2022 Enrollmentchange Form Medical Spending
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File Name: 2022-msc-buyout-waiver-form.pdf
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Summary
PLAN YEAR 2022 ENROLLMENT/CHANGE FORM Employee (Participant) return completed form to: MEDICAL SPENDING CONVERSION (MSC) Agency Benefits Office, NYCAPS Central or HR Shared HEALTH BENEFITS BUY-OUT WAIVER PROGRAM Services Office. See instructions on reverse side
nyc.gov/fsa Please review the MSC Health Benefits Buy-Out Waiver section in the Flexible Spending Accounts (FSA) Program Brochure, which is on theINSTRUCTIONS: FSA website at nyc.gov/fsa. Also, see instructions on reverse side of this form before completing
ENROLLMENT q Open Enrollment (October 12 - November 19, 2021; effective January 1, 2022) Complete Sections I, II, and IV
(Check one): q Mid-Year Enrollment (January 1 - November 11, 2022; effective Qualifying Event date) Complete Sections I, II, III, and IV
I. EMPLOYEE (PARTICIPANT) INFORMATION (Please Print)LAST NAME FIRST NAME M.I. SOCIAL SECURITY NUMBERHOME ADDRESS - NUMBER AND STREET APTCITY STATE ZIP CODE + FOUR -HOME PHONE NUMBER WORK PHONE NUMBER MOBILE PHONE NUMBER E-MAIL( ) - ( ) - ( ) -AGENCY NAME (NOT DIVISION):CUNY EMPLOYEES PLEASE SPECIFY THE NAME OF COLLEGE II. MSC HEALTH BENEFITS BUY-OUT WAIVER PROGRAM SECTION: If completing this section during mid-year, you must also complete Section III below
A) To participate in the Buy-Out Waiver Program, complete this form and a Health Benefits Application or submit through ESS. Return both forms to your agency’s Human Resources Department/NYCAPS (if applicable) for approval and completion
q I wish to participate in the Buy-Out Waiver Program. Check one Non-City group health plan provider (company name) q Individual Coverage ($500) q Domestic Partner/Civil Union Coverage ($500) q Family Coverage ($1,000) Please note: You must attach proof of non-City group health coverage (letter or health insurance card)
B) To terminate your participation in the Buy-Out Waiver Program, you must complete this form and a Health Benefits Application, or submit through ESS, for reinstating City health benefits. Return both forms to your agency’s Human Resources Department/NYCAPS (if applicable) for approval and completion
q I wish to withdraw from the Buy-Out Waiver Program
III. MID-YEAR QUALIFYING EVENT: Newly eligible employees or current employees changing their status during mid-year must complete this section
This is to certify that I incurred the Qualifying Event indicated below and, therefore, wish to modify my benefits as indicated. I understand that the change(s) requestedmust be consistent with the Qualifying Event and that I must submit this form with legal/supporting documentation of all changes to my agency’s Human ResourcesDepartment/NYCAPS (if applicable) and they must be received by the MSC Administrative Office within 30 days after the Qualifying Event to take effect
Date of Qualifying Event: / / 2022 Today’s Date: / / 2022 If Today’s Date is more than 30 days from the Date of Qualifying Event, please note that you are not eligible for Plan Year 2022
Please check one of the following:Employment Status: Documentation must be provided by employer/agency Family Status Change: Legal documentation must be provided by participantq Beginning/termination of employment (q self q spouse) q Marriage/domestic partnerq Unpaid leave of absence (q self q spouse) q Birth or adoption of childq Return from unpaid leave of absence (q self q spouse) q Divorceq Change from P/T to F/T employment or vice versa (q self q spouse) q Ineligibility of dependent (q age q marriage)q Increase in health plan deductions by more than 20% IV. Employee SignatureI have read the MSC Program materials and instructions and I attest that I meet the qualifications to enroll or withdraw from the MSC Health Benefits Buy-OutWaiver Program
Signature:__________________________________________________________________________________________________ Date: _____/ _____/____ V. FOR COMPLETION BY EMPLOYING AGENCY’S HUMAN RESOURCES DEPARTMENT/NYCAPS/HR SHARED PERSONNEL ONLY: Please review the above information and submitted documentation from employee before completing the information below
Note to Benefits/Payroll/NYCAPS/HR Shared Officer:• Send this MSC Form and the Health Benefits Application, along with any legal/supporting documentation, electronically to: https://nyc-fsa.leapfile.net• You should retain a copy of this form for your records
1) For the Health Benefits Buy-Out Waiver Program (Section II), I have reviewed and processed the Health Benefits Application and certify that the employee has listed a non-City group health insurance policy under which he/she is covered. I have notified the appropriate health insurance carrier of this change
2) For mid-year changes, I certify that a Qualifying Event listed in Section III has occurred within 30 days after this request and this form, along with legal/ supporting documentation, have been submitted
Employee’s Agency Appointment Date: / / Effective Date of Health Benefits: / /A) MSC Buy-Out Waiver Effective Date: (Check one) q Open Enrollment: (October 12 - November 19, 2021: effective January 1, 2022) q Mid-Year Enrollment: / / 2022 (January 1, 2022 - November 11, 2022) (June 1- June 30, effective July 1, 2022) (December 1- December 31, effective January 1, 2023)B) MSC Buy-Out Waiver Withdrawal Date: (Check one) q Open Enrollment: (October 12 - November 19, 2021: effective January 1, 2022) q Mid-Year Withdrawal: / / 2022 (January 1, 2022 - November 11, 2022)AGENCY BENEFITS MANAGER/NYCAPS/HR SHARED PERSONNEL SIGNATURE EFFECTIVE DATE WORK PHONE NUMBER / / ( ) -EMPLOYEE AGENCY CODE CUNY STATE I.D. NUMBER E-MAIL ADDRESS MSC ADMINISTRATIVE OFFICE USE ONLYENROLLMENT EFFECTIVE DATE WITHDRAWAL EFFECTIVE DATE PROCESSING DATE PROCESSOR AGENCY PAYROLL CODE / / / / / / J:FSA\PLYR2022\MSC\MSC_FORM_2022.INDD 10/21 1K Print Form Reset Fields MEDICAL SPENDING CONVERSION (MSC) PLAN YEAR 2022INSTRUCTIONS:HEALTH BENEFITS BUY-OUT WAIVER PROGRAM - SECTION II: The Medical Spending Conversion (MSC) Health Benefits Buy-Out Waiver Program allows you to receive an incentive payment for waiving your City health benefits. Refer to the MSC Health Benefits Buy-Out Waiver Program section in the Flexible Spending Accounts Program Brochure for detailed information
A. Enrolling: Please Note: The Internal Revenue Service does not permit any retroactive participation from a previous Plan Year
If you are covered under your spouse’s/domestic partner’s or parent(s)’ non-City group health insurance, or a group health plan available through other employment, you may waive New York City health benefits. Once your enrollment form has been processed and approved, you will receive a confirmation letter from the MSC Administrative Office. Please contact your agency’s Human Resources Department/NYCAPS/HR Shared personnel if you do not receive a confirmation letter
Current employees: You may enroll in the Program during the Open Enrollment Period (October 12, 2021 - November 19, 2021) for an effective date of January 1, 2022. You must complete Sections I, II, and IV. Section V is to be completed by your agency’s Human Resources Department/NYCAPS/HR Shared personnel
Newly eligible employees: You may enroll in the Program within thirty (30) days after becoming eligible for City health benefits. You must complete Sections I, II, III, and IV. Section V is to be completed by your agency’s Human Resources Department/NYCAPS/HR Shared personnel
During mid-year: If you incur a Qualifying Event, you must notify the MSC Program Administrative Office within thirty (30) days after the Qualifying Event in order to participate. You must complete Sections I, II, III, and IV and attach legal/ supporting documentation. Section V is to be completed by your agency’s Human Resources Department/NYCAPS/HR Shared personnel
Any MSC Form received in June will be effective July1st of that Plan Year. Any MSC Form received in December will be effective January 1st of the following Plan Year
By signing the MSC Health Benefits Buy-Out Waiver Program Enrollment/Change Form, you elect to receive $1,000 (family coverage waived), $500 (individual coverage waived), or $500 (domestic partner/civil union coverage waived) annually in lieu of New York City health benefits. You will receive $500 for family coverage, $250 for individual coverage, or $250 for domestic partner/civil union coverage waived at the end of every six-month calendar period. Please note that same sex marriage will be treated as family coverage (This amount will be pro-rated for any period less than six months by the number of days you are in the Health Benefits Buy-Out Waiver Program.) An employee participating in the City’s Deferred Compensation Plan (DCP) in lieu of FICA and participating in the Health Benefits Buy-Out Waiver Program (taxable income), may need to increase his/her salary deferral percentage to an amount higher than 7.5% of annual salary in order to account for the increase in income due to the “Buy-Out Waiver Incentive Payment.” If the 7.5% of total salary income requirement is not met, the participant who is enrolled in the DCP may have to continue to pay FICA taxes until that requirement is met
B. Terminating: Your waiver will remain in effect during the Plan Year unless a) you experience an approved mid-year Qualifying Event or, b) you reinstate your City health coverage during the Health Benefits Program Fall Transfer Period. During the mid-year, your form must be received by the MSC Administrative Office within thirty (30) days after the Qualifying Event in order for the change to be effective. If you are returning from an approved leave of absence or transferring to a new City agency, you must complete the MSC Health Benefits Buy-Out Waiver Program Enrollment/Change Form and the Health Benefits Application within thirty (30) days after such event to be reinstated, or to receive a pro-rated incentive payment
If you wish to terminate your participation in the Health Benefits Buy-Out Waiver Program and reinstate your City health benefits coverage, complete Section II, by indicating your requested change. If you are terminating your participation mid-year, you must also complete Section III
Please Note: If you waive City health coverage, you must have other non-City group health coverage available to you
The Health Benefits Application must accompany this MSC Form so that your agency’s benefits/payroll manager is able to verify that you have other coverage. Your agency’s Human Resources Department/NYCAPS/HR Shared personnel may request additional documentation
This form is not valid if you have not completed Sections I, II, III (for mid-year Qualifying Event) and IV
This form is not valid if Section V has not been completed by your agency’s Human Resources Department/NYCAPS/HR Shared personnel
Please return the completed form and documentation to: • If your agency is a non-centralized agency - Send directly to your agency benefits office
• If your agency is a centralized agency - Send directly to: NYCAPS Central, 1 Centre Street, New York, NY 10007 • DOE Employee/Payroll/Secretary - Send directly to: DOE MSC Unit, 65 Court Street, Rm. 102B, Brooklyn, NY 11201 • H+H Centralized Agency - Please upload via Employee Self Service and contact HR Share Services at 646-458- 5634 for additional assistance
Please review the above information and submitted documentation from employee before completing the information below. Note to Benefits/Payroll/NYCAPS/HR Shared Officer: • …
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Frequently Asked Questions
Is enrollment form 2022 deped a free printable?
Enrollment Form 2022 Deped is a free printable for you. This printable was uploaded at August 04, 2022 by tamble in Enrollment Form. Enrollment Form 2022 Deped - You can find a number of sample enrollment forms in this article.
How did medical enrollment increase in q4 2022?
Medical enrollment increased 2.2 million members year-over-year and 232 thousand members during the quarter to 47.3 million members. Fourth quarter 2022 dividend of $1.28 per share declared to shareholders.
Can i claim medical expenses from march 2021 to march 2022?
For example, you can claim medical expenses from March 2021-March 2022 on your 2022 return as long as you didn’t claim those expenses on your 2021 return. You can claim these expenses for you, your partner, your child under 18, or your other dependant.
What is the enrollment duration factor for the 2022 benefit year?
For the 2022 benefit year, we will continue to apply the current 11 enrollment duration factors of up to 11 months for all enrollees in the adult models with trending adjustments made to project the data used to develop the factors forward to reflect the 2022 benefit year.