with our ability to comply with your request. This information will be maintained by the Director of the Employee Benefits Division, NYS Department of Civil Service, Albany, NY 12239. For information
concerning the Personal Protection Law, call (518) 457-9375. For information related to the Health Insurance Program, contact your Agency Health Benefits
Administrator. If, after calling your Agency Health Benefits Administrator, you need more information, please call (518) 457-5754 or 1-800-833-4344 between the hours of 9:00 a.m. and 3:00 p.m.
AUTHORIZATION
I have read the Pre-Tax Contribution Program memorandum and have made my selection on Page 1 of this document, if applicable. I understand that if I
voluntarily decline or cancel my coverage, I may subject myself and/or my dependents to waiting periods if I decide to enroll at a later date, and I may
be forfeiting the right to such coverage after leaving State service (vest, retirement, etc.). I certify that the information I have supplied is true and
correct. I understand that my failure to provide required proof(s) within 28 days (30 days for newborns) may delay the availability of benefits for me or
any dependent for whom I fail to provide such proof. Any person who makes a misstatement of fact or conceals any pertinent information, commits a
crime which is subject to a $5,000 penalty and the stated value of the claim for each violation. I hereby authorize deduction from my salary or
retirement allowance of the amount required, if any, for insurance indicated above. This authorization shall be in effect until I revoke it in writing.
Employee’s Signature (Required) Signature Date (Required)
AGENCY/EBD USE ONLY
Action/Reason Date of Event Hire Date Date of 1
st
Eligibility
Percentage
Working Agency Code
Neg.
Unit Ret. System
Retirement Tier Registration # Sick Leave Information Date Entered on
NYBEAS Effective Date
# Hours Hourly Rate of Pay
HBA Signature: Date:
2019 Open Enrollment/Change Form - Dental Active Managers, Non-Rep C/S, OSA, DC 37 with NR Benefits and TWU with NR Benefits HR-BEN-367A
Business Service Center
Last Revised: 08/10/2018 Creation Date: 04/01/2012
Section 1 - Information and Instructions
The purpose of this form is to enroll in or change dental insurance, effective January 1, 2019.
Please email a signed copy of the form to [email protected] or fax to 212-852-8700 or drop off at the 180 Livingston Street W alk-in Center
8:30 a.m. to 5 p.m., Monday – Friday. If you have any questions, please contact the Business Service Center (BSC) at 646-376-0123.
Section 2 - Employee Information
Print Name
Last First M.I. Suffix
BSC ID
Pass #
Phone (H) Phone (W ) Email
If your address on your pay stub is incorrect, contact the Business Service Center OR log onto www.mymta.info and change your address online OR complete HR-HRIS-012 Employee Data Change Form. An incorrect address will delay receipt of your new health insurance cards.
Section 3 – Coverage Election – Effective January 1, 2019
Dental Individual Family
Check One
METLIFE
DENTCARE (HEALTHPLEX)
Section 4 – Dependent Information
If you are found to be covering an ineligible dependent, coverage will be terminated retroactive to the date of the ineligibility and NYC Transit will pursue financial restitution for claims and/or premiums for the ineligible dependent.
1. Please fill in all information for new dependents you wish to enroll and submit required documentation (see Section 6). 2. Please fill in all information for any dependents you wish to delete. 3. Please contact the Business Service Center for the Domestic Partnership Package if you wish to enroll a domestic partner. NOTE: Your domestic partner will not be enrolled in health coverage unless an application is submitted and approved by the Benefits Department.
Check One - Indicate (A) Add or (D) Delete Check One - Relationship Gender Date of Birth
A D Name SSN Spouse Domestic Partner Child F M Mo Day Year
Section 5 - Authorization
My signature and date on this form certifies and warrants that all dependent eligibility information is true, correct, and current. I also certify that dependent children from age 19 to 26 that I have enrolled in coverage are not eligible for another employer-sponsored coverage.
Employee Signature:
Date:
2019 Open Enrollment/Change Form - Dental Active Managers, Non-Rep C/S, OSA, DC 37 with NR Benefits and TWU with NR Benefits HR-BEN-367A
Business Service Center
Last Revised: 08/10/2018 Creation Date: 04/01/2012
1. For a Spouse A copy of your Marriage Certificate, Birth Certificate, and Social Security Card are required.
In place of required Birth Certificate, any of the following official government documents can be submitted: o Valid Drivers’ License-New York o Resident Alien Card o Valid US Passport o A letter from Social Security containing your date of birth o Public Assistance ID Card o Government Employment ID Card
If your date of marriage is more than one year old, proof of joint ownership is required.
Both the enrollee’s and spouse’s names must be listed on the documentation of joint ownership. Where indicated, proof* must be dated within the past 90 days. Any financial information or account numbers can be removed.
Examples include a copy of:
o Your most recent tax return showing “Married Filing Jointly” or “Married Filing Separately.” Your spouse’s name must appear on the tax form on the line provided after the “married filing separately” status (or vice versa). Submit page 1 of the tax return.
o Homeowners/Renters Insurance Policy o *Credit Card Statement o *Loan Obligation or Bank Account Statement o Pension/life insurance/a Will designating your spouse as beneficiary o *Mortgage Statement /Rental/Lease Agreement or Property Tax Document o *Utility/phone/internet/cable bills
If you are not able to provide the required documentation, please complete the Employee/Retiree Affidavit, have it notarized and return it with your Enrollment form.
2. For Children
For a Natural-Born Child, a copy of: For a Stepchild, or Legally Adopted Child, a copy of: o Birth Certificate showing employee’s name o Birth Certificate o Social Security card o Social Security card o Puerto Rican Birth Certificates issued prior
to July 1, 2010 are unacceptable
o Legal documentation concerning adoption
3. Dependent Children Coverage between ages 19 and 26 o To enroll a dependent child from age 19 to 26 in your medical, hospital, and prescription drug coverage, add the
child’s name on this form, submit required documentation, and affirm by signing this form that your child is not eligible for other employer-sponsored coverage.
o To continue covering a dependent child from age 19 to 25 on dental, you are required to submit a full-time student verification letter. Students will also be entitled to vision coverage under EyeMed.
Section 6 – Dependent Required Documentation
2019 Annual Open Enrollment/Change Form Active Subway Surface Supervisors Association (SSSA), TWU Local 106 Transit Supervisors Organization (TSO) Operating and
Queens Supervisory, Coin Retriever Employees, MSII SSII and Special Inspectors
HR-BEN-368A
Business Service Center
Last Revised: 08/10/2018 /23/2018
Creation Date: 04/01/2012
Section 1 - Information and Instructions
The purpose of this form is to enroll in or change health insurance, effective January 1, 2019.
Please email a signed copy of the form to [email protected] or fax to 212-852-8700 or drop off at the 180 Livingston Street Walk-in Center 8:30 a.m. to 5 p.m., Monday – Friday. If you have any questions, please contact the Business Service Center (BSC) at 646-376-0123.
Section 2 - Employee Information
Print Name
Last First M.I. Suffix
BSC ID
Pass #
Phone (H) Phone (W) Email
If your address on your pay stub is incorrect, contact the Business Service Center OR log onto www.mymta.info and change
your address online OR complete HR-HRIS-012 Employee Data Change Form. An incorrect address will delay receipt of your
new health insurance cards.
Section 3 – Coverage Election – Effective January 1, 2019
Dental Individual Family
Check One
METLIFE (Fee Schedule)
METLIFE PPO
DENTCARE (HEALTHPLEX)
PLAN A – AMERICAN DENTAL CENTERS
PLAN B – ProBENEFITS Administrators (The Dental Shop)
Section 4 – Dependent Information
If you are found to be covering an ineligible dependent, coverage will be terminated retroactive to the date of the ineligibility and NYC Transit will pursue financial restitution for claims and/or premiums for the ineligible dependent.
1. Please fill in all information for new dependents you wish to enroll and submit required documentation (see Section 6). 2. Please fill in all information for any dependents you wish to delete. 3. Please contact the Business Service Center for the Domestic Partnership Package if you wish to enroll a domestic partner.
NOTE: Your domestic partner will not be enrolled in health coverage unless an application is submitted and approved by the Benefits Department.
Check One - Indicate (A) Add or (D) Delete Check One - Relationship Gender Date of Birth
A D Name SSN Spouse Domestic Partner Child F M Mo Day Year
Section 5 - Authorization
My signature and date on this form certifies and warrants that all dependent eligibility information is true, correct, and current. I also certify that dependent children from age 19 to 26 that I have enrolled in coverage are not eligible for another employer-sponsored coverage.
Employee Signature:
Date:
2019 Annual Open Enrollment/Change Form Active Subway Surface Supervisors Association (SSSA), TWU Local 106 Transit Supervisors Organization (TSO) Operating and
Queens Supervisory, Coin Retriever Employees, MSII SSII and Special Inspectors
HR-BEN-368A
Business Service Center
Last Revised: 08/10/2018 /23/2018
Creation Date: 04/01/2012
1. For a Spouse
A copy of your Marriage Certificate, Birth Certificate, and Social Security Card are required. In place of required Birth Certificate, any of the following official government documents can be submitted:
o Valid Drivers’ License-New York o Resident Alien Card o Valid US Passport o A letter from Social Security containing your date of birth o Public Assistance ID Card o Government Employment ID Card
If your date of marriage is more than one year old, proof of joint ownership is required.
Both the enrollee’s and spouse’s names must be listed on the documentation of joint ownership. Where indicated, proof* must be dated within the past 90 days. Any financial information or account numbers can be removed.
Examples include a copy of:
o Your most recent tax return showing “Married Filing Jointly” or “Married Filing Separately.” Your spouse’s name must appear on the tax form on the line provided after the “married filing separately” status (or vice versa). Submit page 1 of the tax return.
o Homeowners/Renters Insurance Policy o *Credit Card Statement o *Loan Obligation or Bank Account Statement o Pension/life insurance/a Will designating your spouse as beneficiary o *Mortgage Statement /Rental/Lease Agreement or Property Tax Document o *Utility/phone/internet/cable bills
If you are not able to provide the required documentation, please complete the Employee/Retiree Affidavit, have it notarized and return it with your Enrollment form.
2. For Children
For a Natural-Born Child, a copy of: For a Stepchild, or Legally Adopted Child, a copy of: o Birth Certificate showing employee’s name o Birth Certificate o Social Security card o Social Security card o Puerto Rican Birth Certificates issued prior
to July 1, 2010 are unacceptable
o Legal documentation concerning adoption
3. Dependent Children Coverage between ages 19 and 26 o To enroll a dependent child from age 19 to 26 in your medical, hospital, and prescription drug coverage, add the child’s
name on this form, submit required documentation, and affirm by signing this form that your child is not eligible for other employer-sponsored coverage.
o To continue covering a dependent child from age 19 to 25 on dental, you are required to submit a full-time student
verification letter. Students will also be entitled to vision coverage under EyeMed.
Section 6 – Dependent Required Documentation
EMPLOYEE OR RETIREE AFFIDAVIT
STATE OF
COUNTY OF DATE:_________________________
NAME [ ] BSC ID # [ ]
being duly sworn, deposes and says:
1. I am an employee of or have retired from [circle appropriate agency]
New York City Transit Authority or MaBSTOA or SIRTOA or MTA BUS Co.
2. I make this affidavit based on personal knowledge and under penalties of perjury.
3. My spouse [PRINT NAME], ______________________________________________,
is currently not covered by my health insurance as a dependent on my plan.
4. I am unable to provide a copy of the top half of the front page of my most recent federal tax return
that includes my spouse (with financial information blacked out); and the E-File confirmation
page, Tax Preparer’s Summary, or the Federal Return Recap; nor can I provide any of the
following alternate documentation of joint ownership, dated no earlier than twelve (12) months
prior to my application for coverage for my spouse:
Homeowners/Renters Insurance Policy
Credit Card Statement
Loan Obligation or Bank Account Statement
Pension/Life Insurance/a Will designating your spouse as beneficiary
Mortgage Statement/Rental/Lease Agreement or Property Tax Document
Utility/phone/internet/cable bills
Despite my inability to produce any of the necessary documentation, I hereby affirm, under penalties
of perjury, that my spouse and I are currently married and that we are not legally separated or
divorced.
PRINT EMPLOYEE OR RETIREE NAME
Sworn to before me this ____________________________________
_____ day of________ 20____ Date Month Year
SIGNATURE OF EMPLOYEE OR RETIREE
NOTARY PUBLIC ____________________________________ 13333090
OMB 0938-0990
CMS Form 10182-CC Updated July 2018
If you or your family members aren’t currently covered by Medicare and won’t be covered
by Medicare in the next year, this notice does not apply to you.
Important Notice from New York City Transit (NYCT) About
Your Prescription Drug Coverage and Medicare
Please read this notice carefully and keep it where you can find it. This notice has information about your current prescription drug coverage with New York City Transit and about your options under Medicare’s prescription drug coverage. This information can help you decide whether or not you want to join a Medicare drug plan. If you are considering joining, you should compare your current coverage, including which drugs are covered at what cost, with the coverage and costs of the plans offering Medicare prescription drug coverage in your area. Information about where you can get help to make decisions about your prescription drug coverage is at the end of this notice. There are two important things you need to know about your current coverage and Medicare’s prescription drug coverage: 1. Medicare prescription drug coverage became available in 2006 to everyone with Medicare. You can get this coverage if you join a Medicare Prescription Drug Plan or join a Medicare Advantage Plan (like an HMO or PPO) that offers prescription drug coverage. All Medicare drug plans provide at least a standard level of coverage set by Medicare. Some plans may also offer more coverage for a higher monthly premium. 2. NYCT has determined that the prescription drug coverage we offer is, on average for all plan participants, expected to pay out as much as standard Medicare prescription drug coverage pays and is therefore considered Creditable Coverage. Because your existing coverage is Creditable Coverage, you can keep this coverage and not pay a higher premium (a penalty) if you later decide to join a Medicare drug plan.
When Can You Join A Medicare Drug Plan? You can join a Medicare drug plan when you first become eligible for Medicare and each year thereafter during the open enrollment period. For 2019, the open enrollment period will be from October 15th through December 7th, 2018. According to the Paperwork Reduction Act of 1995, no persons are required to respond to a collection of information unless it displays a valid OMB control number. The valid OMB control number for this information collection is 0938-0990. The time required to complete this information collection is estimated to average 8 hours per response initially, including the time to review instructions, search existing data resources, gather the data needed, and complete and review the information collection. If you have comments concerning the accuracy of the time estimate(s) or suggestions for improving this form, please write to: CMS, 7500 Security Boulevard, Attn: PRA Reports Clearance Officer, Mail Stop C4-26-05, Baltimore, Maryland 21244-1850.
OMB 0938-0990
CMS Form 10182-CC Updated July 2018
However, if you lose your current creditable prescription drug coverage, through no fault of your own, you will also be eligible for a two (2) month Special Enrollment Period (SEP) to join a Medicare drug plan.
What Happens To Your Current Coverage If You Decide to Join A Medicare Drug Plan? If you decide to join a Medicare drug plan, you will still be eligible to receive retiree medical and prescription coverage. However, NYCT’s plan will pay secondary to Medicare.
When Will You Pay A Higher Premium (Penalty) To Join A Medicare Drug Plan? You should also know that if you drop or lose your current coverage with NYCT and don’t join a Medicare drug plan within 63 continuous days after your current coverage ends, you may pay a higher premium (a penalty) to join a Medicare drug plan later. If you go 63 continuous days or longer without creditable prescription drug coverage, your monthly premium may go up by at least 1% of the Medicare base beneficiary premium per month for every month that you did not have that coverage. For example, if you go nineteen months without creditable coverage, your premium may consistently be at least 19% higher than the Medicare base beneficiary premium. You may have to pay this higher premium (a penalty) as long as you have Medicare prescription drug coverage. In addition, you may have to wait until the following October to join.
For More Information about This Notice or Your Current Prescription Drug Coverage… Contact information is provided below if you need further information. NOTE: You will get this notice each year. You will also get it before the next period you can join a Medicare drug plan, and if this coverage through NYCT changes. You also may request a copy of this notice at any time.
MTA Business Service Center: Call: 646-376-0123 (8:30 a.m. – 5:00 p.m., Monday through Friday) Fax: 212-852-8700 Email: [email protected]
OMB 0938-0990
CMS Form 10182-CC Updated July 2018
For More Information about Your Options Under Medicare Prescription Drug Coverage… More detailed information about Medicare plans that offer prescription drug coverage is in the “Medicare & You” handbook. You’ll get a copy of the handbook in the mail every year from Medicare. You may also be contacted directly by Medicare drug plans. For more information about Medicare prescription drug coverage: • Visit www.medicare.gov. • Call your State Health Insurance Assistance Program (see the inside back cover of your copy of the “Medicare & You” handbook for their telephone number) for personalized help. • Call 1-800-MEDICARE (1-800-633-4227). TTY users should call 1-877-486-2048. If you have limited income and resources, extra help paying for Medicare prescription drug coverage is available. For information about this extra help, visit Social Security on the web at www.socialsecurity.gov or call them at 1-800-772-1213 (TTY 1-800-325-0778). Remember: Keep this Creditable Coverage notice. If you decide to join one of the Medicare drug plans, you may be required to provide a copy of this notice when you join to show whether or not you have maintained creditable coverage and, therefore, whether or not you are required to pay a higher premium (a penalty).
Agreement to Decline (Opt-Out) Medical Coverage
Non-Represented and Eligible Represented Employees
HR-BEN-036
Section 1 - Information and Instructions
The purpose of this form is to decline MTA sponsored benefits coverage. Unless otherwise stated, the MTA Business Service Center (BSC) will assume that each year you would like to continue your opt-out agreement, and will never request this form again. If you wish to enroll in MTA Benefits coverage during any point of your tenure with the MTA, you will only be able to do so during the open enrollment period, or a qualifying life event.
Please email completed form to [email protected] fax to 212-852-8700.
If you have any questions, please contact the Business Service Center (BSC) at 646-376-0123 or [email protected].
Section 2 - Employee Information
Print Name
Last First M.I. Suffix
BSC ID
Agency/Dept. (check one)
BSC B&T CC HQ NYCT
Department
SIR LIRR MNR MTA Bus MABSTOA
Street Address
City State Zip Code
Phone (H) Phone (W) Email
Section 3 – Incentive Selection
Select the option that will be applicable for the entire year of 20
***INITIAL YOUR SELECTION***
I am an employee who receives medical coverage through my spouse/domestic partner who is also employed by
the Metropolitan Transportation Authority or another MTA agency, and I, therefore, decline health coverage. Incentive
for this option is $1,000 or $550. Payment will occur after the end of the plan year.
I am an employee without dependent(s) declining individual coverage. Incentive for this option is $1,000 or $550. Payment will occur after the end of the plan year.
I am an employee with dependent(s) declining family coverage. Incentive for this option is $3,000 or $1,100. Payment will occur after the end of the plan year.
Note: If you have previously waived coverage or you do not currently have dependent coverage, you must provide documentation for dependents in order to opt out of family coverage. See the enrollment form for details.
Section 4 – Medical Coverage Information
Provide the information relative to the medical plan that you will be enrolled in for the year 20
Name of Insurance Company: Plan Sponsor (Employer):
Name of Policyholder: Relationship:
Section 5 – Medical Coverage Information
I understand that this election will be effective from January 1 through my tenure with the MTA, unless I am no longer allowed by law or as a result of a qualifying event or such other events as the Authority determines will permit a change or revocation of an election. I understand that the lump sum payment will be subject to all applicable federal, state and local taxes. I also understand that these monies will not be considered income for pension purposes and will not be included in any calculation therein.
THIS AGREEMENT IS SUBJECT TO THE TERMS OF THE EMPLOYER'S PLAN, AS AMENDED FROM TIME TO TIME IN EFFECT, SHALL BE GOVERNED BY AND CONSTRUED IN ACCORDANCE WITH APPLICABLE LAWS, SHALL TAKE EFFECT AS A SEALED INSTRUMENT UNDER APPLICABLE LAWS, AND REVOKES ANY PRIOR ELECTION AND COMPENSATION AGREEMENT RELATING TO SUCH PLAN. THE HEALTH BENEFITS WAIVER WILL BE ADMINISTERED AS PERMISSIBLE UNDER IRC SECTION 125.
Employee Signature Date SSN Last 4 Digits
Business Service Center Last Revised: 09/19/2018 Creation Date: 04/01/2012
EMPLOYEE OR RETIREE AFFIDAVIT
STATE OF
COUNTY OF DATE:_________________________
NAME [ ] BSC ID # [ ]
being duly sworn, deposes and says:
1. I am an employee of or have retired from [circle appropriate agency]
New York City Transit Authority or MaBSTOA or SIRTOA or MTA BUS Co.
2. I make this affidavit based on personal knowledge and under penalties of perjury.
3. My spouse [PRINT NAME], ______________________________________________,
is currently not covered by my health insurance as a dependent on my plan.
4. I am unable to provide a copy of the top half of the front page of my most recent federal tax return
that includes my spouse (with financial information blacked out); and the E-File confirmation
page, Tax Preparer’s Summary, or the Federal Return Recap; nor can I provide any of the
following alternate documentation of joint ownership, dated no earlier than twelve (12) months
prior to my application for coverage for my spouse:
Homeowners/Renters Insurance Policy
Credit Card Statement
Loan Obligation or Bank Account Statement
Pension/Life Insurance/a Will designating your spouse as beneficiary
Mortgage Statement/Rental/Lease Agreement or Property Tax Document
Utility/phone/internet/cable bills
Despite my inability to produce any of the necessary documentation, I hereby affirm, under penalties
of perjury, that my spouse and I are currently married and that we are not legally separated or
divorced.
PRINT EMPLOYEE OR RETIREE NAME
Sworn to before me this ____________________________________
_____ day of________ 20____ Date Month Year
SIGNATURE OF EMPLOYEE OR RETIREE
NOTARY PUBLIC ____________________________________ 13333090
Agreement to Decline (Opt-Out) Medical Coverage
Non-Represented and Eligible Represented Employees
HR-BEN-036
Section 1 - Information and Instructions
The purpose of this form is to decline MTA sponsored benefits coverage. Unless otherwise stated, the MTA Business Service Center (BSC) will assume that each year you would like to continue your opt-out agreement, and will never request this form again. If you wish to enroll in MTA Benefits coverage during any point of your tenure with the MTA, you will only be able to do so during the open enrollment period, or a qualifying life event.
Please email completed form to [email protected] fax to 212-852-8700.
If you have any questions, please contact the Business Service Center (BSC) at 646-376-0123 or [email protected].
Section 2 - Employee Information
Print Name
Last First M.I. Suffix
BSC ID
Agency/Dept. (check one)
BSC B&T CC HQ NYCT
Department
SIR LIRR MNR MTA Bus MABSTOA
Street Address
City State Zip Code
Phone (H) Phone (W) Email
Section 3 – Incentive Selection
Select the option that will be applicable for the entire year of 20
***INITIAL YOUR SELECTION***
I am an employee who receives medical coverage through my spouse/domestic partner who is also employed by
the Metropolitan Transportation Authority or another MTA agency, and I, therefore, decline health coverage. Incentive
for this option is $1,000 or $550. Payment will occur after the end of the plan year.
I am an employee without dependent(s) declining individual coverage. Incentive for this option is $1,000 or $550. Payment will occur after the end of the plan year.
I am an employee with dependent(s) declining family coverage. Incentive for this option is $3,000 or $1,100. Payment will occur after the end of the plan year.
Note: If you have previously waived coverage or you do not currently have dependent coverage, you must provide documentation for dependents in order to opt out of family coverage. See the enrollment form for details.
Section 4 – Medical Coverage Information
Provide the information relative to the medical plan that you will be enrolled in for the year 20
Name of Insurance Company: Plan Sponsor (Employer):
Name of Policyholder: Relationship:
Section 5 – Medical Coverage Information
I understand that this election will be effective from January 1 through my tenure with the MTA, unless I am no longer allowed by law or as a result of a qualifying event or such other events as the Authority determines will permit a change or revocation of an election. I understand that the lump sum payment will be subject to all applicable federal, state and local taxes. I also understand that these monies will not be considered income for pension purposes and will not be included in any calculation therein.
THIS AGREEMENT IS SUBJECT TO THE TERMS OF THE EMPLOYER'S PLAN, AS AMENDED FROM TIME TO TIME IN EFFECT, SHALL BE GOVERNED BY AND CONSTRUED IN ACCORDANCE WITH APPLICABLE LAWS, SHALL TAKE EFFECT AS A SEALED INSTRUMENT UNDER APPLICABLE LAWS, AND REVOKES ANY PRIOR ELECTION AND COMPENSATION AGREEMENT RELATING TO SUCH PLAN. THE HEALTH BENEFITS WAIVER WILL BE ADMINISTERED AS PERMISSIBLE UNDER IRC SECTION 125.
Employee Signature Date SSN Last 4 Digits
Business Service Center Last Revised: 09/19/2018 Creation Date: 04/01/2012
EMPLOYEE BENEFITS DIVISION
INSTRUCTIONS FOR THE PS-404
NYS HEALTH INSURANCE TRANSACTION FORM
State of New York
Department of Civil Service
Alfred E. Smith State Office Bldg.
Albany, NY 12239 PS-404 OE2019
Page 1
New Enrollees (also complete 10.G for family coverage)
Note: for new enrollments in a Health Maintenance Organization (HMO), complete an HMO form in
addition to this form.
10.A Request Enrollment – Individual Check box to enroll in individual coverage. Check Medical,
Dental and/or Vision boxes for coverage being enrolled.
10.B Request Enrollment – Family Check box to enroll in family coverage. Check Medical,
Dental and/or Vision boxes for coverage being enrolled.
10.C Elect Pre-Tax Status? New Enrollees choose to enroll in or decline the Pre-Tax
Contribution Program for medical coverage.
10.D Decline Coverage Check box to decline coverage. Check Medical, Dental
and/or Vision boxes for coverage being declined.
Cancellation or Change in Coverage
10.E Voluntarily Cancel
Coverage
The enrollee is entitled to make separate decisions regarding their
medical, dental and vision coverages. Enrollees may cancel or change
their dental and/or vision coverage(s) at any time during the year.
Pre-tax medical enrollees may only cancel coverage during the Pre-
Tax Open Enrollment Period, or with a qualifying event (enter the
qualifying event). If you are going on Leave Without Pay, also
complete Box 12.
10.F Change Coverage Check this box to change from Individual to Family, or from Family to
Individual coverage. Pre-tax medical enrollees may only change their
coverage from Family to Individual during the Pre-Tax Open
Enrollment Period, or with a qualifying event (check the qualifying
event and enter the Date of Event). Check Medical, Dental, and/or
Vision boxes for coverage being changed.
10.G Add/Change/Delete
Dependents
Check the box to add or delete dependents or to change dependent
information. Check Medical, Dental, and/or Vision boxes that apply.
Complete all dependent information including date of birth.
Additional documentation may be required to add the dependent.
10.H Change Medical
Benefit Plan
Complete during annual Option Transfer Period or with a qualifying
event (for example, change of address outside of HMO area.)
10.I Change Pre-Tax Status Existing enrollees can only change pre-tax status during the annual
Pre-Tax Open Enrollment Period in November.
Boxes 1 - 9 All enrollees must complete boxes 1 – 9 with their personal information.
Note: Marital Status Date is used to show date of marriage, separation or divorce when those marital
statuses are selected.
Box 10 (A – I) Complete appropriate sections. The employee is entitled to make separate choices regarding their
medical, dental and vision coverages. They may decline any of the three, all of the three, or none of the
three different coverage options. Also, they many enroll in family coverage in one benefit and
individual coverage in another.
Reminder: Enrollees with a Benefit Fund (CSEA, UUP and DC-37) receive their dental and vision
benefits through that Fund. Do not enter dental and vision information on NYBEAS for these
enrollees.
EMPLOYEE BENEFITS DIVISION
INSTRUCTIONS FOR THE PS-404
NYS HEALTH INSURANCE TRANSACTION FORM
State of New York
Department of Civil Service
Alfred E. Smith State Office Bldg.
Albany, NY 12239 PS-404 OE2019
Page 2
Box 12 LEAVE WITHOUT
PAY SECTION
Enrollees going on leave without pay who request cancellation of coverage at
the time they leave the payroll must complete this section. To request
permanent cancellation of coverage, check the appropriate box and cross out the
sentence which reads “I wish to resume my coverage upon return to the
payroll.”
RETIREMENT
SECTION
Enrollees leaving the payroll due to retirement must complete this section to
indicate their decision to either defer or continue health insurance coverage as a
retiree. A PS-406.2 must be completed for enrollees requesting deferment of
medical coverage, prior to retirement.
AGENCY/EBD USE ONLY This section is for Agency and/or EBD use only and is provided to assist in
updating the enrollee’s record on NYBEAS.
Action/Reason Transaction that will be inputted into NYBEAS by HBA.
Date of Event Date the event took place, which resulted in the enrollee requesting a change to
benefits. Example: first day worked, first day on leave, date of birth, date of
marriage.
Hire Date Original date of hire or rehire. (Only needed for new enrollment).
Date of 1st
Eligibility (PE only) The first day the enrollee is eligible for coverage.
Percentage Working Enrollee’s percentage on payroll.
Agency Code Enrollee’s agency code.
Neg. Unit Enrollee’s negotiating unit.
Ret. System The retirement system for the enrollee (ERS, TRS or PFS)
Retirement Tier Tier 1, 2, 3 or 4.
Sick Leave Information - # Hours Number of sick leave hours for enrollee at time of retirement.
Sick Leave Information - Hourly
Rate of Pay
Enrollee’s hourly rate of pay based on annual salary at the time of retirement.
(See Hourly Rate Calculation memo NY99-22).
Date Entered on NYBEAS Date HBA processes the transaction on NYBEAS.
Effective Date The effective date assigned to the transaction by NYBEAS.
Note: When updating NYBEAS, use Date in Authorization Box as Date of Request.
Legal changed
EXAMPLES OF DOCUMENTATION REQUIRED TO PROCESS YOUR TRANSACTION
Employees Spouse/Domestic Partner Children
Copy of Birth Certificate Copy of Birth Certificate Copy of Birth Certificate
Copy of Social Security Card Copy of Social Security Card Copy of Social Security Card
Copy of Marriage Certificate or Complete PS-425 series Domestic Partner, if Applicable
Completed PS-451 – Statement of
Disability and Required Documentation,
if Applicable
For Changes of Coverage, copy of Marriage
Certificate, Divorce Order, Death Certificate,
PS-425.4 (Domestic Partner), as appropriate
Completed PS-457 – Statement of
Dependence and Required
Documentation, if Applicable
Box 11 Complete previous coverage information, if applicable.
Box 13 Request for Empire Plan Cards Only – complete this section to order a duplicate or replacement Benefit
Card. Do not complete this section if requesting a change to your health insurance coverage. A new card
will be issued automatically.
AUTHORIZATION Employees must SIGN and DATE this form.
INSTRUCTIONS: READ AND COMPLETE BOTH SIDES/PAGES. PLEASE PRINT AND CHECK THE APPROPRIATE CHOICES.
EMPLOYEE INFORMATION (All employees must complete)
1. Last Name First Name MI 2. Social Security Number 3. Sex Male Female
4. Street Address City State
Zip
5. Date of Birth 6. Telephone Numbers
Home ( ) Work ( )
7. Work location and address
8. Marital Status
Single
Married
Widowed
Divorced
Separated Marital Status Date
9. Covered under Medicare? Self Yes No Spouse/Domestic Partner/Dependent? Yes No
10. ENTER REQUEST(S) BELOW
A. Request Enrollment-
Individual
(Select Empire Plan or HMO)
Empire Plan HMO* Code Name
B. Request Enrollment-
Family (Complete G)
(Select Empire Plan or HMO) Empire Plan HMO* Code Name
C. Elect Pre-Tax Status for
Premium deduction? Yes
No
Note: pretax deductions may not be offered by all
agencies. Verify eligibility with your agency.
D. Decline Coverage For Agency Use: (Process WAV/BEN transaction)
E. Voluntarily Cancel Coverage
F. Change Coverage
Date of Event
Change to FAMILY (Complete G)
Marriage
Domestic Partner
First dependent child acquired
Dependent returned to full-time student status Request coverage for dependents not previously covered
Newborn
Previous coverage terminated (Complete Section 11)
Other
Change to INDIVIDUAL I voluntarily cancel coverage for my dependents
I voluntarily cancel coverage for my domestic partner
Only dependent died
Only dependent married
Only dependent graduated
Divorce
Only dependent disqualified by age Termination of domestic partnership (Attach Completed PS-428.4)
Other
G. DEPENDENT INFORMATION (use additional sheets if necessary)
Check One: A (Add), D (Delete) or C (Change) Date of Event
Last Name First Name MI Relationship Date of Birth Sex Address (if different) Social Security
Number
A
D
C
A D
C
A D
C
A D
C
A D
C
* A completed HMO form must be attached.
State of New York
Department of Civil Service
Alfred E. Smith State Office Bldg.
Albany, NY 12239
EMPLOYEE BENEFITS DIVISION
NYS HEALTH INSURANCE TRANSACTION FORM
For Participating Employers PS-404 OE2019
NYS Department of Civil Service, Albany, NY 12239 Health Insurance Transaction Form For Participating Employers
PS-404 PE OE2019 Page 2
10. Continued. ENTER REQUEST(S) BELOW
H. Change Medical Benefit Plan Change to: Empire Plan HMO* Code HMO Name_______________
* A completed HMO form must be attached.
11. PREVIOUS COVERAGE INFORMATION
If you were previously covered under NYSHIP
or another health insurance plan (attach proof,
i.e. insurance bill or letter stating former
coverage), please complete this section.
Previous ID Number Date Coverage
Terminated
Enrollee’s Name Under
Which Previously Covered
Last First Middle Initial
12. LEAVE WITHOUT PAY AND RETIREMENT STATUS
LEAVE
WITHOUT PAY
I wish to continue coverage while I am on authorized leave.
I understand that I will be billed for this coverage.
I do not wish to continue coverage while I am on authorized leave.
I wish to resume my coverage upon return to the payroll.
I understand the requirements for continuing medical insurance coverage
as a retiree and wish to continue my coverage.
RETIREMENT I understand the requirements for continuing medical insurance coverage
as a retiree and wish to defer my coverage. (A completed PS-406.2 must be attached.)
13. REQUEST FOR EMPIRE PLAN CARD ONLY
For Health Maintenance Organization (HMO) cards, contact your HMO.
DUPLICATE CARD
(Previously issued card remains valid.)
REPLACEMENT CARD
(Previously issued card(s), lost or stolen, become invalid.)
FOR ENROLLEE
ENROLLEE AND ALL DEPENDENTS
INDIVIDUAL DEPENDENT
Name
Personal Privacy Protection Law Notification
This information you provide on this application is requested in accordance with Section 163 of the New York State Civil Service Law for the principal purpose of enabling
the Department of Civil Service to process your request concerning health insurance coverage. This information will be used in accordance with Section 96 (1) of the
Personal Privacy Protection Law, particularly subdivisions (b), (e) and (f). Failure to provide the information requested may interfere with our ability to comply with your request. This information will be maintained by the Director of the Employee Benefits Division, NYS Department of Civil Service, Albany, NY 12239. For information
concerning the Personal Protection Law, call (518) 457-9375. For information related to the Health Insurance Program, contact your Agency Health Benefits
Administrator. If, after calling your Agency Health Benefits Administrator, you need more information, please call (518) 457-5754 or 1-800-833-4344 between the hours of 9:00 a.m. and 3:00 p.m.
AUTHORIZATION
I have read the Pre-Tax Contribution Program memorandum and have made my selection on Page 1 of this document, if applicable. I understand that if I
voluntarily decline or cancel my coverage, I may subject myself and/or my dependents to waiting periods if I decide to enroll at a later date, and I may
be forfeiting the right to such coverage after leaving State service (vest, retirement, etc.). I certify that the information I have supplied is true and
correct. I understand that my failure to provide required proof(s) within 28 days (30 days for newborns) may delay the availability of benefits for me or
any dependent for whom I fail to provide such proof. Any person who makes a misstatement of fact or conceals any pertinent information, commits a
crime which is subject to a $5,000 penalty and the stated value of the claim for each violation. I hereby authorize deduction from my salary or
retirement allowance of the amount required, if any, for insurance indicated above. This authorization shall be in effect until I revoke it in writing.
Employee’s Signature (Required) Signature Date (Required)
AGENCY/EBD USE ONLY
Action/Reason Date of Event Hire Date Date of 1
st
Eligibility
Percentage
Working Agency Code
Neg.
Unit Ret. System
Retirement Tier Registration # Sick Leave Information Date Entered on
NYBEAS Effective Date
# Hours Hourly Rate of Pay
HBA Signature: Date:
2019 Open Enrollment/Change Form - Dental Active Managers, Non-Rep C/S, OSA, DC 37 with NR Benefits and TWU with NR Benefits HR-BEN-367A
Business Service Center
Last Revised: 08/10/2018 Creation Date: 04/01/2012
Section 1 - Information and Instructions
The purpose of this form is to enroll in or change dental insurance, effective January 1, 2019.
Please email a signed copy of the form to [email protected] or fax to 212-852-8700 or drop off at the 180 Livingston Street W alk-in Center
8:30 a.m. to 5 p.m., Monday – Friday. If you have any questions, please contact the Business Service Center (BSC) at 646-376-0123.
Section 2 - Employee Information
Print Name
Last First M.I. Suffix
BSC ID
Pass #
Phone (H) Phone (W ) Email
If your address on your pay stub is incorrect, contact the Business Service Center OR log onto www.mymta.info and change your address online OR complete HR-HRIS-012 Employee Data Change Form. An incorrect address will delay receipt of your new health insurance cards.
Section 3 – Coverage Election – Effective January 1, 2019
Dental Individual Family
Check One
METLIFE
DENTCARE (HEALTHPLEX)
Section 4 – Dependent Information
If you are found to be covering an ineligible dependent, coverage will be terminated retroactive to the date of the ineligibility and NYC Transit will pursue financial restitution for claims and/or premiums for the ineligible dependent.
1. Please fill in all information for new dependents you wish to enroll and submit required documentation (see Section 6). 2. Please fill in all information for any dependents you wish to delete. 3. Please contact the Business Service Center for the Domestic Partnership Package if you wish to enroll a domestic partner. NOTE: Your domestic partner will not be enrolled in health coverage unless an application is submitted and approved by the Benefits Department.
Check One - Indicate (A) Add or (D) Delete Check One - Relationship Gender Date of Birth
A D Name SSN Spouse Domestic Partner Child F M Mo Day Year
Section 5 - Authorization
My signature and date on this form certifies and warrants that all dependent eligibility information is true, correct, and current. I also certify that dependent children from age 19 to 26 that I have enrolled in coverage are not eligible for another employer-sponsored coverage.
Employee Signature:
Date:
2019 Open Enrollment/Change Form - Dental Active Managers, Non-Rep C/S, OSA, DC 37 with NR Benefits and TWU with NR Benefits HR-BEN-367A
Business Service Center
Last Revised: 08/10/2018 Creation Date: 04/01/2012
1. For a Spouse A copy of your Marriage Certificate, Birth Certificate, and Social Security Card are required.
In place of required Birth Certificate, any of the following official government documents can be submitted: o Valid Drivers’ License-New York o Resident Alien Card o Valid US Passport o A letter from Social Security containing your date of birth o Public Assistance ID Card o Government Employment ID Card
If your date of marriage is more than one year old, proof of joint ownership is required.
Both the enrollee’s and spouse’s names must be listed on the documentation of joint ownership. Where indicated, proof* must be dated within the past 90 days. Any financial information or account numbers can be removed.
Examples include a copy of:
o Your most recent tax return showing “Married Filing Jointly” or “Married Filing Separately.” Your spouse’s name must appear on the tax form on the line provided after the “married filing separately” status (or vice versa). Submit page 1 of the tax return.
o Homeowners/Renters Insurance Policy o *Credit Card Statement o *Loan Obligation or Bank Account Statement o Pension/life insurance/a Will designating your spouse as beneficiary o *Mortgage Statement /Rental/Lease Agreement or Property Tax Document o *Utility/phone/internet/cable bills
If you are not able to provide the required documentation, please complete the Employee/Retiree Affidavit, have it notarized and return it with your Enrollment form.
2. For Children
For a Natural-Born Child, a copy of: For a Stepchild, or Legally Adopted Child, a copy of: o Birth Certificate showing employee’s name o Birth Certificate o Social Security card o Social Security card o Puerto Rican Birth Certificates issued prior
to July 1, 2010 are unacceptable
o Legal documentation concerning adoption
3. Dependent Children Coverage between ages 19 and 26 o To enroll a dependent child from age 19 to 26 in your medical, hospital, and prescription drug coverage, add the
child’s name on this form, submit required documentation, and affirm by signing this form that your child is not eligible for other employer-sponsored coverage.
o To continue covering a dependent child from age 19 to 25 on dental, you are required to submit a full-time student verification letter. Students will also be entitled to vision coverage under EyeMed.
Section 6 – Dependent Required Documentation
2019 Annual Open Enrollment/Change Form Active Subway Surface Supervisors Association (SSSA), TWU Local 106 Transit Supervisors Organization (TSO) Operating and
Queens Supervisory, Coin Retriever Employees, MSII SSII and Special Inspectors
HR-BEN-368A
Business Service Center
Last Revised: 08/10/2018 /23/2018
Creation Date: 04/01/2012
Section 1 - Information and Instructions
The purpose of this form is to enroll in or change health insurance, effective January 1, 2019.
Please email a signed copy of the form to [email protected] or fax to 212-852-8700 or drop off at the 180 Livingston Street Walk-in Center 8:30 a.m. to 5 p.m., Monday – Friday. If you have any questions, please contact the Business Service Center (BSC) at 646-376-0123.
Section 2 - Employee Information
Print Name
Last First M.I. Suffix
BSC ID
Pass #
Phone (H) Phone (W) Email
If your address on your pay stub is incorrect, contact the Business Service Center OR log onto www.mymta.info and change
your address online OR complete HR-HRIS-012 Employee Data Change Form. An incorrect address will delay receipt of your
new health insurance cards.
Section 3 – Coverage Election – Effective January 1, 2019
Dental Individual Family
Check One
METLIFE (Fee Schedule)
METLIFE PPO
DENTCARE (HEALTHPLEX)
PLAN A – AMERICAN DENTAL CENTERS
PLAN B – ProBENEFITS Administrators (The Dental Shop)
Section 4 – Dependent Information
If you are found to be covering an ineligible dependent, coverage will be terminated retroactive to the date of the ineligibility and NYC Transit will pursue financial restitution for claims and/or premiums for the ineligible dependent.
1. Please fill in all information for new dependents you wish to enroll and submit required documentation (see Section 6). 2. Please fill in all information for any dependents you wish to delete. 3. Please contact the Business Service Center for the Domestic Partnership Package if you wish to enroll a domestic partner.
NOTE: Your domestic partner will not be enrolled in health coverage unless an application is submitted and approved by the Benefits Department.
Check One - Indicate (A) Add or (D) Delete Check One - Relationship Gender Date of Birth
A D Name SSN Spouse Domestic Partner Child F M Mo Day Year
Section 5 - Authorization
My signature and date on this form certifies and warrants that all dependent eligibility information is true, correct, and current. I also certify that dependent children from age 19 to 26 that I have enrolled in coverage are not eligible for another employer-sponsored coverage.
Employee Signature:
Date:
2019 Annual Open Enrollment/Change Form Active Subway Surface Supervisors Association (SSSA), TWU Local 106 Transit Supervisors Organization (TSO) Operating and
Queens Supervisory, Coin Retriever Employees, MSII SSII and Special Inspectors
HR-BEN-368A
Business Service Center
Last Revised: 08/10/2018 /23/2018
Creation Date: 04/01/2012
1. For a Spouse
A copy of your Marriage Certificate, Birth Certificate, and Social Security Card are required. In place of required Birth Certificate, any of the following official government documents can be submitted:
o Valid Drivers’ License-New York o Resident Alien Card o Valid US Passport o A letter from Social Security containing your date of birth o Public Assistance ID Card o Government Employment ID Card
If your date of marriage is more than one year old, proof of joint ownership is required.
Both the enrollee’s and spouse’s names must be listed on the documentation of joint ownership. Where indicated, proof* must be dated within the past 90 days. Any financial information or account numbers can be removed.
Examples include a copy of:
o Your most recent tax return showing “Married Filing Jointly” or “Married Filing Separately.” Your spouse’s name must appear on the tax form on the line provided after the “married filing separately” status (or vice versa). Submit page 1 of the tax return.
o Homeowners/Renters Insurance Policy o *Credit Card Statement o *Loan Obligation or Bank Account Statement o Pension/life insurance/a Will designating your spouse as beneficiary o *Mortgage Statement /Rental/Lease Agreement or Property Tax Document o *Utility/phone/internet/cable bills
If you are not able to provide the required documentation, please complete the Employee/Retiree Affidavit, have it notarized and return it with your Enrollment form.
2. For Children
For a Natural-Born Child, a copy of: For a Stepchild, or Legally Adopted Child, a copy of: o Birth Certificate showing employee’s name o Birth Certificate o Social Security card o Social Security card o Puerto Rican Birth Certificates issued prior
to July 1, 2010 are unacceptable
o Legal documentation concerning adoption
3. Dependent Children Coverage between ages 19 and 26 o To enroll a dependent child from age 19 to 26 in your medical, hospital, and prescription drug coverage, add the child’s
name on this form, submit required documentation, and affirm by signing this form that your child is not eligible for other employer-sponsored coverage.
o To continue covering a dependent child from age 19 to 25 on dental, you are required to submit a full-time student
verification letter. Students will also be entitled to vision coverage under EyeMed.
Section 6 – Dependent Required Documentation