the archdiocese of new york benefits administration resource guide

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Eligibility Effective Date Employee Contribution Benefit Summary ARCHDIOCESE OF NEW YORK Group Health Benefits Eligibility Employees who are regularly scheduled to work a minimum of 20 hours each week. Eligible dependent spouse. Unmarried, dependent children (natural or adopted) are eligible until the end of the calendar year in which the child turns 19 years old. Dependent children enrolled as full time college students are eligible unitl the end of the year the child turns 25 years old as long as he/she is unmarried and enrolled in an accredited school on a full time basis. First of the month following 30 days of employment, provided you have completed the health enrollment form. **(Refer to footnotes) Fixed schedule based on type of coverage elected and regularly scheduled work hours. Refer to the following section which describes: *United Healthcare Choice Plus Plans: (In -network providers can be accessed via 800.736.1264 or www.myuhc.com) *Medicare Supplement for Retired Lay Employees over age 65, Clergy and Religious who have Medicare Primary Benefits. (MSYRX) *Notice of Privacy Practice (To be given to all health plan participants) *Authorization for Use and Disclosure of Private Health Information. (Health plan participants must complete and sign form to authorize local benefits administrator to help resolve health claim issues. Additional form is required by the health plan participant to authorize other persons to use and disclosure of medical claims information such as family member etc.) **Effective date is immediate for: Divs. 001 thru 005 - Bargaining/Non-Bargaining Lay Faculty Div. 040 - Non-Bargaining Lay Employees of CHSA Divs. 043 & 044 - Aegis of Religious Orders for Parish/CHSA & Private schools Divs. 050 & 051 - Religious Brothers & Sisters Div. 053 & 156 - Clergy Div. 055 - Seminarians Div. 153 - Clergy with Medicare Primary Coverage Div. 154 - Active and Retired Religious with Medicare Primary Coverage **Effective date is first of the month following 30 days of service: Div. 006 - Trustees of St. Patrick's Cathedral Div. 024 - Non-Bargaining Lay Employees of Cemeteries Div. 030A - Lay Employees of Outside Affiliated Agencies Div. 030B - Employees of Dominican Sisters Div. 031 - Catholic Charities Div. 032 - Non Bargaining Lay Employees of Private Schools Div. 033 - Central Services Div. 034 - Non Bargaining Lay Employees of Parishes and Parish Schools Div. 035 - Office of Drug Education (ADAPP) Div. 037 - St. Raymond's Cemetery (Non-Bargaining Employees) Div. 038 - Lay Employees of Dominican Fathers Div. 045 - St. Vincent de Paul Residence Grandfathered closed group Div. 134 - Active Non-Bargaining Lay Employee with Medicare Primary (>age 65 & < 20 ees) **Effective date is three months for: Div. 017 - Mission of the Immaculate Virgin (Non-bargaining) Div. 018 - Cabrini Home Div. 019 - St. Dominic's Home Div. 025 - Incarnation Children Center Div. 036 - Beacon of Hope Div. 047 - Mission of the Immaculate Virgin (Bargaining Unit) 11 07/2009
HOW TO ENROLL IN THE GROUP HEALTH BENEFIT PLAN AND/OR MAKE CHANGES TO A MEMBERS GROUP HEALTH BENEFIT COVERAGE OR CHANGE PERSONAL INFORMATION To enroll a new member, or to make changes to an existing member’s benefit Information: • The member must manually complete a “Health Benefit Plan Enrollment and Change Form” The new member should return the completed enrollment forms, to their local benefits administrator. The local administrator should retain copies of the completed forms for their records, and forward the original forms to: Employee Benefit Connections 1011 First Avenue – Room 1679 New York, NY 10022 212.371.1000, Ext. 3060 Fax 212.644.0690 Employee Benefit Connections must have the completed enrollment information, with all required documentation within 30 days of date of eligibility. Incomplete applications, or applications received more than 30 days after the effective date will NOT be processed. This applies to new enrollments, and as well as changes. Failure to comply can result in loss of member’s coverage. CHANGES TO HEALTH BENEFITS The member must complete a Health Benefit Plan Enrollment & Change Form, and attach any required documentation, and submit the form and documents to their local administrator. The administrator is responsible to review the forms and documents for accuracy and completeness, make copies for their records, and mail the original forms to Employee Benefit Connections (Address listed on form) for processing. TO OBTAIN HEALTH BENEFIT PLAN ENROLLMENT AND CHANGE FORMS PLEASE CONTACT EMPLOYEE BENEFIT CONNECTIONS AT: 212.371.1000, EXT. 3060 - 12 - Revised 07/2009
Page 1 and 2: THE ARCHDIOCESE OF NEW YORK BENEFIT
Page 3 and 4: THE ARCHDIOCESE OF NEW YORK BENEFIT
Page 5 and 6: Section I Important Information
Page 7 and 8: NEW EMPLOYEE CHECKLIST The followin
Page 9 and 10: BENEFITS ADMINISTRATOR RESOURCE CON
Page 11 and 12: VENDOR CONTACT PHONE WEBSITES POLIC
Page 13 and 14: RULES FOR MEMBER GROUPS PARTICIPATI
Page 15 and 16: 5. All clergy and religious orders
Page 17 and 18: BENEFIT ELIGIBILITY OUTLINE -5-
Page 19 and 20: BENEFITS ELIGIBILITY EFFECTIVE DATE
Page 21 and 22: DIVISION CLAIM CODES -6-
Page 23: Group 3000 - New York State Continu
Page 27 and 28: HEALTH INSURANCE PORTABILITY & ACCO
Page 29 and 30: Revised: January 1, 2006 Effective:
Page 35 and 36: ARCHDIOCESE OF NEW YORK AUTHORIZATI
Page 37: AUTHORIZATION FOR THE USE AND DISCL
Page 41 and 42: Annual Salary (Benefit Administrato
Page 43 and 44: ARCHDIOCESE OF NEW YORK Group Healt
Page 45 and 46: ARCHDIOCESE OF NEW YORK Group Healt
Page 47 and 48: STATEMENT OF DEPENDENT ELIGIBILITY
Page 49 and 50: THE ARCHDIOCESE OF NEW YORK SUMMARY
Page 51 and 52: Choice Plus Benefits Summary Types
Page 53 and 54: UnitedHealthcare Additional Benefit
Page 57 and 58: Choice Plus Benefits Summary Types
Page 59 and 60: UnitedHealthcare Additional Benefit
Page 63 and 64: Medicare Supplemental Plan Benefits
Page 65 and 66: Exclusions UnitedHealthcare Except
Page 67: HOW TO FILE A MEDICAL CLAIM There a
Page 70 and 71: HOW TO FILE A CLAIM FOR PRESCRIPTIO
Page 72 and 73: FILL IN FOR UP TO TWO PEOPLE WHO WI
Page 74 and 75: STEP 2 Submission Requirements: You
Page 77 and 78: ARCHDIOCESE OF NEW YORK BENEFITS TR
Page 79 and 80: ★ ★ REEMPLOYMENT RIGHTS YOUR RI
Page 81 and 82: ARCHDIOCESE OF NEW YORK NOTICE OF G
Page 83 and 84: Archdiocese of New York Group Healt
Page 87 and 88: GROUP HEALTH BENEFITS FOR EMPLOYEES
Page 89 and 90:
ARCHDIOCESE OF NEW YORK Group Healt
Page 91 and 92:
ARCHDIOCESE OF NEW YORK Group Healt
Page 93 and 94:
___________________________________
Page 95 and 96:
Section VI Administration of Life,
Page 97 and 98:
ARCHDIOCESE OF NEW YORK Life and Ac
Page 99:
HOW TO FILE A CLAIM FOR BASIC GROUP
Page 115 and 116:
GROUP LIFE INSURANCE BENEFITS FOR E
Page 122 and 123:
GROUP LIFE INSURANCE BENEFITS FOR E
Page 128 and 129:
Section VII Administration of Short
Page 130 and 131:
HOW TO FILE A CLAIM FOR NEW YORK ST
Page 132 and 133:
NOTICE AND PROOF OF CLAIM FOR DISAB
Page 134 and 135:
NOTICE AND PROOF OF CLAIM FOR DISAB
Page 136 and 137:
ARCHDIOCESE OF NEW YORK Benefit Pla
Page 148 and 149:
Section IX Administration of Dental
Page 150:
CIGNA Dental for Religious and Cler
Page 153 and 154:
ARCHDIOCESE OF NEW YORK CIGNA Denta
Page 155:
HOW TO FILE A DENTAL CLAIM There ar
Page 160 and 161:
DAVIS VISION CARE VISION CARE BENEF
Page 162 and 163:
ARCHDIOCESE OF NEW YORK Benefit Hig
Page 164 and 165:
HOW TO FILE A VISION CARE CLAIM (Cl
Page 166 and 167:
Section XI Administration of Volunt
Page 168 and 169:
ARCHDIOCESE OF NEW YORK SUPPLEMENTA
Page 170 and 171:
INTERNAL USE ONLY Institution Name:
Page 172 and 173:
PERSONAL HEALTH APPLICATION Thank y
Page 174 and 175:
Employee: First Name_______________
Page 176 and 177:
Employee: First Name_______________
Page 178:
IMPORTANT NOTICE The Archdiocese of
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