the archdiocese of new york benefits administration resource guide

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Select from the following coverage options for the Plan Year: MEDICAL PLAN ELECTION • Type of Medical Coverage: ❑ Single ❑ Two Person ❑ Family ❑ Medicare Supplement ❑ Waive Medical Coverage Payroll contribution Election: I elect that the employee contributions for the coverage I have selected be subtracted from my paycheck on the following basis: ❑ Pre-Tax ❑ Post-Tax ❑ N/A OTHER MEDICAL COVERAGE Are you a dependent/or spouse covered by another health plan? ❑ Yes ❑ No. If “Yes”, please complete this section: Name and address of other insurance carrier: ______________________________________________________ Policy Number_______________________ Other Insurance Carrier Phone #:________________________ Primary Named Insured_____________________________________________ Person(s) Covered: ❑ Self ❑ Spouse ❑ Child(ren) Policyholder___________________________________________________ Address____________________________________________________________________________________________ Employer___________________________________________________ Address_____________________________________________________________ Phone_____________________________ Association (if applicable)______________________________________ Address____________________________________________________________ Phone_____________________________ Effective Date_______/________/_________ Plan Type: ❑ Hospital ❑ Medical ❑ Major Medical ❑ Extended Medical MEDICARE INFORMATION If this election form includes a person with Medicare coverage, complete the following (Attach a copy of your red, white and blue Medicare card): Name of Medicare Eligible Person Hospital (Part A) Effective Date Medical (Part B) Effective Date Medicare Identification # HIB Suffix VISION CARE - CLERGY AND RELIGIOUS ONLY Clergy: ❑ Yes ❑ No Coverage Religious: ❑ Yes ❑ No Coverage (Coverage is mandatory for Religious on stipend) My signature below affirms eligibility for coverage, and authorization to deduct any contribution from my paycheck. All information provided is complete and true to the best of my knowledge. Any person who knowingly and with intent to defraud an application of health benefits or statement of claim containing any materially false information or conceals for the purpose of misleading information concerning any fact material thereto commits a fraudulent act, which subjects such person to civil penalties. If retired or otherwise not actively at work, I agree to pay the applicable premium required or portion thereof within 30 days of the premium due date. Employee/Participant Signature (Required):_________________________________________________________________________________ Date:_________________________________ Employer’s Signature (Required):_________________________________________________________________________________________ Date:_________________________________ Employer Print Name (Required):_________________________________________________________________________________________ Administrators: Mail completed form to – Employee Benefit Connections, 1011 First Avenue, Suite 1679, New York, New York 10022 or Fax form to 212.644.0690 Contact us: ebc@archny.org Web Page: www.archny.org/benefits Revised 05/01/08 Page 2 of 2
ARCHDIOCESE OF NEW YORK Group Health Benefit Election Form Non-Bargaining Full-Time Employees Effective January 1, _____ to December 31, _____ Name_______________________________________________ Soc. Security Number_________________________ Address_______________________________________ City________________________ State______ Zip________ Institution___________________________________________ Inst. No._______________ Division No.___________ Effective Date____________________ No. of Work Hrs./Week______ Payroll File# (If applicable)_____________ Select the appropriate member annual contribution option for the current benefit plan year: United Healthcare Plan (PPO) Single Coverage Two Person Coverage Family Coverage [ ] $______ [ ] $______ [ ] $_______ Dependent Coverage Name___________________________________________ Relationship______________ Date of Birth____________ Name___________________________________________ Relationship______________ Date of Birth____________ Name___________________________________________ Relationship______________ Date of Birth____________ Name___________________________________________ Relationship______________ Date of Birth____________ Name___________________________________________ Relationship______________ Date of Birth____________ Waiver of Medical Coverage Complete this section if you are waiving employee and/or dependent coverage. [ ] I elect to waive the employee health coverage under this plan. [ ] I elect to waive the dependent health coverage under this plan. (Check this box only if you have eligible dependents that you will not be covering under this plan). If you waive medical coverage, you (and/or your eligible dependents) will not be eligible to participate in the plan until the next benefit plan year, unless you experience a life status change. Life status changes include marriage, birth or adoption of a child, death, or a change in your or your spouse’s employment status, which affects you or your dependents’ eligibility for medical coverage. I elect that the employee contributions for the coverage I have selected be deducted from my paycheck on the following basis: [ ] Pre-tax [ ] After-tax If you select to have your contributions deducted from your pay on a pre-tax basis, your earnings for the purposes of computing Social Security benefits could be reduced. If you have concerns regarding this issue, contact your accountant or tax advisor before selecting this option. I understand that this election is effective during the current benefit plan year, unless there is a life status change. Life status change include marriage, divorce, birth, or adoption of a child, death, or change in employment status for my spouse or me, which would affect my dependents’ or my eligibility for coverage. I certify that all of the information contained on this coverage election form and my application is true. I understand the elections that I have indicated above and agree to have any employee contribution(s) deducted from my paycheck. Signed______________________________________________________________________ Date______________________________________ Member: Return this form to your local administrator Local Administrator: PLEASE RETAIN THIS FORM IN YOUR FILES FOR PAYROLL DEDUCTIONS Revised 01/2008
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 and 40: HOW TO ENROLL IN THE GROUP HEALTH B
Page 41: Annual Salary (Benefit Administrato
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 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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