Welcome to Your Benefits Choices for 2019! · your benefits record by logging on to My MTA Portal at . Click the My Benefits ribbon to view your benefits information. If your dependent’s

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

mailto:[email protected]

http://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


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.





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.


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.

https://www.mymta.info/prod/groups/public/documents/authored/mtabscdmprd3236131.pdf


https://ucm.mtabsc.info/prod/groups/public/documents/authored/mtabscdmprd000239.pdf


http://www.mymta.info./

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.


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.


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.






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

http://www.cs.ny.gov/

http://www.healthplex.com/

http://www.metlife.com/

www.americandental.com

www.probenefitsadmin.com

http://www.eyemedvisioncare.com/

http://www.padmin.com/

http://www.prudential.com/mta

http://www.ny529atwork.com/

http://www.transitchek.com/

http://www.padmin.com/

http://www.mymedicare.gov/

http://www.ssa.gov/

http://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,


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.




State of New York




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


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



Albany, NY 12239



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_______________


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:




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


Last Revised: 08/10/2018 /23/2018

Creation Date: 04/01/2012


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.


Print Name


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.



Check One

METLIFE (Fee Schedule)

METLIFE PPO


PLAN A – AMERICAN DENTAL CENTERS

PLAN B – ProBENEFITS Administrators (The Dental Shop)



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.





Employee Signature:

Date:



HR-BEN-368A


Last Revised: 08/10/2018 /23/2018


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







2. For Children




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.


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


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


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).

http://www.medicare.gov/

http://www.socialsecurity.gov/

Agreement to Decline (Opt-Out) Medical Coverage

Non-Represented and Eligible Represented Employees

HR-BEN-036


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].


Print Name


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


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:


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


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].


Print Name


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


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.


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:


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




State of New York




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,


10.B Request Enrollment – Family Check box to enroll in family coverage. Check Medical,


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.




State of New York




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


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


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


State of New York



Albany, NY 12239



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_______________


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:





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.


Print Name


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.



Check One

METLIFE




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.





Employee Signature:

Date:




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







2. For Children




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.




HR-BEN-368A


Last Revised: 08/10/2018 /23/2018



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.


Print Name


BSC ID

Pass #


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.



Check One

METLIFE (Fee Schedule)

METLIFE PPO


PLAN A – AMERICAN DENTAL CENTERS

PLAN B – ProBENEFITS Administrators (The Dental Shop)



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.





Employee Signature:

Date:



HR-BEN-368A


Last Revised: 08/10/2018 /23/2018


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







2. For Children




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.


Documents

Welcome to Your Benefits Choices for 2019! · your benefits record by logging on to My MTA Portal at . Click the My Benefits ribbon to view your benefits information. If your dependent’s