the archdiocese of new york benefits administration resource guide

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ADDITIONAL INFORMATION CONCERNING CHANGES PERMITTED OUTSIDE OF INITIAL ELIGIBILITY PERIOD AND OPEN ENROLLMENT Qualified Life Events: The following are qualified life events* which would permit employees and their eligible dependents to special enroll in the group medical plan outside the initial enrollment or open enrollment period: • Loss of other medical coverage due to loss of employment or reduction in hours • Marriage • Birth or adoption of a child • Death of employee spouse through whom member had medical coverage Other Changes Permitted: • Terminate medical coverage for member, member’s spouse/child who is no longer an eligible dependent under the terms of the group medical plan • Change of home address, martial status • Change of base salary (effects the amount of Life, AD&D and LTD Insurance) • Retirement • Under certain circumstances, when a member of the Clergy aged 65 & over, is fully retired and has enrolled in Medicare (Part A and Part B) Coverage, medical coverage may be changed to a Medicare Supplemental Plan. A photocopy of the Medicare card must accompany the new health enrollment form. ** • Religious Sister who reaches age 65 and eligible for Medicare (Part A and Part B) Coverage. Secure a copy of the Medicare I.D. card and attach the copy to the Health Benefit Plan Enrollment & Change Form and mail it to Employee Benefit Connections, 1011 First Avenue, Room 1679, New York, New York 10022. * Documentation will be required to validate life event ** Contact Employee Benefit Connections (212.371.1000, Ext. 3060) for details. Revised 07/2009
Annual Salary (Benefit Administrator Use Only) $______________ ARCHDIOCESE OF NEW YORK HEALTH BENEFIT PLAN ENROLLMENT & CHANGE FORM Note: Return your completed form to you Local Benefits Administrator within 30 days of the date of enrollment, a life event, date of any change(s). Failure to do so may result in loss of coverage. Effective Date of Coverage or Change Month/Day/Year / / Please indicate the reason you are completing this form: ❑ New Hire ❑ Open Enrollment ❑ Waive Coverage ❑ Marital/ Status Change ❑ Dependent Enrollment ❑ Medicare Enrollment ❑ Retirement ❑ Work Hours Change ❑ Update Salary ❑ Name Change ❑ Address Change MEMBER INFORMATION Last Name_____________________________________________ First Name__________________________________________ MI____ Social Sec. #:__________-_________-___________ Date of Birth_____/_____/_____ Gender: ❑ Male ❑ Female Home Address:_________________________________________________________________________ Apt. No.__________ City________________________________________________________ State______ Zip__________ Home Phone__________________________ Work Phone_________________________ Status: ❑ Active ❑ Retired Occupation__________________________________________ Covered by Collective Bargaining Agreement: ❑ Yes ❑ No Date of Hire_____/_____/_____ ❑ Part Time Employee ❑ Full Time Employee Regular Weekly Work Hours______ Marital Status: ❑ Single ❑ Married Marriage Date: ____/____/_____ ❑ Divorced ❑ Widowed DEPENDENT INFORMATION List below your name and the name(s) of eligible dependent(s) to be covered, your spouse and dependent children. A child will be considered a dependent if: 1) Age 19 to the end of calendar year) or 2) Age 25 (if full-time college student-to the end of a calendar month in which child reaches age 25 as long as he/she is unmarried and enrolled in an accredited school on a full time basis.) Obtain the Statement of Dependent Eligibility Beyond Limiting Age in Plan Due to Mental Retardation or Mental or Physical Handicap Form to apply for extension of coverage for a disabled child before the child reaches the limiting age. First Name of Dependent (Include Last Name if Different from Yours) Sex M/F Date of Birth Mo./Day/Yr. Relationship to Employee Social Security Number Full Time Student? Yes/No Disabled? Yes/No EMPLOYER INFORMATION Employer (Institution)_____________________________________________________________________ Institution No.___________ Division Code__________ Employer Street Address ______________________________________________________________________________ City____________________________________________________ State________ Zip Code___________ Phone__________________________ IMPORTANT FORM CONTINUES ON THE REVERSE SIDE Page 1 of 2 Contact us: ebc@archny.org Web Page: www.archny.org/benefits Revised 05/01/08
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 and 38: AUTHORIZATION FOR THE USE AND DISCL
Page 39: HOW TO ENROLL IN THE GROUP HEALTH B
Page 43 and 44: 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 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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