Health Insurance Plan Overview

Overview

N.Y. City and your Union, the UFA, offer a variety of Primary Health & Supplemental Plan coverage. Figuring out what health care systems cover and where you can get help can be confusing and intimidating. The info in this chapter was compiled from various NYC & FDNY published sources to help you better understand how these systems work and how to quickly navigate to the info and/or professional contacts you need to make the best health care decisions for you and your family. It also includes info re: new dependents, eligibility, changing plans, filing claims, notification requirements, medical payroll deductions, coordinating spouse benefits, tax deductible medical and dependent care options, termination and continuation of coverage, retirement/Medicare, helpful tips regarding the health plans most UFA members use, and additional insurances and organizations that provide other assistance/coverage for an additional cost (or even for free). Instructions are also provided on emergency leave, Family Leave Act, and how to file a complaint with the N.Y. State against incompetent or unethical doctors.

Choosing a Health Plan

The following providers offer health coverage through your NYC Plan: Aetna QPOS, GHI-CBP/Empire Blue Cross Blue Shield, Empire EPO, HIP Prime POS, Aetna (HMO), CIGNA Healthcare (HMO), Empire (HMO) NY-NJ, GHI (HMO), HIP Prime (HMO), Vytra Health Plans (HMO). For specific plan descriptions & Costs, see next paragraph. To select a health plan that best meets your needs, you should consider at least four factors:

Coverage: The services covered by the plans differ. For example, some provide preventive services while others do not; some plans cover routine podiatric (foot) care, while others do not. Optional Riders, other Insurances & Benefits provide additional coverage for an extra cost, some for free. See below.
Choice of doctor: Some plans provide partial reimbursement when non-participating providers are used. Other plans only pay for participating providers.
Convenience of Access: Certain plans may have participating providers or centers that are more convenient to your home or workplace. You should consider the location of physicians’ offices and hospital affiliations.
Cost: Plan costs vary in a number of ways:
- Some plans require payroll and pension deductions for basic coverage.
- The costs of Optional Riders also differ.
- Some plans require a co-payment for each routine doctor visit.
- Some plans require you to pay a yearly deductible and coinsurance before the plans will reimburse you for the use of non-participating providers.

If a plan does not cover certain types of services that you expect to use, you should also consider the out-of-pocket cost of these services.

Health Plan Provider Descriptions (GHI, HIP, etc.)

For individual Plan Description Summaries, Costs & Optional Riders they offer, see Supplement #1 at the end of this Chapter (Health Plan Provider Summaries), or the Summary Description Booklet or CD of all plans offered that the City normally provides each member every Fall, or visit the NYC Health Benefits Program Website. You can also contact the Health Insurance Plan Providers directly to receive benefits/costs packages and provider directories. They include: Aetna QPOS, GHI-CBP/Empire Blue Cross Blue Shield, Empire EPO, HIP Prime POS, Aetna (HMO), CIGNA Healthcare (HMO), Empire (HMO) NY-NJ, GHI (HMO), HIP Prime (HMO), Vytra Health Plans (HMO), and even more for retirees. (Your plan’s phone number is on the back of your plan’s ID card.) If you can’t find the info you need, FFs can contact the FDNY Health Benefits Unit, which can provide you answers or steer you in the right direction. Retirees should contact the NYC Health Benefits Program for this help. For more information on other Insurances & Benefits, including many for free, see ‘Additional Benefits & Important Info’ section later in this chapter. It’s easy reading and briefly describes many super-important benefits for you and your family that you would have never known about. Make sure you check this out!

Which Type Plan Covers What?

Doctors & Hospitals: The NYC Health Benefits Program (GHI, HIP, Blue Cross/Blue Shield, Empire, Aetna, CIGNA, Vytra, etc.) covers much of your (and your dependents’) doctor costs, diagnostics and hospital bills through either HMOs, POS Plans, EPOs or PPOs (See ‘Medical Plan Terminology Definitions’ below). There is no cost for basic medical coverage under some plans. Others require payroll/pension deductions, co- payments and/or yearly deductibles, or cash outlay with later reimbursement. You may purchase additional benefits through Optional Riders for all plans. The City normally provides each member every year with a Summary Description Booklet or CD of all plans offered. See prior paragraph titled ‘Health Plan Provider Plan Descriptions’ to find complete plan descriptions.
Injuries at Work (Line-of-Duty): Medical treatment and medication for active Firefighters are NEVER covered by your City Health Plan or Union Drug Plan. They are covered 100% by the FDNY Bureau of Health Services. You must get written authorization from the Bureau of Health Services (BHS) in advance (except for emergencies), otherwise, you will have to pay for it yourself! See Additional Benefits & Important Info section, Line-of-Duty Injuries subsection for more info.
Dental, Vision, Drugs, Hearing Aid: NYC Health Plan Coverage does NOT cover Dental, Optical, Hearing Aid or Prescription Drugs. Your union covers this (and supplemental anesthesia for active FFs only). However, a Drug Rider is available for members who are not enrolled in GHI or HIP-HMO. See Health Book, Security Benefits Fund (SBF) chapter for specific coverage info.

Medical Plan Terminology Definitions:

HMO (Health Maintenance Organization plans) are a system of health care that provides managed, pre-paid hospital and medical services. You choose a Primary Care Physician (PCP) from within the HMO network, and the PCP manages all medical services, provides referrals, and is responsible for non- emergency admissions. You receive health care at little or no out-of-pocket cost, provided you use the HMO’s doctors and facilities. Because the HMO provides all necessary services, there are usually no deductibles to meet or claim forms to file. In most plans, if a physician outside of the health plan is used without a referral from the PCP, the patient is responsible for all bills incurred.
EPO (Exclusive Provider Organization plans) offer a higher level of choice and flexibility than many other managed care plans. You can see any provider in the EPO network, which contains family and general practitioners as well as specialists in all areas of medicine. No need to choose a primary care physician and no referrals are necessary to see a specialist. EPOs provide an extensive local, national, and worldwide network of providers. No claim forms to file and you will never have to pay more than the co- payment for covered services. There is no out-of-network coverage.
POS (Point-of-Service plans) offer freedom to use either a network provider or an out-of-network provider for medical and hospital care. If you use a network provider, health care delivery resembles that of a traditional HMO, with prepaid comprehensive coverage and little out-of- pocket costs for services. If you use an out-of-network provider, health care delivery resembles that of an indemnity insurance product, with less comprehensive coverage and subject to deductibles and/or coinsurance.
PPO (Participating Provider Organization/Indemnity plans) offer freedom to use either a network provider or an out-of-network provider for medical and hospital care. PPO/Indemnity Plans contract with health care providers who agree to accept a negotiated lower payment from the health plan, with co- payments from the subscribers, as payment in full for medical services. If you use a non-participating provider, it is subject to deductibles and/or coinsurance.
IRS Approved Health (or Dependent) Care Spending Accounts: Active firefighters may also choose to establish IRS approved Health (or Dependent) Care Spending Accounts which save you money on a pre-tax basis. These plans allow you pre-tax deductions of $5000 annually for Family Health Care, and again up to $5000 Child Care while you are at work. See the ‘IRS Tax Deductible Flexible Spending Accounts” section— later in this chapter.
Buy-Out Waiver Program for $$: Active FFs may opt to receive cash from the City instead of enrolling in one of its health plans. See the ‘Buy-Out Waiver Program’ section — later in this chapter.

Optional Riders to Health Plans

Payroll Deductions: All health plans have an Optional Rider consisting of benefits that are not part of the basic plan. You may elect Optional Rider coverage when you enroll and pay for it through payroll or pension deductions. Each rider is a package, and you may not select individual benefits from the rider. The City normally provides each member every year with a Summary Description Booklet or CD of all plans (with costs) offered. See ‘Paycheck Deductions for Coverage & Riders’ section below for cost info.
Union (UFA-SBF) Benefits: Active and retired members get additional health benefits through the UFA’s Security Benefits Fund (SBF). If the SBF is providing benefits similar to some (or all) of the benefits in your plan’s Optional Rider, those specific benefits will be provided only by the SBF and will not be available through your health plan rider. Pension and payroll deductions will be adjusted accordingly. See Health Book, Security Benefits Fund (SBF) chapter for specific UFA-SBF coverage info. The UFA also recommends several private optional insurance plans to cover additional costs associated with cancer, catastrophic medical, accidental injury and life insurances. See Health Book; Insurances & Free Benefits chapter; Primary Health/Medical section for specific info.
Prescription Drugs: The UFA’s SBF and the NYC Health Benefits Unit PICA drug programs provide prescription drug benefits. Therefore, you should not choose any drug Optional Rider because payroll or pension deductions will not be adjusted automatically to account for union & PICA benefits. See Health Book, Security Benefits Fund (SBF) chapter for union & PICA drug coverage info.

$$ Paycheck Deductions for Coverage & Riders

From Paychecks – If there is a payroll deduction for your plan’s basic coverage, or if you apply for an Optional Rider, your paycheck should reflect the deduction within two months after submitting a Health Benefits Application. The City normally provides each member every year with a Summary Description Booklet or CD of all plans (with costs) offered. See References Book, Contacts chapter for contact info of Health Insurance Providers, which can provide you with annual costs. Also, the NYC Website, Health Benefits Program section has Biweekly/Monthly check deduction charts.
From Pension Checks – It may take considerable time before health plan deductions start from retirees’ pension checks. Retroactive deductions (not to exceed $35.00 a month in addition to the regular deduction) are then made to pay for coverage during the period from retirement to the time of the first deduction. Although deductions may not be taken for a month or more, your coverage still is in effect. When either you or a dependent becomes eligible for Medicare (by reaching age 65 or through disability), the amount deducted is adjusted after you notify the Health Benefits Program of Medicare coverage (See ‘Medicare – Eligible Retirees’ section later in this chapter). This adjustment may also take time to be processed. See References Book, Contacts chapter for contact info of your Health Insurance Carrier, who can provide you with monthly check deduction charts. Also, the NYC Website, Health Benefits Program section has Biweekly/Monthly check deduction charts.
Incorrect Deductions – If the deduction does not appear in due time or is incorrect, you must report the error within 31 days. Employees must contact the FDNY Health Benefits Unit. Retirees must contact the NYC Health Benefits Program. Corrections will be made as quickly as possible after notification.

Help! Who/When to Call?

Calling Sick

Calling Sick from Home: Off-duty members must call the FDNY BHS Automated Citywide Medical Leave System 24/7 (which will prompt you to provide certain identifying information) at 718-330- 2204, at least two hours before your next tour starts, or as soon as possible if you can’t call within two hours. You are also required to notify your Officer from your unit within the above timeframe. You will be assigned a date to appear at the FDNY Bureau of Health Services (BHS) to see a Department Doctor. After your medical examination, you must pick up your duty determination record and sign out. Close attention should be paid to your next duty status and start date. See Additional Benefits & Important Info section, Medical Leave/Time Off sub-section for more info.
Calling Sick/Injured from Work: On-duty members must immediately notify their Officer. Your Officer will then call Car 32/33 and forward your request. Your Officer will then inform you that you may be granted Medical Leave, but may also be directed to report to the Bureau of Health Services between 0700 hours and 2300 hours for medical evaluation. For members requested medical leave during the tour between 2300 hours and 0700 hours, they may be granted medical leave and may be directed to report to the Bureau of Health Services effective 0700 hours.

For any member who reports fatigue or exhaustion, the member may be granted R&R. If the member still requests medical leave at the conclusion of the R&R period, the member will be placed on medical leave and may be directed to report to the Bureau of Health Services prior to 2300 hours or at 0700 if after clinic hours.

The UFA strongly advocates that our members base their decisions on the severity of the injury or sickness and possible limitations of such. The UFA feels that any directive that might have a negative effect on your injury or sickness and prolong medical leave should be addressed through the BHS Postponement Desk (718-999- 1918/19/20). It is important to always document your injury and who you talked to!

Postponement of Medical Office Appearance: We want to make it clear that firefighters are required to obey all legal orders from the Medical Office (Bureau of Health Services or ‘BHS’). However, a firefighter is not required to obey an order that will unnecessarily endanger his health or safety. Accordingly, if you reasonably feel that you are too ill or injured to report to the Medical Office, you should express that to whomever you speak to at the FDNY BHS Postponement Desk (718-999-1918/19/20). If necessary, request to speak to a Dept Doctor. You should be ready to explain why you are unable to appear. Your reason may well be that traveling to the Medical Office may endanger you and others, that you have an excellent medical leave record and that there is no reason to compel your immediate appearance. You cannot be denied the right to postpone if it may be hazardous to your health and well being. If you are too ill or injured to travel and are instructed that you can’t postpone, ask for a Department ambulance to pick you up, transport you to the BHS and transport you home. If this is denied, ask for a BHS doctor to examine you at your home. If both requests are denied (they most likely will be denied), inform the BHS that you “are postponing and will try again tomorrow.” You can also call your firehouse to ask for Company Journal entries be made to document your postponement.
Get a Doctor’s Note: On 12/28/04 then Chief of Operations Cassano, in a memo to all Borough Commands, stated “When postponements are granted, members are required to obtain a note from their private physician”. The UFA’s position is that you cannot be disciplined for postponing merely because you did not bring in a note later, but having a note may save you a lot of aggravation—and prevent having to fight possible AWOL charges from an ‘over-eager’ officer. It is recommended that you obtain a note from your private physician, your local medical center or Emergency Room confirming your illness and the inadvisability of your traveling to Brooklyn. This will help validate for the Department your reason for postponement. Dept. PA/ID 2-87 states that Medical Office appearances may only be postponed “if the member is non-ambulatory” (unable to travel). It is not sufficient to assert that you have family obligations, i.e., you have to pick up your children, you need to get your car fixed, etc. Those reasons are not acceptable and will not withstand scrutiny. For each day you are really too ill to travel and you don’t want to worsen your medical condition, you can postpone again via the same procedure.
Document All BHS Correspondences: We recommend that you keep a record of any conversation with the Medical Office staff to confirm exactly what both you and they say-and write down the date, time and name of the person(s) you speak with. We further recommend that if you believe you are not receiving proper medical care or consideration, you should immediately notify the UFA Health & Safety Officer / Sergeant-at-Arms or the Trustee of the Day of the specific facts of your case by immediately calling 212-683-4832.

See FDNY Book; Bureau of Health Services chapter for complete info about the FDNY Bureau of Health Services (BHS). It is loaded with info that will help you anytime you have an issue that involves the BHS.

Line-of-Duty Injury (LODI) Treatment & Drugs

Active Members: NOT covered by your NYC Health Plan while you are an active member! You must have written authorization (except for emergencies) for treatment from the FDNY Bureau of Health Services (BHS) prior to any treatment of a LODI, including WTC. While active, the Dept pays 100% of all authorized treatment and diagnostics for LODI injuries. Use your LODI or WTC Drug Cards—not the UFA SBF Card!!!
Retired Members: NOT covered by the FDNY after your retirement date! The moment you retire, the Dept will no longer pay for your LODI treatment. Instead, your normal NYC Health Plan will cover it, subject to your plan’s limitations. EXCEPTION: Retired members use the WTC Drug Card for all WTC related drugs.
LODI Prescription Drugs: The FDNY’s Bureau of Health Services (BHS) is required to pay it! Never try to use your SBF drug plan for any line-of-duty injury (LODI) drug prescriptions—ever! If you do, the cost will come out of your union benefits plan. Use your LODI or WTC Prescription Drug Card.

See ‘Additional Benefits & Important Info’ section of this chapter, Line-of-Duty Injury Medical Treatment sub- section for complete info

Surgery – Hospitalization – Cardiac – Pre-Natal

$500 Penalty (GHI-CBP & Empire Blue Cross/Blue Shield only): To avoid possible reduction in your benefits (up to $500 penalty), GHI & Blue Cross members MUST call NYC Healthline (not GHI/Blue Cross) as instructed below. The below info is excerpted from the back of your GHI & Blue Cross Health Plan insurance ID cards (the Healthline phone # is also there).

Hospital or Cardiac Rehabilitation: at least 10 days prior to any for non-Line-of-Duty (LOD) related admission that is scheduled in advance.
Admission: as soon as possible before any urgent non-LODI related admission;
Admission: within 48 hours of any emergency for non-LODI related admission;
Pre-Natal: after the first pre-natal visit (ideally within the first 3 months of pregnancy)

EXCEPTIONS: These requirements do not apply to any covered city person who has primary coverage through another health plan, including Medicare.

Call Your Health Plan Insurance Carrier

Active & retired members should contact your individual Health Plan Insurance carrier (GHI, HIP, Blue Cross, Empire, Aetna, CIGNA, Vytra, etc.) directly for any of the below issues. When writing, include your Name, Address, SS #, Certificate # (if different), Group #, Dates of Service & Claim # (if applicable).

Benefit Description Packages (booklets)
Provider Directories (list of doctors)
Health Plan service areas & primary care physicians
Covered Services & Medical Services: questions & written info
Written information about covered services
Claims: Information about status of pending claims or claim disputes
Claim allowances: (How much will a plan pay towards a claim?)
Certificate of Insurance (to obtain it)
Termination: if coverage (you or dependent) terminated by your Health Plan

Call Union (UFA-SBF) Supplemental Health Fund

Active & retired members should contact the UFA Security Benefits Fund (SBF) for assistance with below items.

See Health Book (Security Benefits Fund chapter) for specific coverage info.

Prescription drug coverage (for PICA Drugs call Express Scripts/NPA, NYC Health Benefits Program)
Vision/Optical coverage
Dental benefits
Hearing Aids
Anesthesia, active FF only (for coverage in addition to your City Health Plan coverage)
Problems with your Medical Provider (Active FF only) If your NYC Health Plan carrier & FDNY Health Benefits Unit are BOTH unable to help you, then contact the SBF supervisor.
Problems (Retirees only) If the NYC Health Benefits Program office is unable to help you, contact SBF Retiree Liaison(M-W-F).
UFA Group Life Insurance: contact UFA Group Life Insurance

Call FDNY Health Benefits Unit (active FF only)

Contact FDNY Health Benefits Unit (if you can’t find the info in this chapter) for questions or help related to:

Problems with your Medical Insurance Provider that you just can’t get help with.
Transfer Periods (changing health plans) See ‘Enrollment Periods to Change Plans’ section first
Enrollment (adding new or removing former dependents) See ‘Keeping Your Info Current’section first
Eligibility (determining if your dependents are covered) See ‘Eligibility Criteria for Coverage’ section first
Paycheck Deduction questions/errors
Requests for a Health Benefit
To enroll in a Medicare HMO Application

Call NYC Health Benefits Program (retired FF only)

Contact the NYC Health Benefits Program for assistance with the below items (if you can’t find the info in this chapter). Always include your: Name, Address, Telephone #, SS#, Certificate # & Pension #.

Problems with your Medical Insurance Provider or PICA Drug issues that you just can’t get help with.
Pension Check Deductions: questions/errors
Add or drop dependents
Add or drop the optional rider
Waive health coverage
Change plans (excluding Medicare HMOs, which require a special application from the plan)
Obtain information and an application for Continuation of Benefits (COBRA) See ‘Termination, Suspension, Continuation of Benefits’ section first
Change your address
Questions about or problems with Health Benefits
Notification of enrollment in Medicare
Questions regarding Medicare Part B reimbursements
Termination: if coverage (you or dependent) terminated by your Health Plan

Keeping Your Insurance Info Current

For more information, contact the Health Insurance Plan Carrier you are interested in for benefits packages and provider directories. The NYC Health Benefits Program Website has additional info. Phone numbers are always on the back of your plan’s ID cards.

Change of Beneficiary Checklist:

The UFA, FDNY and certain insurance carriers do not share member and beneficiary info. It is advisable to review your beneficiaries each time any of the following occur: marriage, divorce, change of domestic partners, new birth or adoption, loss of a family member, change of eligible dependents, add or remove a person as a life insurance or other beneficiary if you or your spouse die, or to add or remove a person from any health insurance policy.

 Time Sensitive: These notifications are often time sensitive. You may lose benefits if you make a late notification. Be sure to notify each of your insurance providers ASAP to insure that coverage will remain in full force for the beneficiaries you wish it to. Make sure you do the following, if applicable:

FDNY Pension Beneficiary: re your retirement pension contributions return and entitlements upon your death; to change a designated beneficiary, send a notarized ‘Designation of Beneficiary of Death Benefits’ to FDNY Pension Benefits Unit.
NYC Health & Medical Plans: Doctor/medical care & hospitalization; fill out and forward ERB Form (Employee Health Benefit Application) with copies of Birth Certificate and Social Security Card, to add dependent to your medical plan to the FDNY Bureau of Personnel Resources/Health Plan Unit. Must be submitted within 31 days of the event.
FDNY Life Insurance Fund: is automatically updated when you notify the FDNY Bureau of Personnel Resources/Health Plan Unit
UFA Security Benefits Fund (SBF) Supplemental Health Benefits Coverage: Prescription drugs, dental, optical, anesthesia supplement, hearing aids; Copies, as appropriate, of marriage certificate, birth certificate, adoption decree, court guardianship papers, death certificate, divorce decree, certificate of domestic partnership, or affidavit of domestic partnership termination MUST accompany your notification to SBF Office for each respective matter. Submit these with a letter within 31 days of the event to SBF.
UFA Death Benefit: Which is separate from the UFA Group Life Insurance, is automatically updated when you notify the SBF as noted above.
UFA Group Life Insurance: Term coverage through the UFA; fill out UFA Group Life Insurance Beneficiary form and send to UFA Group Life Insurance Office.
Surgical Assistance Fund: is automatically updated when you notify the SBF of change of beneficiary.
UFA Catastrophic Major Medical Insurance Plan: a UFA affiliated program; you must directly notify Seabury & Smith /Marsh Affinity (formerly Albert Wohlers & Co.) through the contact info listed on your policy and by sending a letter regarding the change of covered person. Note: This company is especially strict when it comes to notification. If you do not let it know of additions within 30 days of a new birth, then that dependent will be added, BUT the 12 month restriction concerning pre-existing medical conditions only begins when that addition notification is made—and plan coverage will not be retroactive.
AFLAC Cancer Plan: a UFA affiliated program; you must directly notify AFLAC in writing through the contact info listed on your policy regarding the change of covered person.
AFLAC Personal Accident Expense Plan: a UFA affiliated program; you must directly notify AFLAC in writing through the contact info listed on your policy regarding the change of covered person.
Deferred Compensation: a NYC payroll deduction investment plan; to change the beneficiary, fill out and forward Enrollment/Change Form to Deferred Compensation.
Compensation Accrual Fund (Annuity): your automatic annuity investment plan; notify the SBF in writing of change of beneficiary.
Fraternal Organizations or Societies Life Insurance: to change beneficiaries, notify the respective organization for instructions.

Change of Address Checklist:

The UFA, FDNY and certain insurance carriers do not share member info. If you change your address or phone number, be sure to notify each of your insurance providers. Active FFs must notify the FDNY Health Benefits Unit (and the UFA-SBF) in writing so that your records are kept up-to-date. Always provide your Certificate or ID number when communicating with Health Plans. Retirees must notify the NYC Health Benefits Program. This will insure that your coverage will remain in full force and that you will continue to receive any timely notifications, invoices and new info. Make sure you do the following, if applicable:

NYC Health & Medical Plans: Doctor/medical care & hospitalization; prepare and submit Change of Address Forms with the FDNY through your Officer.
FDNY Life Insurance Fund: is automatically updated when you notify the FDNY.
UFA Security Benefits Fund (SBF) Supplemental Health Benefits Coverage: Prescription drugs, dental, optical, anesthesia supplement, hearing aids; prepare an SBF Change of Address Form and submit to SBF
UFA Death Benefit: is separate from the UFA Group Life Insurance, and is automatically updated when you notify the UFA SBF of change of address.
UFA Group Life Insurance: Term coverage through the UFA; contact the UFA Life Insurance Office.
Surgical Assistance Fund: is automatically updated when you notify the UFA SBF of change of address.
UFACatastrophic Major Medical Insurance Plan: a UFAaffiliated program; you must directly notify Seabury & Smith /Marsh Affinity (formerly Albert Wohlers & Co.) through the contact info listed on your policy.
AFLACCancer Plan: a UFAaffiliated program; youmustdirectlynotifyAFLACthroughthecontact info listed on your policy.
AFLAC Personal Accident Expense Plan: a UFAaffiliated program; you must directly notify AFLAC through the contact info listed on your policy.
Family Status Change – Adding or Dropping Dependents

Participants should report all changes in family status to the FDNY Personnel Office (for FFs) or the Health Benefits Program (for retirees). Both active and retired FFs must also notify the UFA-SBF. Check the UFA website, www.ufanyc.org, for additional checklist for new parent(s), newly divorced, and newlyweds in the Forms section. Use the Health Benefits Application to add dependents due to marriage, domestic partnership, birth or adoption of a child, and to drop dependents due to death, divorce, termination of domestic partnership, or a childreaching an ineligible age or losing full-time student status. Forms must be submitted within 31 days of the event. If a covered dependent loses eligibility, that person may obtain benefits through the COBRA Continuation of Benefits provisions. FFs and Retired members must also notify the UFA Security Benefits Fund (SBF) .

Plan Change

To change your individual Health Plan to a different plan, see ‘Enrollment Periods to Change Plans’ section of this chapter.

Transfer from Other City Agency to FDNY

If you leave the employment of one City agency at which you are covered under the City’s Health Benefits Program, and join FDNY, your coverage will become effective on your appointment date, provided that no more than 90 days have elapsed since your coverage terminated at the first agency. Your coverage will reinstate by submitting a completed Health Benefits Application. See ‘Termination, Suspension & Continuation of Benefits’ section, later in this chapter for more info.

Transfer In/Out of Your Plan’s Service Area

If you permanently move outside of your plan’s service area, you may transfer within 31 days to another plan without waiting for the next Transfer Period. Also, if you move into the service area of a plan, you may transfer within 31 days to that plan. (Exception: When transferring into a Medicare HMO plan other than during Transfer Periods, transfers will become effective on the first day of the month following the processing of the special health plan application.)

Leave of Absence Coverage

The Federal Family and Medical Leave Act of 1993 (FMLA) entitles eligible City employees to twelve weeks of family leave in a 12-month period to care for a dependent child or covered family member, and for the serious illness of the employee. FFs using this leave may be able to continue their City health coverage through the FMLA provisions. Contact the FDNY Payroll or Personnel Office for details. See Legal Book; Family Leave Act chapter for more info.

Union Membership Change

Title changes that result in a change of union membership may require a change in payroll deductions for any Optional Rider coverage. You must contact the FDNY Health Benefits Unit and UFA Security Benefits Fund (SBF) within 31 days if you have changed unions.

Eligibility Criteria for Coverage

All categories listed below are covered/eligible under your NYC Health Plan, except where noted otherwise below. However, eligibility will be denied if notifications are not made within prescribed time limits. See ‘Enrollment Periods to Change Plans’ section for specific time requirements.

Firefighters, Fire Marshals, Marine Engineers, Pilots & Wipers
1. all are eligible.

Retired Members

Eligible if you meet all of the following criteria:

You have, at the time of retirement, at least ten (10) years of credited service as a member of a retirement or pension system maintained by the City (if you were an employee of the City on or before December 27, 2001, then at the time of your retirement you must have at least five (5) years of credited service as a member of a retirement or pension system maintained by the City). This requirement does not apply if you retire because of accidental disability; and
You have been employed by the City immediately prior to retirement, as a member of such system, and have worked regularly for at least 20 hours per week; and
You receive a pension check from a retirement system maintained by the City.

Dependents of Retired Members are all eligible as described below.

Dependent Coverage & Domestic Partners

Eligible if their relationship to the eligible participant is one of the following:

Spouse: legally married husband or wife, Line-of-Duty Death widow(er), but never an ex-spouse. If your spouse has employer coverage, see ‘Coordination of Benefits’ which follows this section.
Widow(er): Line-of-Duty Death widows(ers) are Eligible. For info re non-Line-of-Duty Death widows(ers) coverage, see ‘Termination, Suspension, Continuing Benefits (COBRA)’ Section later in this chapter.
Domestic Partner: at least 18 years of age, living together with you in a current continuous and committed relationship, although not related by blood to the participant in a manner that would bar marriage in NYS. More details concerning eligibility and tax consequences are available from FDNY Health Benefits Unit or the Office of Labor Relations Domestic Partnership Liaison Unit.
Children under age 26 (whether married or unmarried): Under the Federal health care reform law, the Patient Protection and Affordable Care Act (PPACA), health plans that cover dependent children must continue to make dependent health coverage available until a dependent turns age 26, will terminate (other than eligible disabled children) at the end of the month in which the “child” reaches age 26. In addition, he or she must meet the definition of “children” under the City’s Health Benefit Program, which follows:

Effective July 1, 2011 the term “children” means the following:

natural children;
children for whom a court has accepted a consent to adopt and for the support of whom an employee or retiree has entered into an agreement;
children required to be covered under a qualified medical child support order until the court order expires, at which time the child may continue to be eligible for coverage under (1) or (2) above;
children for whom a court of law has named the employee or retiree as legal guardian;
any other child who lives with an employee or retiree in a regular parent/child relationship and is the employee’s or retiree’s tax dependent. A child is the employee’s or retiree’s tax dependent if the employee or retiree claims the child on his/her income tax return as a dependent.
- `Dependent Children – Disabled: Unmarried children age 26 and older who cannot support themselves because of a disability, including mental illness, developmental disability, mental retardation or physical handicap are eligible for coverage if the disability occurred before the age at which the dependent coverage would otherwise terminate. Employees or retirees must provide medical evidence of the disability. The proof of disability must be submitted to the health plan within 31 days of the date the dependent reaches age 26. Eligibility for such dependents only applies to current employees whose disabled dependent children reach the age limitation while covered by a City health plan. New employees with disabled dependent children already over the age limitation may not include such children as dependents on their City health plan coverage. In addition, employees may not add disabled dependent children to their health plan coverage, if the child is already over age 26.

Double City Coverage Prohibited

If a person is eligible for the City Health Plan as both a participant and a dependent, the person must choose one status or the other. Similarly, no person can be covered by two City Health Plan contracts at the same time. Eligible dependent children must all be enrolled as dependents of one parent. If both spouses or partners are eligible and one is enrolled as the dependent of the other, the dependent may pick up coverage in his or her own name if the other’s contract is terminated.

Auto Insurance Exclusion (No-Fault)

The NYC Health Benefits Program will not provide benefits for any services for which benefits are available under a no-fault automobile policy.

Coordination of Benefits with Spouse Benefits

Overview – Saves $$

You may be covered by two or more group health benefit plans that may provide similar benefits. Should you have services covered by more than one plan, your City health plan will coordinate benefit payments with the other plan. One plan will pay its full benefit as a primary insurer, and the other plan will pay secondary benefits. This prevents duplicate payments and overpayments. Coordinated Benefits allow the secondary plan to pick up costs after the primary plan coverage reached its limits. It saves you money by combining both spouses’ plans to cover up to 100% of a charge, but in no event shall payments exceed 100% of a charge, as noted below:

Benefits under a plan that is primary are calculated as though other coverage did not exist.
Benefits under a plan that is secondary will be reduced so that the combined payment or benefit from all plans are not more than the actual charges for the covered service. The plan that is secondary will never pay more than its full benefits.

Note: It is illegal to use both spouse’s plans for the same bill unless you Coordinate Benefits as noted above.

Rules of Coordination

The City program follows certain rules that have been established to determine which plan is primary; these rules apply whether or not you make a claim under both plans. The rules for determining primary and secondary benefits are as follows:

Spouses or registered domestic partners who are both City employees may not coordinate NYC benefits. However, they may coordinate their UFA Security Benefits Fund Benefits (dental, drugs, optical, etc.). See Health Book, Security Benefits Fund Chapter for more info.
The plan covering you as an employee is primary before a plan covering you as a dependent.
When two plans cover the same child as a dependent, the child’s coverage will be as follows:
1. The plan of the parent whose birthday falls earlier in the year provides primary coverage.
2. If both parents have the same birthday, the plan that has been in effect the longest is primary.
3. If the other plan has a gender rule (stating that the plan covering you as a dependent of a male employee is primary before a plan covering you as a dependent of a female employee), the rule of the other plan will determine which plan will cover the child. See next section ‘Special Rules…’ for special rules concerning dependents of separated or divorced parents.
If no other criteria apply, the plan covering you the longest is primary. However, the plan covering you as a laid-off or retired employee, or as a dependent of such a person, is secondary, and the plan covering you as an active employee, or as a dependent of such a person, is primary, as long as the other plan has a Coordination of Benefits provision similar to this one.

Special Rules for Dependents of Separated / Divorced Parents

If two or more plans cover a dependent child of divorced or separated parents, benefits are to be determined in the following order:

The plan of the parent who has custody of the child is primary.
If the parent with custody of a dependent child remarries, that parent’s plan is primary. The step-parent’s plan is secondary and the plan covering the parent without custody is tertiary (third).
If the specific decree of the court states one parent is responsible for the health care of the child, the benefits of that parent’s plan are determined first. You must provide the appropriate plan with a copy of the portion of the court order showing responsibility for health care expenses of the child.

Enrollment Periods to Change Plans

Annual Open Transfer Period

Health Benefits Transfer Open Enrollment Periods are usually scheduled once in the Fall each year (retirees every two years—see below). Dates are normally posted by the FDNY on Dept Orders and on the NYC Website. You may transfer from your current health plan to any other plan for which you are eligible, or may add or drop Optional Rider coverage to your present plan. If you do not apply for an Optional Rider when you first enroll, you may add these additional benefits only during a Transfer Period, upon retirement, or if there is a change in your union or union welfare fund coverage. You must prepare and return a Health Benefits Application to the FDNY Health Benefits Unit during the annual Transfer Period. Once you submit an Application, the Transfer Period is over for you and your transfer is irrevocable.

New Firefighters

Required paperwork is provided to you during your first few days at the Fire academy. The form must be filed within 31 days of your appointment date. If you do not file the form on time, the start of your coverage will be delayed and you may be subject to loss of benefits. New employees or employees enrolling for the first time are required to provide acceptable documentation to support the eligibility status of all persons to be covered on their City health plan coverage.

Retirement

Prior to Retirement – You must file a Health Benefits Application at the FDNY Health Benefits Unit, ideally 4 to 6 weeks prior to retirement to continue your coverage into retirement.
Retiree Transfer Opportunities – Retirees may transfer or add an Optional Rider during the even- numbered year Transfer Periods. Additionally, retirees who have been retired for at least one year can take advantage of a once-in-a-lifetime provision to transfer or add an optional rider at any time. Once-in-a- lifetime transfers become effective on the first of the month following the date that the Health Benefits Application is processed. (Exception: When transferring into a Medicare HMO plan other than during Transfer Periods, transfers will become effective on the first day of the month following the processing of the special health plan application.)

Transfer In/Out of Your Plan’s Service Area

Required Documentation & Forms to File

Active FFs: –To enroll, you must file a Health Benefits Application (from the FDNY Health Benefits Unit).
Retired FFs – To enroll after retirement, you must file the Health Benefits Application with the NYC Health Benefits Program.
Document Relationship – Appropriate documentation of marital status, domestic partnership, or birth or adoption of a child is required. It may consist of marriage or birth certificate; adoption or guardianship papers; or copies of tax returns indicating a child is claimed as a dependent.
Domestic Partners – documentation must consist of a copy of the Certificate of Domestic Partnership

and a completed Declaration of Financial Interdependence accompanied by two items of proof evidencing financial interdependence (non-New York City residents must complete an ‘Alternative Affidavit of Domestic Partner’).

Dates of Coverage

Active Firefighters – Coverage begins on your appointment date, provided your Health Benefits Application has been received by the FDNY Health Benefits Unit within 31 days of that date.
Dependents – Coverage for eligible dependents listed on your Health Benefits Application will begin on the day that you become covered. Dependents acquired after you submit your Application will be covered from the date of marriage, domestic partnership, birth or adoption, provided that you submit the required notification documentation within 31 days of the event. (See Keeping Your Info Current section; Family Status Change sub-section.)
Retired Firefighters – If you file the Health Benefits Application for continuation of coverage into retirement with your agency payroll or personnel office prior to retirement (C9 ideally 4 to 6 weeks notice), coverage begins on the day of retirement for most retirees. Employees who had previously waived coverage can reenroll upon retirement. The effective date of the reinstatement will be the date of retirement, or the first day of the month following the processing of the health benefits application.
Late Enrollment – Enrollment is considered late if an application is filed more than 31 days after the event that made the employee, retiree, or dependent eligible. In cases of late enrollment, coverage will begin on the first day of the payroll period following the receipt of the application (for retirees, the first day of the month following the processing of a Health Benefits Application by the agency payroll or personnel office.

Participation in the Medical Spending Conversion (MSC) Programs may limit health plan enrollment and/or status changes. If such changes affect your health plan deductions, they must be made within 31 days of the Qualifying Event or they cannot be made at all until the next Transfer Period (See ‘Pre-Tax Health Plan Paycheck Deductions’ and the ‘Health Benefits Buy-out Waiver: $$$ to You’ sections, which describe the Medical Spending Conversion Programs.)

Termination, Suspension, Continuing Benefits (COBRA)

Termination of Your Health Coverage

Paycheck Termination: for an employee or retiree and covered dependents, when the employee or retiree stops receiving a paycheck or pension check (with an exception for people eligible for SLOAC or FMLA).
Divorce: for a spouse, when divorced from an employee or retiree.*
Domestic Partnership Ends: for a domestic partner, when partnership terminates.*
Death: for all dependents, unless otherwise eligible, when the City employee or retiree dies.*

Pre-Existing Exclusion Certificate: This certificate provides the necessary information to certify coverage that will be credited against any pre-existing condition exclusion period provided under a new health plan. The Health Insurance Portability & Accountability Act of 1996 (HIPAA) requires that the plan administrator issue certificates of group health plan coverage to employees upon termination of employment that results in the termination of group health coverage. Each individual, upon termination, will receive a certificate of credible coverage from the plan administrator.

Returning to Duty—Reinstating Your Coverage

If you have been on approved leave without pay, or have been removed from active pay status for any other reason, your health coverage may have been interrupted. Contact FDNY Health Benefits Unit within 31 days of your return to duty in order to complete a new Health Benefits Application. If you are returning from an approved leave of absence or your coverage has been terminated for less than 90 days, coverage resumes on the date you return to duty. When returning from approved leave of absence, or your coverage has been terminated for less than 90 days, coverage resumes on the date you return to duty. If you were not on an approved leave of absence, or if your coverage has been terminated for more than 90 days, the effective date of coverage rules are specified under Enrollment Periods to Change Plans section, Dates of Coverage sub-section earlier in this chapter.
If you waived or cancelled your City health plan coverage and subsequently wish to enroll or reinstate your benefits, coverage will not start until the beginning of the first payroll period 90 days following the date you submit your Health Benefit Application, unless the enrollment or reinstatement is the result of a loss of other group coverage.

Conversion Option when City Coverage Terminates

Purchase Your Own Plan: Employees and covered dependents may purchase individual health coverage through their City plan if their City group coverage ceases for any of the below reasons. Unlike COBRA, these benefits do not automatically terminate after a limited time, and may vary from the City’s “basic” benefits package in both the scope of benefits and in cost.

leaves City employment
employee or retiree dies;
an employee loses City coverage due to a reduction in the work schedule;
dependent spouse divorced from employee or retiree;
domestic partnership terminates;
dependent children exceed the allowable age limits;
coverage under the provisions of COBRA expires. See COBRA section to follow.

* If both husband and wife, or domestic partner, are eligible for City health coverage as either an employee or a retiree, and one is enrolled as the dependent of the other, the person enrolled as dependent may pick up coverage in his/her own name within 31 days if the participant leaves City employment or dies.

Widow(er) of Retired FF Coverage

Effective 11/13/01, NYS Law provides that surviving spouses of retired FDNY & NYPD members can continue health benefits for life at a cost of 102% of the group rate. Coverage must be elected within one (1) year of date of death of spouse. Contact the NYC Health Benefits Program in writing, for an application.

COBRA Benefits (Continuation of Benefits)

The Federal Consolidated Omnibus Budget Reconciliation Act of 1985 (COBRA) requires that the City offer employees, retirees and their families the opportunity to continue group health and/or welfare fund coverage in certain instances where the coverage would otherwise terminate. The monthly premium will be 102% of the group rate (or 150% of the group rate for the 19th through 29th months in cases of total disability see B). All group health benefits, including Optional Riders, are available. The maximum period of coverage 36 months.

Eligibility – The following are eligible for continuation of coverage under COBRA:
- Employees Not Eligible for Medicare – Employees whose health and welfare fund coverages are terminated due to termination of employment (for reasons other than gross misconduct). Termination of employment includes unpaid leaves of absence of any kind. More information concerning situations involving termination due to gross misconduct is available from the FDNY benefits representative.
- Spouses/Domestic Partners Not Eligible for Medicare – Spouses/Domestic Partners who lose coverage for any of the following reasons: 1) death of the City employee or retiree; 2) termination of the employee’s City employment (for reasons other than gross misconduct); 3) loss of health coverage due to a reduction in employee’s hours of employment; 4) divorce from the City employee or retiree; 5) termination of domestic partnership with the City employee or retiree; 6) retirement of the employee. (See Retirees below.)
- Dependent Children Not Eligible for Medicare – Dependent children who lose coverage for any of the following reasons: 1) death of a covered parent (the City employee or retiree); 2) the termination of a covered parent’s employment (for reasons other than gross misconduct); 3) loss of health coverage due to the covered parent’s reduction in hours of employment; 4) the dependent ceases to be a “dependent child” under the terms of the Health Benefits Program; 5) retirement of the covered parent. (See Retirees below.)
- Retirees – Retirees who are not eligible to receive City-paid health care coverage (see ‘Eligibility Criteria for Coverage section’) and their dependents (if not Medicare-eligible) may continue the benefits received as an active employee for a period of 18 months at 102% of the group cost under COBRA. Retirees eligible for Medicare should refer to the Medicare-Eligible section. Retirees whose welfare fund benefits would be reduced or eliminated at retirement are eligible to maintain those benefits under COBRA for 18 months at 102% of the cost to the union welfare fund. Contact the union welfare fund for the premium amounts and benefits available. A list of welfare fund administrators can be obtained from City payroll or personnel offices.

NOTE: Individuals covered under another group plan are not eligible for COBRA continuation benefits unless the other group plan contains a pre-existing condition exclusion. However, these people may be able to purchase certain welfare fund benefits. For more information, contact the appropriate fund.

Time Periods of COBRA Continuation

Termination of Employment – 36 Months: If benefits are lost due to termination of employment, the maximum COBRA can continue coverage is 36 months. This period will be measured from the loss of coverage under the City plan.
Disabled After Termination – 29 Months: If a beneficiary becomes disabled (as determined under Title 11 or XVI of the Social Security Act) during the first 60 days of the 18-month COBRA period, coverage can be extended for an additional 11 months after the end of the original continuation period. Notification must be made to the plan administrator within 60 days after the Social Security Administration’s determination of disability and before the end of the initial 18- month COBRA continuation period. The plan administrator must also be notified within 30 days if the Social Security Administration determines that the disability no longer exists. The otherwise applicable COBRA premium must be paid during any extension period, i.e., 150% of the premium, must be paid during any extension period.
Disabled On Termination – 18 Months: Those who are totally disabled because of an injury or illness on the date of termination remain covered for that disability up to a maximum of 18 additional months for the GHI-CBP/EBCBS plan and up to 12 months for all other plans, except GHI Type C/EBCBS, which provides only 31 days of additional coverage. This extension of benefits applies only to the disabled person and only covers the disabling condition. Under the GHI/Blue Cross plans, if a subscriber is hospitalized at the time of termination, hospital coverage is extended only to the end of the hospitalization. Contact the specific Health Insurance Plan Carrier.
Dependent Loses Coverage – 36 Months: If dependents lose benefits due to death, divorce, domestic partnership termination, or loss of coverage due to the Medicare-eligibility of the contract holder, or due to the loss of dependent child status, the maximum period for which COBRA can continue coverage is 36 months. This period will be measured from the loss of coverage under the City plan.
Qualified Beneficiary Definition: includes a child born to or adopted by certain qualified beneficiaries during the COBRA continuation period. A child born to or adopted by you during the COBRA continuation period will become a qualified beneficiary in his or her own right only if you are a qualified beneficiary by reason of having been an employee. This means that if you should lose your COBRA coverage, your new child may have an independent right to continue his or her coverage for the remainder of the otherwise applicable continuation period. However, you must cover your new child as a dependent within 30 days of the child’s birth or adoption in order to have this added protection. Any increase in COBRA premium due to this change must be paid during the period for which the coverage is in effect.
Maximum Time – 36 Months: Continuation of coverage can never exceed 36 months in total, regardless of the number of events that relate to a loss in coverage. Coverage during the continuation period will terminate if the enrollee fails to make timely premium payments or becomes enrolled in another group health plan (unless the new plan contains a pre-existing condition exclusion).

60 Day Special Notification Responsibilities

Member & Dependents: Under the law, the employee or family member must notify the FDNY Health Benefits Unit and the applicable welfare fund within 60 days of the death, divorce, domestic partnership termination, or change of address of an employee, or of a child’s losing dependent status. Retirees and/or the family members must notify the Health Benefits Program and the applicable welfare fund within 60 days in the case of death of the retiree or the occurrence of any of the events mentioned above.
Disabled (Totally) Employees: (as determined by Social Security) within 60 days after the date of termination of employment must notify their individual Health Plan carrier of the disability. The notice must be provided within 60 days of Social Security’s determination and before the end of the 18-month continuation period. If Social Security ever determines that the individual is no longer disabled, the former employee must also notify their individual Health Plan of this. This notice must be provided within 30 days from Social Security’s final determination.
COBRA Packet: When a qualifying event (such as an employee’s death, termination of employment, or reduction in hours) occurs, the employee and family will receive a COBRA information packet (from the City agency) describing continuation coverage options.

Election of COBRA Continuation

To elect COBRA continuation of health coverage, the eligible person must complete a COBRA – Continuation of Coverage Application. Employees and/or eligible family members can obtain application forms from the FDNY Health Benefits Unit. Retirees’ eligible family members can obtain application forms by contacting the Health Benefits Program. Please contact the UFA SBF if you wish to purchase its COBRA benefits.
60 Day Notice Required: Eligible persons electing COBRA continuation coverage must do so within 60 days of the date on which they receive notification of their rights, and must pay the initial premium within 45 days of their election. Premium payments will be made on a monthly basis. Payments after the initial payment will have a 30-day grace period.

Health Plan Transfer Opportunities

Processing Changes: City agencies do not handle COBRAenrollee transfers, or process any future changes such as adding dependents. All future transactions will be handled by the Health Plan Insurance Carrier in which the person eligible for COBRA is enrolled.
Open Enrollment Periods: Former employees and dependents who elect COBRA continuation coverage are entitled to the same benefits and rights as employees. Therefore, COBRA enrollees may take part in the annual Transfer Period. Dependents of retirees enrolled in COBRA continuation coverage will continue to receive the same transfer opportunities available to retirees: once-in-a-lifetime transfer (if not already used), and transfer during the normal Transfer Period for retirees.
Address Change: Individuals eligible for COBRA may also transfer when a change of address allows or eliminates access to a health plan that requires residency in a particular Zip Code.
Application: forms to be used during the Transfer Period (or after a qualifying event) should be obtained from the COBRA enrollee’s current health plan or from the Health Benefits Program website at www.nyc.gov/olr in the pdf titled COBRA Notice of Rights and COBRA rates. Applications should be returned to the current Health Insurance Plan Carrier, which will forward enrollment information to the new plan. Be sure to elect a primary care physician for each family member if selecting an HMO that requires you to do so. These transfers will become effective on January 1, unless otherwise specified.

NYC Health Benefits Program, Office of Labor Relations (OLR) Go to the NYC Website: www.nyc.gov/html/olr for more info.

Medicare-Eligible Retirees

Overview – Your First Level of Health Benefits

When you or one of your dependents becomes eligible for Medicare at age 65 (and thereafter) or through special provisions of the Social Security Act for the Disabled, your first level of health benefits is provided by Medicare.
The Health Benefits Program provides a second level of benefits intended to fill certain gaps in Medicare coverage. In order to maintain maximum health benefits, it is essential that you join Medicare Part A (Hospital Insurance) and Part B (Medical Insurance) at your local Social Security Office as soon as you are eligible. If you do not join Medicare, you will lose whatever benefits Medicare would have provided.
The City’s Health Benefits Program supplements Medicare but does not duplicate benefits available under Medicare. Medicare-Eligibles must be enrolled in Medicare Parts A and B in order to be covered by a Medicare HMO plan.

Enrollment (Retirees Only)

To enroll in Medicare and assure continuity of benefits upon becoming age 65, contact your Social Security Office during the three-month period before your 65th birthday. In order not to lose benefits, you must enroll in Medicare during this period even if you will not be receiving a Social Security check.
If you are over 65 or eligible for Medicare due to disability and did not join Medicare, contact your Social Security Office to find out when you may join. If you do not join Medicare Part B when you first become eligible, there is a 10% premium penalty for each year you were eligible but did not enroll. In addition, under certain circumstances there may be up to a fifteen-month delay before your Medicare Part B coverage can begin upon re-enrollment.
If you or your spouse are INELIGIBLE for Medicare Part A although over age 65 (reasons for ineligibility include non-citizenship or non-eligibility for Social Security benefits for Part A), contact the NYC Health Benefits Program
Coverage for those not eligible for Medicare Part A can be provided under certain health plans. Under this Non-Medicare eligible coverage, you continue to receive the same hospital benefits as persons not yet age 65.
If you are living outside the USA or its territories, Medicare benefits are not available. Under this Non- Medicare eligible coverage, you continue to receive the same hospital and/or medical benefits as persons not yet age 65. If you do not join and/or do not continue to pay for Medicare Part B however, you will be subject to penalties if you return to the USA and attempt to enroll. Please provide full identifying information, including name, date of birth, address, agency from which retired, pension number, health plan and certificate numbers, health code, Social Security Number and Medicare claim number (if any). Also give the reason for ineligibility for Medicare Part A and/or Part B.
If you are eligible for Medicare Part B as a retiree but neglect to file with the Social Security Office during their enrollment period (January through March) or prior to your 65th birthday, you will receive supplemental medical coverage only, and only through GHI/EBCBS Senior Care.

Eligibility Notification

You must notify the NYC Health Benefits Program in writing immediately upon receipt of your or your dependent’s Medicare card. Include the following information: a copy of the Medicare card and birth dates for yourself and spouse, retirement date, pension number and pension system, name of health plan, and name of union welfare fund.

Part B Premium Reimbursement

Once the NYC Health Benefits Program is notified that you are covered by Medicare, deductions from your pension check will be adjusted, if applicable, and you will automatically receive the annual Medicare Part B premium reimbursement (See b, c & d below for reimbursement info). The NYC Health Benefits Program will notify your health plan that you are enrolled in Medicare so that your benefits can be adjusted. This may take several months. If your plan does not accept Medicare-Eligibles, you will receive special instructions concerning changing to another health plan. NOTE: If you are Medicare-Eligible and are enrolling in an HMO you must complete an additional application form, which is available directly from your Health Insurance Plan Carrier.
The City will reimburse retirees and their eligible dependents for the basic monthly premium for Medicare Part B.
Periodically, the Medicare Part B premium is increased by the Social Security Administration. At the time of each increase, legislation must be approved by the City Council authorizing the City to reimburse you at a new rate.
If you are receiving a Social Security check, the premium for Medicare Part B will be deducted from that check monthly. If you are not receiving a Social Security check, you will be billed quarterly by the Social Security Administration. You must be receiving a City pension check and be enrolled as the contract holder for City health benefits in order to receive reimbursement for Part B premiums. For most retirees, the refund is issued automatically by the NYC Health Benefits Program. Medicare Part B reimbursement checks are generally issued once a year in the summer following the year in which premiums are paid.

Medicare Part D—Prescription Drugs

Medicare Part D Prescription Drug Coverage

Information and updates were mailed to all retired members outlining their Prescription Drug Benefits along with a Summary of Benefits (with Charts) and Frequently Asked Questions. Please refer to this information. Updates regarding Medicare Part D benefits will continue to be mailed directly to each retired member’s residence as new information becomes available. Please retain this important info for future reference as needed.

For more information your current prescription drug coverage contact the Benefits Access Center, call your prescription drug provider, CVS Caremark, visit Medicare online, call your State Health Insurance Assistance Program, call Medicare, or call UFA Retired SBF.

Medical Misconduct & Malpractice

Professional Misconduct

If you feel that any doctor (including FDNY BHS Doctors) treating you or your dependents has not practiced honestly or competently, you may (with the guidance of — and recommended by — the UFA Health & Safety Office) file a complaint with the N.Y. State Dept. of Health (DOH), which investigates all professional misconduct by physicians or physician assistants. All reports are kept confidential. Investigation may result in a hearing before a committee of the Board for Professional Misconduct. There must be sufficient evidence of a possible violation before a hearing is held. The Board consists of physicians and consumer members, which will acknowledge receipt of your complaint, provide specific information regarding the investigation and will inform you of the final determination. If the doctor at issue is an FDNY BHS Medical Officer or a doctor assigned/referred by the BHS, after reading this section also refer to the ‘FDNY Book’ (BHS Chapter: Difficulties with Medical Office Personnel section) for additional instructions.

Medical Malpractice

Professional Medical Misconduct is different than Medical Malpractice. Malpractice cases are heard in civil court and seek financial awards for patients or families who claim harm by a physician. Contact your County Clerk’s office for information related to malpractice, or the UFA Health & Safety Office and/or the UFAGeneral Counsel for additional guidance. To look up a doctor’s history or to see if they have been disciplined, go to the Docfinder website. Go to your state board’s home page, then search for your Physician (free). Or go to DocInfo. For a small fee you will find out if a doctor has been disciplined courtesy of the Federation of State Medical Boards.

Frequently Asked Questions

The following are questions frequently asked of the staff of the Office of Professional Medical Conduct. This office, which is part of the New York State Department of Health, investigates all reports of possible professional misconduct by physicians and physician assistants. This information is from the NYS DOH website.

What does the Office of Professional Medical Conduct do? The mission of the Office of Professional Medical Conduct (OPMC) is to protect the public through the investigation of professional discipline issues involving physicians and physician assistants. OPMC is responsible for investigating all complaints of misconduct, coordinating disciplinary hearings which may result from an investigation, monitoring physicians whose licenses have been restored after a temporary license surrender and monitoring physicians and physicians assistants placed on probation as a result of disciplinary action. If you feel that your doctor has committed misconduct, you should file a report with the NYS DOH Office of Professional Medical Conduct. Reports of misconduct are kept confidential.
What is misconduct? Examples of medical misconduct include (but are not limited to): practicing fraudulently, practicing with gross incompetence or gross negligence; practicing while impaired by alcohol, drugs, physical disability or mental disability; being convicted of a crime; willfully filing a false report; guaranteeing that treatment will result in a cure; refusing to provide services because of race, creed, color or ethnicity; performing services not authorized by the patient; willfully harassing, abusing or intimidating a patient; ordering excessive tests; and abandoning or neglecting a patient in need of immediate care; failing to make X-rays or records available to the patient or another physician, upon a patient’s request.
What are examples of the kinds of cases which have resulted in disciplinary action?
1. Failed to treat a patient with an ovarian cyst, failed to adequately treat another patient with an enlarged thyroid gland, did not properly monitor anticoagulation therapy for another patient and inadequately investigated complaints of chest pain by yet another patient. For admitted incompetence, the physician agreed to surrender license.
2. Found guilty of prescribing drugs to patients without doing even minimally necessary exams or histories. The physician was found to have given one patient drugs that were excessive in number, too high in dosage, dangerous in their combined side effects, and in some instances, contraindicated. In two other cases, the physician gave a patient enormous doses of addictive drugs that were contraindicated and prescribed drugs for another patient over a three- year period without any indication of the reason or the necessity for the prescriptions. The physician’s license was revoked for negligence.
3. For failure to adequately perform and interpret ultrasound examinations, failure to perform or order necessary laboratory tests, failure to diagnose an ectopic pregnancy and appropriately treat a patient’s complaint of lack of fetal movement, a physician’s license was revoked due to negligence and incompetence.
Not Misconduct? Certain types of complaints are not considered misconduct and therefore are not under the jurisdiction of OPMC. These include complaints regarding fees (unless they represent fraud), and complaints about a physician’s attitude, communication skills or rude behavior. OPMC does not condone uncaring behavior, but such actions do not, by themselves, constitute misconduct.
Who do I contact about filing a misconduct complaint? To discuss filing a misconduct complaint against a physician or physician assistant, contact the Office of Professional Medical Conduct, NYS Department of Health. All complaints are kept confidential. Complaints against other licensed professionals should be directed to the State Education Department, Office of Professional Discipline. If the complaint is about an FDNY BHS doctor, contact the UFA Health & Safety Office and/or the UFA General Counsel for recommendations and additional guidance before taking any action.
What happens once I make a complaint?
1. Once a written complaint has been received, it is reviewed by investigative and medical staff at the Office of Professional Medical Conduct. All complaints are kept confidential A charge of misconduct is serious and there must be sufficient evidence of a possible violation before a hearing is held. If the investigation reveals sufficient evidence, an investigative committee determines if disciplinary action is warranted. A Health Department attorney prepares a notice of hearing and a Statement of Charges.
2. At that point, a disciplinary hearing is held before a committee of the Board for Professional Medical Conduct. The Board is composed of physicians, physician assistants and laypersons who fulfill major roles in the disciplinary process by serving on investigative, hearing and license restoration committees. The Hearing Committee, which is composed of two physicians and one layperson, makes a finding of guilt or innocence and imposes a penalty if appropriate. The licensee and the Director of the OPMC may appeal the decision to an Administrative Review Board.
3. The Board for Professional Medical Conduct has the authority to revoke or suspend a physician’s license. The Board can also limit a physician’s license, issue a censure and reprimand, order education and/or retraining, levy a fine or require community service. The Board cannot direct a physician to reimburse a patient, change a diagnosis or alter an opinion.
4. Effective 11/7/08 all charges will be made public via the NYS DOH Office of Professional Medical Conduct.
Will I be interviewed or have to testify about my complaint? The person who makes a complaint (the complainant) usually is interviewed. The interview may be conducted over the telephone or in person. If a disciplinary hearing is held, the complainant may be requested to testify.
Time to Resolve? Because medical conduct investigations are complex, it often takes months to resolve complaints. Cases that go to hearing typically take longer.
Have there been complaints about my physician in the past? Complaints against physicians are public information only if they result in a final disciplinary action. Info on closed complaints, dismissed actions and on-going investigations is not available to the public. To learn if a physician has been disciplined, call NYS DOH Office of Professional Misconduct or access the NYS DOH Medical Conduct Website (select Information for Consumers). There is no fee for this information.
How can I find out if my physician is licensed in New York State? Contact or visit the website of the State Education Department, Division of Professional Licensing Services. It can also tell you where a physician attended medical school.
How can I find out if my physician is board-certified? Many doctors become certified in a specialty by completing special training and passing formal examinations. To find out if your physician is board- certified, contact the American Board of Medical Specialties.
Can your office recommend a physician for me? The OPMC cannot give any recommendation for, or against, a physician or physician assistant; the office can only inform you whether a disciplinary action has been taken against the physician/physician assistant. For information on how to locate a physician in your area, you may want to contact your county or state’s Medical Society.
Can a physician refuse to accept me as a patient? Physicians are generally free to accept or reject patients; however, a doctor may not discriminate against patients on the basis of race, gender or creed.
Does a physician have the right to terminate me as a patient? Yes, a physician can stop seeing a patient. Although no regulations require a physician to provide advance notice, typically he/she would give the patient two to four weeks to locate a new physician.
How much can a physician charge for services? Generally, physician fees are not regulated in New York State. Complaints regarding fees are not under the jurisdiction of the Office of Professional Medical Conduct unless they represent fraud (for example, a charge for tests or services not provided).
How can I get a copy of my medical records and is there a fee? Can a physician refuse to let me see my records if I haven’t paid a bill? You can request a copy of your medical records from your physician. The cost can be no more than 75 cents per copied paper page. A physician cannot refuse to let a patient see medical records because of an unpaid bill. For more information, contact the NYS DOH Access to Patient Information Program.
How long must a physician keep medical records? Physicians must keep patient records for six years after the last visit. Records for children are kept for one year after the child’s 18th birthday.

Docfinder Searches and other licensee searches: (online physician directory at www.docboard.org) The AIM DocFinder is recognized for its easy-to-use search engine. It remains the only combined public online physician database in the nation that has its direct source of data from state government licensing boards and that also remains free of charge to the public. DocFinder contains the licensing background and disciplinary information of physicians and other health care practitioners with much more detailed Medical Malpractice, Hospital Discipline and Criminal Conviction information from Physician Profile Law states such as First in the Nation Massachusetts. Very popular with consumers, DocFinder has been featured in numerous state and national publications such as Newsweek Magazine as well as national and local news broadcasts.

Additional Benefits & Important Info

Leave Time Entitlement

Unlimited Medical Leave for FDNY – NYC Firefighters are entitled to unlimited medical leave for injuries and illnesses. Unlimited medical leave for Line-of-Duty injuries and illnesses (LODI) is protected by NYC Administrative Code (Law). Unlimited medical leave for non-LODI is protected by the UFA Collective Bargaining Agreement with the City—not by the NYC Administrative Code. See Legislative Book; Legislative Accomplishments, Laws & Definitions chapter; Unlimited Medical Leave Law section for additional info.
Emergencies: Family Member Illness – Members will be granted emergency leave for serious illness of a spouse, child, parent (step, foster or natural), brother or sister of a member. The first scheduled tour of any emergency leave shall not be deducted from annual leave allowances. Any tours of duty granted as an extension will be deducted from annual leave allowances. In lieu of deductions from annual leave allowances, members may work equal reimbursement tours to repay the time. See Dept. Regs, Ch. 17.4.1 &17.1.12 for more info.
Maternity Leave – You may take paid and unpaid leave for pregnancy and after your child is born.
Unpaid – In accordance with Federal Law members are entitled to 12 workweeks of unpaid leave during any 12-month period due to a new birth, major illness of dependents, in accordance with certain definitions. This is in additional to other leave you are entitled to with pay while you are pregnant and after birth. See Legal Book; Family & Medical Leave Act chapter or section & see FDNY Book; Bureau of Health Services chapter; Maternity Leave section for more info. Also refer to DO #138 of 1993.
Paid – Under the Department’s Special Leave with Pay policy, any member may request leave with pay immediately prior to or immediately after the birth of his or her child. “Special Leaves of Absence for personal business or other reasons shall be applied for well in advance of dates on which leaves are desired. All pertinent information indicating the necessity for such leaves shall be included.” This documents the Department’s willingness and commitment to accommodate requests for immediate vacation leave when a member or his/her spouse has a newborn child. You can use unused vacation time or even accrued vacation entitlement. If there are any problems, special conditions, or unusual circumstances, your Delegate can help you with the assistance of the UFA Trustee, if needed. See DO 15 of 1995, sec 2.4 for more specific info.

Line-of-Duty Injuries — Medical Treatment: Who Pays?

The FDNY pays directly for any medical services active members receive in connection with a LODI—but ONLY if you receive prior written approval. Always get written authorization from the FDNY BHS before you go for outside consultation or medical treatment for a LODI Injury. If you seek your own treatment without prior written authorization and then attempt to have the bill paid by the FDNY—don’t waste your time, trouble, phone calls or stamps—because all your attempts at reimbursement or payment will prove fruitless! Do it right the first time.

Active: NOT covered by your NYC Health Plan while you are an active member! You must have prior written authorization (except for emergencies) from the FDNY’s Bureau of Health Services (BHS) if you expect the FDNY to pay for any treatment of a LODI. If you have authorization, the Dept pays 100% of all authorized treatment and diagnostics for LODI injuries. Medical services for LODI are NOT covered by your NYC Health Plan while you are an active member!
Retired: NOT covered by the FDNY after your retirement date! The moment you retire, the Dept will no longer pay for your LODI treatment. Instead, your normal NYC Health Plan will cover it, subject to your plan’s limitations. In other words, your LODI coverage will most likely not be as thorough once you retire.

EXCEPTION: WTC related injuries may be treated by FDNY BHS under certain circumstances if you are retired. Contact FDNY BHS re the WTC Medical Monitoring Program.

Prescription Drugs — Who Pays?

Non-Line-of-Duty—Union Pays: Use your UFA-SBF Prescription Drug Card, or PICA Drug Card. See Health Book; Security Benefits Fund (SBF) chapter; Prescription Drugs section for more info. Or contact the UFA Security Benefits Fund. Never try to use your UFA SBF drug plan/card for any line-of-duty injury (LODI) drug prescriptions—ever! If you do this, the cost comes directly out of the limited money the City contributes annually into your SBF dental, optical, prescription drug, anesthesia, hearing aid, and other supplemental health benefits plan. It’s your money, and it will come out of your union plan benefits. Don’t waste it—the Dept is required to pay it!
Line-of-Duty—FDNY Pays —Line of Duty Drug Card: Whenever you are prescribed drugs for a Line- of-Duty Injury, you must use your FDNY LODI drug card or WTC drug card to fill the prescription. Do NOT use your UFA SBF drug card.
Retired: LODI drugs are NOT covered by the FDNY after your retirement date! Instead, the UFA SBF or Medicare (see Medicare-Eligible Retirees section) will cover it, subject to your plan’s limitations. EXCEPTION: WTC related injury drugs are covered by your WTC Drug Card.

Doctors, Hospitals, Ambulances

Line-of-Duty Injury Hospital & Doctor Bills – Never give your home or firehouse address to a hospital or doctor for LODI injuries. If you do, all bills and collection notices and calls will come to you! Use FDNY BHS, 9 Metrotech Center, Brooklyn, NY 11201 for all LODI medical forms. This address is also on your UFA calendar for reference at any time.
Hospitals: AFLAC & Catastrophic Insurance Penalties! Do not under any circumstances mention to hospital personnel, or write on the forms, that you have Catastrophic or AFLAC plans. If you do, your medical insurance providers may refuse to pay for your treatment—and you will be harassed by hospitals for payment. Technically, these policies are not medical insurance, though your NYC Medical Plan providers may erroneously believe this to be the case.
Second Medical Opinions Free-Pro Bono Medical Panel – This group of highly regarded independent physicians, who are experts in their specialties, will render a second opinion to our members and their immediate families, without charge. The initial consultation will be provided free to uniformed members with non-service-connected medical conditions and their legal spouses or minor children. (DO #53 of 1992) See Health Book; Insurances & Free Benefits chapter; Health/Medical Help-Free section for more info.
Emergency Room Extra Doctor Fees: Empire Blue Cross/Blue Shield – For those members who are covered by Empire BlueCross BlueShield, please note that the cost of most physicians who see you in the emergency room — including for X-rays and pathology — is covered by your plan. However, not all hospital doctor services are completely covered. Be aware that if you are treated by a specialist called in by the hospital who is not a staff employee, you could be billed hundreds of dollars. If you get billed more than your copayment, call Empire BlueCross BlueShield.
Elective Surgery (GHI/Empire only): Ten days prior to an elective surgery or within 24 hours after an emergency admission, call NYC Healthline at 800-521-9574 to avoid $500 in penalties.
Overseas Hospitals: (Empire Blue Cross/Blue Shield only) If you are traveling overseas, check the Empire BlueCross BlueShield Website for a list of participating hospitals in the country you plan to visit, or call Empire BlueCross BlueShield to save any out-of-pocket expense.
Free Family Transportation-Fire Family Transport Foundation – The FFT vehicle is intended to ensure that members who are seriously injured in the line of duty have their families transported to medical institutions in a way befitting their special needs. The FFT vehicle was donated to the Fire Department by the Fire Family Transport Foundation, Limited, a non-profit corporation founded by members of the Department. See Health Book; Insurances & Free Benefits’ chapter; Health/Medical Help-Free section for more info.
Ambulance, TV & Phone Assistance-Welfare Fund – Helps cover costs for hospitalized LODI members for TV & telephone use. It will assist non-LODI members with its own ambulance or private ambulance service. See Health Book; Insurances & Free Benefits’ chapter; Health/Medical Help-Free section for more info.
Hospital Room Services – See above for info.

Wellcare/Preventive & Retirement Health Exams

Complete Medical Wellness Program – Any member or spouse (active or retired) who is between the ages of 45 and 65 will now be allowed to receive a complete medical exam for just the normal GHI co-pay. This is part of a wellness/prevention program that was worked out by the City unions. GHI also includes discounted rates from selected providers/venders for: fitness club discounts, weight loss programs, acupuncture, massage therapy, nutrition programs / supplements and personal medical data credit card size disks. Other City Health Plan Providers may also provide Wellness coverage. See Contacts section for contact info of your specific Health Plan Provider.
Retirement Planning Medical Screening – It is highly recommended that members planning to retire receive full diagnostic medical exams for possible heart conditions and cancers, or any other disabilities that may be job related, but not so readily detectable. Many members have retired only to tragically discover days or months later that they have a serious or terminal illness that would have qualified for a Line-of-Duty pension had it been discovered before their retirement date. Some of these tests are covered under your plan, some are not. Spend the money to receive all recommended examinations and diagnostics. Once you retire, it is against the law for your pension to change to a disability pension unless you filed for a disability pension prior to your retirement date. See Financial Book; Retirement Planning section.

Inoculations & Immunizations

The Department’s immunization and inoculation program is an excellent free benefit that can save you and your family from severe illnesses and high medical costs. The BHS administers tuberculosis tests and updates other needed immunizations at no cost, including tetanus and Hepatitis B. The BHS maintains your immunization & inoculation records in its computer system and will provide any written documentation you request. You may want to bring your UFA Locker Medical Monitoring Card with you for your Annual Medical. The BHS will enter any inoculation dates into its system for you so the BHS can automatically remind you of needed boosters, etc. whenever you take your Medical.

Inoculations may also be for biological or chemical agents in response to terrorist attacks. These are often done on a schedule or by emergency announcements in various firehouses.

Hepatitis inoculation is a series of 3 or 4 injections which protects you and your family. It has been reported that the most accurate results (to see if you are protected from Hepatitis) are measured if the testing is done after a three month wait (after your last shot). About 20% of those taking the series require the 4th shot. Currently (2010), all newly hired firefighters are offered Hepatitis B inoculations. BHS Nurses will be sent to Probie School to administer the first two inoculations for Hepatitis B-if a probie is not immunized already. Probies will also receive inoculations for measles, rubella and mumps, if needed. Their third Hepatitis B inoculation is administered at their 5th Grade Medical or next Annual Medical. Booster inoculations will be administered to any member whose immunity levels are too low. If you are concerned about the prevention of these illnesses, contact the FDNY BHS to see if/when any program is active. It’s a generous benefit. Make sure you take full advantage of it!

Blood Program

Your individual Health Plan Insurance Carrier covers the cost of administering transfusions and pays blood processing fees for employees, retirees and eligible family members. It does not pay for the storage of your own blood for future use. Blood replacement fees are not covered by any health plan offered by the City. To help our community maintain the blood reserves required to avoid resumption of replacement fees, the Employee Blood Program sponsors a voluntary donor program for City employees, called the City Donor Corps. City Donor Corps members who donate once a year are entitled to certain benefits for themselves and family members. For further information, the FDNY Health Benefits Plan Unit.

Surgical Assistance Fund

The UFA/UFOA Surgical Assistance Fund (SAF) provides coverage from $10.00 to $650.00 per member per year, according to an established fee schedule to its members for surgical procedures only, and certain specified additional items. These benefits are provided at $15.00 annually for Family Group membership and $10.00 annually for Single Group membership. This additional coverage is free for Retirees who were paying active members of the SAF for two years immediately prior to retirement. See Health Book; Insurances & Free Benefits chapter; Surgical Assistance Fund section for additional info about this fund.

Anesthesia

The UFA Security Benefits Fund supplements your Surgical & Maternity Anesthesia coverage (for active FFs only) in many cases, including for in-hospital oral surgery. See Health Book; Security Benefits Fund chapter; Anesthesia section for additional info.

Dental Care/Oral Surgery

Dental Care is not covered by the NYC Plan. It is covered by the UFA Security Benefits Fund. This includes anesthesia coverage for in-hospital oral surgery. See Health Book; Security Benefits Fund chapter; ‘Dental’ and ‘Anesthesia’ sections for additional info.

Vision Care/Optical

Optician examinations, glasses and contact lenses are not covered by the NYC Plan. They are covered by the UFA Security Benefits Fund. See Health Book; Security Benefits Fund chapter; ‘Optical Benefits’ section for additional info.

Hearing Aid

Hearing Aides are not covered by the NYC Plan. They are covered by the UFA Security Benefits Fund. See Health Book; Security Benefits Fund chapter; ‘Hearing Aid Benefits’ section for additional info.

Counseling

See Psychiatric, Counseling, Alcohol & Substance section of this chapter. You can also contact the UFA Security Benefits Fund for guidance re coverage for these types of problems.

Alcoholism

See Psychiatric, Counseling, Alcohol & Substance section of this chapter. You can also contact the UFA Security Benefits Fund for guidance re coverage for these types of problems.

Substance Abuse

See Psychiatric, Counseling, Alcohol & Substance section of this chapter. You can also contact the UFA Security Benefits Fund for guidance re coverage for these types of problems.

Psychiatric, Counseling, Alcohol & Substance

You can also contact the UFA Security Benefits Fund for guidance re coverage for these types of problems.

Counseling Services Unit of the FDNY (CSU) – The CSU is a unit of the FDNY Bureau of Health Services (BHS). Its purpose is to assist members with the intention of restoring the member to a healthy state of mind so members may perform their duties safely. If you are experiencing any problems that you feel may be interfering with safely performing your duties, or causing a danger to your health, the CSU may be able to help you, and grant time off for you to address a particular issue. The CSU has assisted many members work their way through some of the following issues: dealing with serious injuries, death or serious illness of loved ones, marital problems, trauma stress, feeling down, depression, suicidal thoughts or other mental issues, referrals to therapists, and addressing substance/alcohol problems. See FDNY Book; BHS Chapter; Counseling Services Unit section for more info.

Confidential Counseling Services – Don’t Want FDNY to Know? The UFA Health & Safety Office keeps note of programs available through other counseling sources, where no person in the Dept., CSU, or the UFA will have any ability to know you are going for treatment anonymously. If you do not want to personally make the call for help, you can have your Delegate (or a concerned friend or family member) anonymously contact the UFA Health & Safety Office for you.

Disabilities: Reasonable Accommodation Americans with Disability Act (ADA)

The ADA defines Disability as: “someone who has a physical or mental impairment which substantially limits one or more major life activities; or has a record of such physical or mental impairment; or is regarded as having such a

physical or mental impairment.” Disabled persons have certain employee rights under Federal Law. Under certain circumstances employers must provide work assignments to disabled employees if such positions can be reasonably accommodated. See Legal Book; Americans with Disabilities Act chapter or section for more info. Also see PA/ID 1- 2000 and the Americans with Disability Act website, www.ada.gov.

Cancer Insurance

When diagnosed with cancer, this plan provides benefits for hospital confinement, radiation and chemotherapy and surgery, among others. AFLAC pays cash directly to you as soon as you or a covered family member gets cancer. From that point on, cash benefits are paid for most treatments received during your struggle to get well. Premiums are paid through payroll deductions. You can keep the plan after you retire. See Health Book; Insurances & Free Benefits chapter; Primary Health/Medical section for comprehensive info.

Accident/Injury Insurance

The AFLAC Accident Plan helps cover expenses associated with an accidental injury. It pays you directly regardless of any other insurance you may have. Benefits include: accident hospital confinement, ambulance, accidental death and dismemberment and many others—including Line-of-Duty Injuries. Payroll deduction. There are no medical questions to answer and no money needed to join. See Health Book; Insurances & Free Benefits chapter; Primary Health/Medical section for comprehensive info.

Catastrophic Insurance

For coverage that picks up medical costs that exceed your NYC Health Insurance Plan cap, including Medicare. See Health Book, Insurances & Free Benefits chapter; Primary Health/Medical section for comprehensive info.

Life (Death) Insurance

There are several optional and automatic enrollment life insurance plans offered or recommended by the FDNY & UFA. See Health Book; Insurances & Free Benefits chapter; Life Insurances section for comprehensive info.

IRS Tax Deductible Flexible Spending Accounts & Plan Buyout for Cash

Overview: The four programs described in this section are allowable under Internal Revenue Code (IRC) Section 125. One Program allows you to opt out of Health Insurance Coverage in exchange for annual cash payments under certain circumstances (not tax deductible). The three other programs allow active FFs to deposit a portion of their pre-tax income into accounts maintained for certain health care and dependent/child day-care/babysitting expenses while you work. You can save over a thousand dollars in taxes each year depending on what your tax bracket is and what your family’s particular needs are. These programs include:

Medical Spending Conversion (MSC) Premium Conversion Program: All active firefighters are automatically enrolled in this program. See ‘section K. Pre-Tax Health Plan Paycheck Deductions’ later in this section.
Health Care Flexible Spending Account (HCFSA): See ‘section L. Tax Free Health Care Flexible Spending Account’ later in this section.
MSC Health Benefits Buy-Out Waiver Program: opt out for annual cash payments. See ‘section M. Health Benefits Buy-Out Waiver: Cash to You’ later in this section.
Dependent Care Assistance Program (DeCAP): See ‘section N. Dependent Care Assistance Program’’ later in this section.

See the following sections K, L, M & N for additional info, and the NYC Website, Flexible Spending Programs section for complete info. You can also contact the FDNY Health Benefits Unit to answer your questions.

Pre-Tax Health Plan Paycheck Deductions

Enrollment in the Medical Spending Conversion (MSC) Premium Conversion Program is automatic for all NYC Firefighters. Health insurance benefit premium payments (if any) are deducted automatically from your paycheck on a pre-tax basis, thereby reducing your gross income for tax purposes. It allows City employees who have payroll deductions for health insurance premiums and optional riders to increase their take-home pay.

In other words, if you are covered by HIP, GHI, Blue Cross/Blue Shield or one of the other major medical plan providers that the City offers, then you are already enrolled in the MSC Premium Conversion Program and do not need to do anything in order to benefit. Currently, health plan deductions for basic and/or optional benefits are deducted from your salary. For tax purposes, payments made on a before-tax basis effectively reduce the salary on which your taxes are computed by the amount of the health plan deduction. Therefore, federal and Social Security taxes that must be withheld are reduced. The net effect is that you receive more money in your paycheck. See the Premium Conversion Program section of the NYC Website for complete info.

Change Premium Payments from Pre-Tax to Post-Tax

While automatically enrolled on a pre-tax basis, you are able to choose post-tax premium payments if you wish. In order to do this, you must obtain and submit a Medical Spending Conversion (MSC) Enrollment/Change Form available at the FDNY Health Benefits Unit, or you may call the MSC Administrative Office directly. The completed form should be returned to your FDNY Health Benefits Unit, which will complete the benefit section and sign the MSC Enrollment/Change Form and send it to the MSC Administrative Office for processing. Changing from pre-tax to post-tax or vice-versa can be done during the Annual Health Benefits Fall Transfer Period. However, employees must choose to pay on a pre-tax or post-tax basis for an entire Plan Year. If the above sounds confusing, the FDNY Health Benefits Unit will help if you call.

Mid-Year Changes of Medical Plans & Qualifying Events

In certain circumstances, such as change in family status or employment, employees can change their tax status in the program. Enrollment in the Premium Conversion Program remains in effect during the Plan Year and your status cannot change unless an approved Qualifying Event occurs mid-year. Similarly, employees who waived enrollment in the Premium Conversion Program may enroll mid-year only if they incur a Qualifying Event listed below:

A change in family status such as marriage, divorce, annulment or legal separation;
The death of a participant, spouse/domestic partner, or dependent;
The birth or adoption of a child who will be the participant’s dependent;
The attainment of the maximum age for coverage of a dependent child;
The participant becomes divorced and is required under court order to provide health insurance coverage for eligible dependent children;
A choice of another carrier (e.g., resulting from a move out of an HMO service area);
A participant has a change in title which necessitates a change in health plan;
The termination of the participant’s employment for any reason including retirement;
A change in spouse’s/domestic partner’s coverage that is significant and outside the spouse’s control (e.g., due to termination of employment or benefit reduction);
A spouse has a change in employment status that results in a change for health insurance coverage (either acquiring or losing eligibility for coverage);
A change in employment status from part-time to full-time, or vice-versa, by the participant or the participant’s spouse/domestic partner;
The taking of, or returning from, an approved unpaid leave of absence by the participant or the participant’s spouse/domestic partner;
An increase in the employee’s health insurance contribution amount by more than 20%.

Note: Participants will not be allowed to make changes inconsistent with the Qualifying Event.

Effect on Salary, Taxes & Other Benefits

MSC Premium Conversion Program affects your salary, taxes, and benefits as follows:

Effect on Gross Salary: There is a reduction in the taxes withheld from your gross salary which will be shown on your Form W-2, under IRC 125, at the end of the year. Please note, you must add back the amount listed as IRC 125 on your Form W-2 to your state/city gross wages. The unadjusted gross salary will only appear on your last paycheck of the year as a year-to-date figure. (Some agencies may show individual gross salaries differently depending on the software and payroll systems in use.)
Tax Savings: Savings will vary and be based on, among other things, your health plan option, whether you have individual or family coverage, the number of withholding allowances that you claim for tax purposes and the amount of your income. There will be savings on federal as well as Social Security taxes (FICA).
Effect on Other Benefits
- Social Security Tax (FICA): You will save on Social Security taxes due to the Premium Conversion Program. However, based on current Social Security law, Social Security benefits at age 65 will be slightly less due to the Premium Conversion Program. The effect would be minimal and would be offset by the amount saved in taxes today.
- Pension: The Premium Conversion Program will have no effect on your pension contributions or benefits.
- Deferred Compensation: The Premium Conversion Program will have no effect on your contributions to a deferred compensation plan (457, 401(k), or 403(b)).

Tax Free Health Care Flexible Spending Account

With Health Care Flexible Spending Accounts (HCFSA), active firefighters can pay for eligible out-of-pocket medical, dental, vision, and hearing expenses on a pre-tax basis, with deductions taken directly from salary. You not only plan for anticipated expenses, but these deductions also reduce your gross income on your Form W-2 for federal and Social Security tax purposes. The ed result is that your health care expenses are lower, and you save on your taxes. See the Health Care Flexible Spending Account section of the NYC Website for complete info.

How the Plan Works

First, pre-tax contributions are made to your HCFSA account through automatic payroll deductions. The minimum contribution is $260; the maximum is $5,000 per year. You estimate your pre-tax contribution to your account for the Plan Year, based on your anticipated expenses. Then you fund your account through automatic payroll deductions that add up to this estimated amount.
Next, you submit a claim on a Claims Form for any uninsured eligible health care (deductibles, co- insurance and out-of-pocket) expenses you incur for yourself, your spouse, and your eligible dependents. This includes but is not limited to braces, physicals, OTC drugs, prescription drugs, prescription frames/contacts, psychologist fees, etc. For more information, please contact the FDNY Health Benefits Unit or call the HCFSA Program’s Administrative Office
Finally, you receive a check from your HCFSA. When you are reimbursed from your account, you receive that money free of federal and FICA taxes. You will also receive a personal account statement every quarter.

Note: Dependents must be listed on your FSA Program Enrollment/Change Form in order to receive HCFSA benefits for the Plan Year. If, for any reason, you do not notify the FSA Program Administrative Office that you have a new dependent, then any claim submitted on behalf of such unreported health care recipient will be denied.

Over-the-Counter Drugs Reimbursement

You must submit a claims form, along with a copy of the prescription (effective 1/1/2011), and an itemized receipt for most over-the-counter drugs. The itemized receipt must include the name of the drug, date the drug was purchased, and amount paid for drug. If submitting a claim for over-the-counter drugs attach a copy of the product box if the receipt does not indicate the name of the drug. You may submit claims for any drugs that diagnose, cure, treat, prevent, or mitigate ailments. However, sundries, toiletries, and cosmetic items are not eligible. For example, aspirin and cold medicine are eligible, but toothpaste, shampoo, and vitamins or supplements are not eligible.

Use it – Or Lose It Rule!

Forfeit Unused Contributions: According to IRS rules, amounts not used by the end of the Plan Year will be forfeited. Caution: federal regulations require that you use the entire amount in your HCFSA account by the end of each Plan Year (December 31st). If you do not use the entire amount you allocate to your account, you forfeit the unused balance. This is often referred to as the “Use It or Lose It” rule. Before participating in HCFSA, you should carefully consider what your eligible expenses might be. Reviewing your expenses from previous years can help. Once you have estimated the amount of your expenses, you may then determine how much to contribute to HCFSA.
Grace Period: Under federal law, any money that you put into an HCFSA account must be used for expenses incurred during the Plan Year in which it was contributed. A grace period is provided, following the close of the Plan Year, to submit claims for eligible health care expenses incurred from January 1st through March 15th following the end of the Plan Year using the remaining balance in your previous Plan Year account in which you were a participant in HCFSA. (For example, at the end of Plan Year 2012, you have $300 remaining in your HCFSA. You may submit claims for eligible medical expenses incurred from January 1, 2013 through March 15, 2013 to be reimbursed with the remaining $300 in your account from Plan Year 2012.)
In the event that you are unable to submit HCFSA claims by the end of the Plan Year or accompanying Grace Period, a Claims Run-Out Period is provided following the close of the Grace Period, during which you may submit claims for services performed during the previous Plan Year or accompanying Grace Period. The Claims Run-Out period ends on May 31st following the end of the Plan Year. (For example, the 2010 Claims Deadline was May 31, 2011). If you overestimate your expenses and contribute more thanyour actual expenses, or if you do not submit approved claims equaling in total your annual allocation prior to the end of the grace period, you will permanently forfeit any unused amounts remaining in your FSA account.
Other Savings Options: see next two paragraphs.

Note: If you participate in both HCFSA and DeCAP, the amount you allocate to one account cannot be transferred to the other. For more info about the plan, contact the FSA (Flexible Spending Accounts) Administrative Office.

Savings Calculator

To estimate how much $$ you will save, go to the HCFSA website HCFSA Program Savings Calculator. You enter your financial info on a worksheet that automatically calculates your annual HCFSA tax savings.

Vision Care & Elective Procedures

Other items and procedures may also be allowable expenses under your Flexible Spending Account. When in doubt, check with your tax advisor and/or FDNY Health Benefits Unit or call the HCFSA Program’s Administrative Office. If you are coming to the end of your year year with money left in your account, rather than let it go to the federal government, you may want to get a set of prescription glasses or have an elective procedure taken care of that you normally might not have budgeted. These are just some options you may want to consider which may be allowable:

Glasses/Contact Corrective Lenses: if by prescription are allowable expenses, including prescription sunglasses. You may also wish to stockpile disposable or planned-replacement contacts, or even colored prescription lenses your teenagers have been bugging you for.
Elective Procedures or Surgery:
- LASIK surgery
- Dermatological care for skin problems
- Orthopedic Procedures & Physical Therapy: You may want to consider therapy or surgery to correct that nagging injury or chronic condition
Mental Health: if you or any of your dependents need help, this may be allowable also.
Preventive Care: You never know when a thorough physical/medical examination might save your life!

Health Benefits Buy-Out Waiver: Cash to You

Overview: The Health Benefits Buy-Out Waiver Program (Medical Spending Conversion—MSC) allows eligible employees who can obtain non-City group health benefits to waive their New York City health benefits in return for an annual cash incentive payment. It allows City employees who are covered under their spouses’/partners’ group health insurance through another employer’s group plan, or through Medicare Part A and Part B, to waive their City health benefits and receive an annual incentive payment. Note: Before deciding to waive City health benefits coverage, make sure that your other coverage alone will meet your needs.

Financial Benefit – Cash to You

Annual payments, which are taxable as ordinary income, are $500 for those waiving individual coverage and $1,000 for those waiving family coverage. If your spouse/domestic partner is employed by the City, you are not eligible for the Buy-out. Employees may enroll in the Buy-Out Program within 31 days of becoming eligible for benefits or during the Open Enrollment Period. Payments will be made in June and December of the Plan Year. Therefore, if you are eligible to receive a $1,000 incentive payment, you will receive two payments of $500 each in your regular paycheck with the first payment issued in June and the second payment issued in December. Incentive payments will not be retroactive to a prior Plan Year. Note: Members who opt for the Buy-Out Waiver Program will not be entitled to PICA Drug Benefits.

UFA Welfare Fund Benefits

Waiver of health benefits does not waive your union’s Security Benefits Fund supplemental benefits. However, the costs of Psychotropic, Injectable, Chemotherapy or Asthma (PICA) drugs if you use them and have no other drug coverage, will come out of your union SBF benefits plan—which is not recommended. It is important that you

contact the UFA SBF Administrator if you are considering the Buy-Out Waiver Program and may require use of PICA drugs.

Eligibility Criteria for Enrollment

Qualifications: All NYC Firefighters qualify to opt out of City health benefits and waive coverage if they have available to them:
- A spouse’s/domestic partner’s or parent(s)’ employer-provided non-City group health plan; or
- A group health plan available through other employment; or
- Medicare Part A and Part B
Exclusions: You are ineligible for participation in the Health Benefits Buy-Out Waiver Program if you are:
- Waiving coverage in order to be covered by a spouse who works for the City (or a City-related agency), who is covered through the City’s Health Benefits Program; or
- Retired from the City of New York; or
- Covered by an individual direct payment health plan, including enrollment in COBRA as a result of losing coverage through a non-City of New York group health plan; or
- Covered by Medicaid; or
- Covered by Medicare; or
- on Worker’s Compensation leave.

Enrollment: How/When?

Open Enrollment Period – You may enroll in the Health Benefits Buy-Out Waiver Program during the annual Open Enrollment Period, which is normally in the Fall each year. The dates are normally announced on Department Orders each year. Once enrolled, you are in the program until you reinstate your City health benefits. Therefore, you do not need to re-enroll every year.
New Hires Enrollment – Newly eligible firefighters may participate as soon as they become eligible for City health benefits. To participate, newly eligible employees must complete and submit both the Health Benefits Application Form and the MSC Enrollment/Change Form to the FDNY Health Benefits Unit for review and completion. The forms and legal/supporting documentation must be received by the MSC Administrative Office within 30 days of the employee becoming eligible for the program.
Other Enrollment Opportunities See ‘Qualifying Events’ later in this section.
Forms to Submit – To enroll, you must submit a Health Benefits Application Form and a Medical Spending Conversion (MSC) Enrollment/Change Form, which you can either download from the NYC Website or obtain from the FSA Program Administrative Office or the FDNY Health Benefits Unit. The completed forms should be returned to your FDNY Health Benefits Unit, which will complete the benefits section, sign the forms and return them to the MSC Administrative Office for processing. Should you require assistance in completing the MSC Enrollment/Change Form, call the MSC Administrative Office, 9am – 4pm, M-F. In-house counseling is by appointment only.

Mid-Year Changes: Qualifying Events

Enrollment after the initial 30 day period can only occur if you have a Qualifying Event (see below). Any Qualifying Event that occurs in June will be effective after July 1st of that Plan Year. Any Qualifying Event that occurs in December will be effective after January 1st of the following Plan Year. When covered for a portion of the benefit period, the amount of the incentive payment will be pro-rated by the number of days you are in the Health Benefits Buy-Out Waiver Program. Your waiver will remain in effect unless you file an MSC Enrollment/Change Form indicating a Qualifying Event to withdraw from the Program.

Qualifying Events

Similarly, employees who have not enrolled in the Health Benefits Buy-Out Waiver Program may waive City health benefits coverage mid-year only if they incur a Qualifying Event. If you experience a Qualifying Event, contact your benefits or personnel officer IMMEDIATELY to obtain the appropriate forms. Completed forms must be received by the MSC Administrative Office within 31 days of the Qualifying Event. The events listed below qualify you for mid-year changes:

A change in family status such as marriage, divorce, annulment, or legal separation between the participant and spouse;
The death of a participant, spouse, domestic partner, or dependent;
The birth or adoption of a child who will be the participant’s dependent;
The participant becomes divorced and is required under court order to provide health insurance coverage for eligible dependent children;
The termination of the participant’s employment for any reason including retirement (forms must be submitted to terminate the Health Benefits Buy-Out Waiver Program);
A change in spouse’s/domestic partner’s coverage that is significant and outside the control of the spouse, e.g., benefit reduction (see Reinstatement of City Health Benefits Section);
The participant’s spouse/domestic partner has a change in employment status that results in a change of health insurance coverage, either acquiring or losing eligibility for coverage (see instructions for reinstatement);
A change in employment status from part-time to full-time or vice-versa by the participant or the participant’s spouse/domestic partner (increase above 20 hours or reduction below 20 hours in regular hours worked per week);
The taking of, or returning from, an approved unpaid leave of absence by the participant or the participant’s spouse/domestic partner.
Increase in the non-City of New York group health insurance premium by more than 20%.

Note: Participants will not be allowed to make changes inconsistent with the Qualifying Event.

Reinstatement of Your Health Benefits Coverage

If you are currently enrolled in the Health Benefits Buy-Out Waiver Program but want to return to coverage by the City Health Benefits Program:

Open Enrollement Period – The employee must complete a Health Benefits Application and an MSC Enrollment/Change Form. Both forms must be submitted to the FDNY Health Benefits Unit.
Mid-Year – To reinstate health benefits mid-year, YOU must provide proof of a Qualifying Event. If proof and notice are received 30 days after the event, reinstatement will be retroactive to the date of the Qualifying Event.
At Retirement – Access to health benefits at retirement will be unaffected by your prior participation in the Health Benefits Buy-Out Waiver Program. To reinstate City health benefits at retirement, you must complete a Health Benefits Application and an MSC Enrollment/Change Form to withdraw from the Health Benefits Buy-Out Waiver Program. NOTE: Once retired, you may not be enrolled in the Buy-Out Waiver Program.
Leave of Absence – Employees who take an approved unpaid leave of absence must complete the MSC Enrollment/Change Form to withdraw from the Health Benefits Buy-Out Waiver Program. Returning employees who wish to be reinstated into the Program must re-enroll by completing an MSC Enrollment/Change Form and submitting it within 30 days of returning to work.
Agency Transfer – Employees who transfer from one City of New York agency to another within the City of New York or who have an agency payroll code change must notify the FSA Program Administrative Office in writing within 30 days after the transfer.

Dependent Care Assistance Program (DeCAP)

Overview—Tax Free Child Care for Working Parents

DeCAP provides you with the opportunity to use Federal and Social Security (FICA) tax-free dollars (up to $5000 per year) to pay for expenses to care for your child(ren) or other dependents while you and, if married, your spouse works or attends school full-time. Expenses on a pre-tax basis, with deductions taken directly from your paycheck. This reduces the gross income on your Form W-2 for Federal and Social Security tax purposes. DeCAP helps you plan for anticipated dependent care expenses, and the end result is that you save on taxes. NOTE: Unused contributions must be used by the end of each year or they are forfeited!! See ‘Forfeit Unused Contributions’ later in this section. See NYC Website, Flexible Spending Programs, DeCap section for complete info.

How DeCAP Works – First, you estimate the pre-tax contribution needed in your account to cover dependent care expenses for the Plan Year. Second, you fund your account through pre-tax automatic payroll deductions. Next, you submit a claim on a Claims Form for any eligible dependent care expenses you incur. Finally, you receive a reimbursement check from your DeCAP account. When you are reimbursed from your account, you receive that money free of federal and FICA taxes.

Annual Contribution Limits

The minimum contribution is $500 and the maximum* is $5000 per calendar year. The amount you elect to contribute to your DeCAP account is a before-tax salary reduction. This includes an annual administrative fee of

$48. The $5,000 maximum is reduced to $2,500 if you are married and file a separate federal income tax return (unless you are legally separated), or by the amount your spouse is contributing to a dependent care assistance program through his/her employer. If you or your spouse earn less than $5,000 a year, your maximum benefit is limited to the lesser of the two incomes. If your spouse is a full-time student at an educational institution during at least five months of the Plan Year or is incapable of self-care during any month, your maximum contribution is

$250 a month for one dependent and $500 a month for two or more dependents.* The maximum may be less in certain cases; e.g., highly compensated employees.

Missed Deductions – If for any reason deductions cannot be made from any paycheck, your annual contribution allocation will be decreased by the amount of any missed payroll deductions. You will not be entitled to increase subsequent deductions to replace those missed. Therefore, it is important to notify the FSA Administrative Office if you are not experiencing payroll deductions.

Savings Calculator

Calculate your potential savings using the DeCap Savings Calculator. Enter your financial info and see how much you’ll save! See ‘NYC Website, Flexible Spending Programs, Dependent Care Assistance (DeCAP) Program Savings Calculator’.

Forfeit Unused Contributions!!!

Use it-Or Lose It Rule – Under this rule, you forfeit any money that’s left in the account at the end of the year. Federal regulations require you to use the entire amount in your DeCAP account by the end of each Plan Year (December 31st). If you do not use the entire amount, you forfeit the unused balance. Before participating, you should carefully consider what your eligible expenses might be. Reviewing your expenses from previous years can help. Once you have estimated your expenses, you may then determine how much to contribute to your DeCAP account. Note: If you participate in both HCFSA and DeCAP, the amount you allocate to one account cannot be transferred to the other.
Grace Period – A grace period is provided, following the close of the Plan Year, to submit claims for services performed during the previous period of coverage. This period usually ends February 28th each year. You may submit any claims incurred during the Plan Year in which you were a participant in DeCAP as follows: If you overestimate your expenses and contribute more than your actual expenses, or if you do not submit approved claims equaling in total your annual allocation, prior to the end of the grace period, you will permanently forfeit any unused amounts remaining in your FSA account.

Eligible Expenses, Claims, Reimbursements & Statements

This section explains which expenses are eligible for reimbursement under this program, and how the program defines a dependent care recipient, a qualifying caregiver, and a qualifying day care center. You may reduce your taxable income by the amount you contribute to your DeCAP account for eligible dependent care expenses. These expenses must meet the requirements listed below.

Eligible Employment-Related Dependent Care Expense: A dependent care service that is related to the care of one or more dependent care recipients (including household services related to such care), and that is performed within or outside your home during the period that you and your spouse are at work or attend school full-time. Note: Under DeCAP, you may only claim expenses if you are the custodial parent of a dependent child. You may not be reimbursed for any child support.
Dependent Care Recipient: You may receive benefits for any dependent claimed as an exemption on your tax return who is:
- Your child (son, daughter, stepson, or stepdaughter) who is under age 13*; or
- Your spouse who is mentally or physically incapable of self care and lives with you for more than one-half of the year; or any individual who is physically or mentally incapable of self care, lives with you for more than one-half of the year, and is your dependent or could be claimed as your dependent except, 1) his or her gross income exceeds the amount of the personal exemption for the current year, 2) he or she filed a joint return, or 3) you or your spouse could be claimed as a dependent on someone else’s Federal tax return.

* Expenses for disabled dependents over age 13 are only eligible if the primary purpose is to provide care for the disabled dependent while you and your spouse work or attend school full-time. In addition, the type of care provided for a disabled dependent must be specific to the dependent’s disability.

Qualifying Caregiver: A person performing eligible employment-related services who is:
- Not your dependent (or anyone you can claim as a dependent);
- Not your spouse; or
- Not your child or your spouse’s child unless he/she has attained the age of 19 as of the close of the Plan Year in which the services were provided.
Qualifying Day Care Center: Licensed nursery schools, pre-schools, day camps (not overnight camps), and child care centers that provide day care. The day care center must:
- Comply with all applicable laws and regulations of the state, city, town, or village in which it is located;
- Provide care for more than six individuals (other than individuals who reside at the day care center);
- Receive a fee, payment, or grant for any of the individuals to whom it provides services (regardless of whether such facility is operated for a profit); and
- Not be primarily for the purpose of education.

Note: Your dependents must be listed on your FSA Program Enrollment/Change Form in order to receive DeCAP benefits for the Plan Year. Under DeCAP, you may only claim expenses if you are the custodial parent of a dependent child. If, for any reason, you do not notify the FSA Program Administrative Office that you have a new dependent, then any claim submitted on behalf of such unreported dependent care recipient will be denied.

Enrollment Periods

Annual Open Enrollment Period – You may enroll in the DeCAP Program during the annual Open Enrollment Period, which is normally in the Fall each year. The dates are normally announced on Department Orders each year. Your selections will be effective January 1st or the date of your first payroll deduction if you become eligible after the beginning of the Plan Year. Enrollment is not automatic from year to year. You must re-enroll each year during the annual Open Enrollment Period.
Newly Appointed Firefighters – Newly eligible firefighters may participate as soon as they become eligible for City health benefits, and must submit a Flexible Spending Accounts (FSA) Program Enrollment/Change Form within 30 days of being hired. Your annual election will be prorated over the remaining pay periods. If you do not enroll in the DeCAP Program when you are first eligible, you must wait until the next annual Open Enrollment Period before you can enroll.
Documentation Required – To enroll in the DeCAP Program, you must obtain an FSA Enrollment/Change Form for current Plan Year from the NYC Website, the FSA Program Administrative Office, or the FDNY Health Benefits Unit. Call the FSA Administrative Office’s automated help line to request forms and brochures be faxed back to you immediately or leave your information to have them mailed to you. Should you require assistance in completing the Enrollment/Change Form, call the FSA Administrative Office week days. In-house counseling is by appointment only. Completed forms must be returned during the Annual Open Enrollment Period to the Flexible Spending Accounts Program.

Filing Claims

Documentation & Paperwork – To request reimbursement, you must complete a DeCAP Claims Form. Filing a claim is easy. Receipts and billing statements are not needed. First, list each separate expense individually on the Claims Form. Then have the dependent care provider sign and date the form and provide his/her name, address, and Federal Tax ID or Social Security number. Finally, submit all claims directly to the FSA Administrative Office. It must be received by the last day of the month to be processed for that month. Although you can file monthly reimbursement requests, you also have the option of letting your claims accumulate and filing every few months. You will only be reimbursed for dependent care expenses that are provided during the applicable Plan Year. Note:
- No reimbursement can be made prior to the service being provided.
- No reimbursement can be made for any expense incurred while you and/or your spouse are not at work (i.e., sick leave, maternity leave, summer vacation, etc.).
- Claims should be submitted in a timely manner. A grace period is provided, until February 28th, following the close of the Plan Year, to submit claims for services performed during the previous period of coverage.
Claims Denial & Appeal – If, for any reason, it is necessary for the FSA Administrative Office to deny a claim, you will receive a denial/appeal letter stating the reason for denial. You may appeal the denial by filing a written appeal with the FSA Appeals Panel within 60 days of your receipt of the denial notice. The Appeals Panel will review your claim and determine within 60 days of receipt of your written notice for appeal.
- Reimbursements – Approve claims processed during one month will be automatically deposited into the account you indicated on your Enrollment/Change Form or Direct Deposit Form by close of the following month. Claims will only be reimbursed up to the current balance in your account. If for any reason there are insufficient funds in your account to cover the expenses claimed, only that portion of your claim for which there are sufficient funds will be reimbursed. The balance will be carried forward to next month for payment. If a claim exceeds your balance at the end of the Plan Year, you will receive a check exhausting your account. Note: Payments will not be made to the service provider.
- Account Statements – Every month, you will receive a statement indicating your opening account balance, all contributions to your account, processed claims, an account administrative fee of $4.00 per month, and your closing account balance. After the year-end grace period, you will receive an annual statement that reflects the total amount contributed to and reimbursed from your account for the Plan Year. In addition, the amount you contribute to DeCAP will be reflected on your Form W-2, which you receive from your employer. Your gross income for federal tax purposes will reflect the adjusted amount.

* Tax Filing: See “Effects on Other Benefits & Taxes” subsection later in this section for important DeCAP tax filing info.

Mid-Year Changes & Qualifying Events

Under certain circumstances, such as qualifying events and termination of employment, changes can be made to your account.

Qualifying Event List – Under DeCAP, you may only make changes in the amount you contribute, the number of dependents covered or to terminate the plan. However, you must first experience a mid-year Qualifying Event in order to effect such a change, then you must notify the FSA Administrative Office directly by submitting a DeCAP Qualifying Event Mid-Year Change Form and an FSA Enrollment/Change Form within 30 days of the Qualifying Event with proper documentation. The definition of a Qualifying Event is governed by the Internal Revenue Code (IRC). Qualifying Events include but are not limited to:
- start or termination of employment of participant or participant’s spouse; or
- Marriage, divorce or annulment; or
- Birth or adoption of a child; or
- Death of a spouse or dependent; or
- Ineligibility of a dependent; or
- Start or termination of employment of participant or participant’s spouse; or
- Changing from part-time to full-time status or vice-versa by participant or participant’s spouse; or
- Taking an unpaid leave of absence by participant or participant’s spouse.

Note: You can have more than one Qualifying Event per Plan Year.

Agency Transfer – If you transfer agencies within the City or transfer to a City-related agency, you must notify the FSA Administrative Office at least 30 days prior to your transfer in order to continue your payroll deductions.
Termination of Employment – If the Qualifying Event is due to your termination, your contribution to DeCAP will cease as of your date of termination from employment. However, any remaining balance in your account prior to your termination date will be available for reimbursement upon receipt of a valid claim incurred during the Plan Year.
Death – If you pass away during the Plan Year, the same conditions for termination as described above will apply. In addition, any claims for services provided before your death must be submitted by your spouse or your estate and will be paid to same. Documentation will be required.

Effect on Other Benefits & Taxes

DeCAP and the Federal Dependent Care Tax Credit – Any payments received from DeCAP will reduce dollar-for-dollar the amount that can be considered for a Federal Dependent Care Tax Credit and vice- versa.
Social Security Tax (FICA) – Contributions to DeCAP may reduce your Social Security taxes. If so, based on current Social Security law, Social Security benefits at your retirement age may be slightly less as a result of your participation in DeCAP. However, the effect would be minimal and would be offset by the amount saved in taxes today.
DeCAP & Taxes – Contributions to DeCAP are made through automatic payroll deductions on a before-tax basis. Therefore, your gross income on your Form W-2 will be reduced for federal income taxes and Social Security taxes (FICA). DeCAP will not affect your state or local taxes, but note the following required paperwork.
State/City W-2 Adjustments – You must add back the amount listed as IRC 125 on your Form W- 2 to your state/city gross wages.
Form 1040 Attachment – You must also attach Form 2441 Child and Dependent Care Expenses to your Form 1040.
- Pension: Contributions – to DeCAP have no effect on your pension contributions or benefits.
- Deferred Compensation – If you contribute to a deferred compensation plan (457, 401(k), or 403(b)), participation in DeCAP will have no effect.

See Financial Book, Tax Return/Deduction section for additional info regarding DeCAP and federal dependent care credit.

Supplement #1 to Health Book Chapter 2

Health Plan Provider Summaries

Individual Plan Summaries, Costs & Optional Riders

NYC Health Plan Provider Summaries. This Supplement contains photocopies excerpted from the Summary Description Booklet Booklet/CD that the City normally provides every active member each fall, and retired members every other fall. This info and more can also be found on the NYC Website, Health Benefits Program section. The following excerpted pages (inapplicable pages are not included) describe the below items.

*The page numbers noted are the numbers used in the booklets they are copied from.

See previous page 6 for Definitions/Explanations of HMO, POS, EPO, PPO…

Active & Retired (POS, EPO, PPO/Indemnity Plans) 20

(Point of Service Plans, Exclusive Provider Plans, Participating Provider Plans)

1. Health Plan 21
2. GHI-CBP/Empire BlueCross BlueShield 23
3. Empire EPO 25
4. HIP Prime POS 26
Active & Retired Health Maintenance Organizations (HMOs) 27
1. Aetna HMO 28
2. CIGNA HealthCare 29
3. Empire HMO (NY & NJ) 30
4. GHI HMO 31
5. HIP Prime HMO 32
6. Vytra Health Plus 34
Health Plans for Medicare Enrollees 36
1. Rate Chart 50
2. Basic Plan & Optional Rider Costs for Active FF’s 50
3. Monthly Health Plan Rates for Retirees & their dependents 51

Comprehensive Info Packages: To receive comprehensive benefits/costs packages and provider directories about any Plan, contact the Health Insurance Plan Providers directly.

Your plan’s phone number is on the back of your plan’s ID card. If you can’t find the info you need, active FFs can contact the FDNY Health Benefits Unit, which can provide you answers or steer you in the right direction. Retirees should contact the NYC Health Benefits Program for this help. For more information on other other Insurances, Help & Free Benefits, see Health Book: ‘Insurances & Free Benefits’ Chapter/Booklet. It describes many critically important benefits for you and your family that you would have never known about. Make sure you check this out!

DISCLAIMER FROM THE CITY OF NEW YORK:

The health plan summary descriptions and comparison charts contained in this booklet are for informational purposes only and are subject to change. The benefits are subject to the terms, conditions and limitations of the applicable contracts and laws.

Contacts Section

FDNY – N.Y.C. Fire Department

9 Metrotech Center, Brooklyn, NY 11201
FDNY General Phone: 718-999-2000
FDNY Bureau of Health Services (BHS) / Medical Office
BHS General Number: 718-999-1849/1850
FDNY BHS Automated Citywide Medical Leave System: 718-330-2204 (prompts you to provide certain identifying info (available 24/7)
FDNY BHS Postponement Desk: 718-999-1918/19/20
FDNY BHS Medical Officer on Emergency Duty Fax: 718-999-0035
LODI Prescription Drug Reimbursement: Justine Lashkow, Head Nurse, 9 Metrotech Centre, 2nd floor, Brooklyn, NY 10012
FDNY Compensation Desk (for LODI Medical Bills)
- FDNY Compensation Desk, 9 Metrotech Center, Brooklyn, NY 11201
- Inquiry Phone Number: 718-999-1838 or 1839
FDNY Counseling Services Unit (CSU): 212-570-1693
FDNY Health Benefits Unit: 718-999-2196
- Camille Isaacs, 9 Metrotech Center, Brooklyn, NY 11201 9 Metrotech Center, Brooklyn, NY 11201
- ERB (Employee Health Benefit Application)
- FDNY Health Desk (request of forms)
Pension Benefits Unit 718-999-2324 (Pensions/Benefits Analyst)

UFA – Uniformed Firefighters Association

204 East 23rd Street, New York, NY 10010
General Tel Number & Emergencies: 212-683-4832 (212-683-4UFA)
General Fax: 212-683-0710
www.UFANYC.org
UFA SBF – Security Benefits Fund (SBF): 3rd floor
- Phone: 212-683-4723
- SBF Retiree Liaison: ext. 5977 (M-W-F)
- SecurityBenefitsFund@UFANYC.org
- UFA Trustee-On-Duty
Emergencies: 212-683-4832
- Trustees Fax: 212-683-0690
- UFA Health & Safety Officer/Sergeant-at-Arms
Emergencies: 212-683-4832
- Non emergencies: 212-545-6965 or 6964
- Fax: 212-683-4768
- Email: Health&Safety@UFANYC.org
UFA Recording Secretary: 212-683-4832
- Fax: 212-683-4359
- Email: RecordingSecretary@UFANYC.org
UFA Disability Pension Consultant: 212-683-4359 (Lou Sforza)
UFA General Counsel: 212-732-9000 (Mike Block)
Group Life Insurance Office, 3rd floor, Phone: 212-683-4723, 1, x5903/05 #

NYC Health Benefits Program, Office of Labor Relations (OLR)

Administrative Office, 40 Rector Street, 3rd Floor, New York, NY 10006
Phone: (212) 513-0470
NYC Website: www.nyc.gov/html/olr
Domestic Partnership Liaison Unit, OLR: Active FFs 212-306-7605, Retired FFs (212) 513-0470
Express Scripts/NPA, NYC Health Benefits Program Tel: (800) 467-2006 (PICA Drugs)
Medical Spending Conversion (MSC) Administrative Office at (212) 306-7760
Health Care Flexible Spending Account (FSA) Administrative Office at (212) 306-7760
FSA Savings Calculator: www.nyc.gov/html/olr/html/flex_spending/hcfsa_calculator.shtml
Health Care Flexible Spending Programs, Dependent Care Assistance (DeCap)
DeCAP Savings Calculator: www.nyc.gov/html/olr/html/flex_spending/decap_calculator.shtmlthe
•Prescription Drug Coverage
Benefits Access Center: (800) 581-4222
CVS Caremark: (866)832-0563
State Health Insurance Assistance Program (See your copy of the Medicare & your handbook for their telephone number.)

NYS Department of Health (DOH)

Office of Professional Medical Conduct, 433 River Street, Troy NY 12180-2299
Phone: 518-402-0836 or 1-800-663-6114.
NYS DOH Access to Patient Information Program: 800-663-6114 • Medical Conduct Website, NYS DOH: www.health.state.ny.us (select Information for Consumers)
Physician Professional Misconduct: www.health.state.ny.us/nysdoh/opmc/main.htm
Physician Misconduct Records: w3.health.state.ny.us/opmc/factions.nsf
Physician Profiles: www.nydoctorprofile.com/about.jsp
Physician Sexual Misconduct: www.health.state.ny.us/nysdoh/opmc/miscon.htm

NYC Deferred Compensation Form

Request forms at 212-306-7760, or visit www.nyc.gov/deferredcomp, click “Library” then choose “457/401(K)PlanChangeForm.pdf”
Send form to: DEFERRED COMPENSATION PLAN
Bowling Green Station, PO Box 93, New York, NY 10274-009

DocFinder & DocInfo Searches: Physician Profiles & Records

www.docboard.org (free)
www.docinfo.org (small fee)

State Education Department

Division of Professional Licensing Services, Cultural Education Center, Albany NY 12230
- Phone: 518-474-3817
- Web site: www.op.nysed.gov
Office of Professional Discipline, 1 Park Avenue, 6th Floor, New York NY 10016
- Phone: 800-442-8106

American Board of Medical Specialties

Phone: 1-866-275-2267
- Web site: www.abms.org

NYC Health Plan Carriers

Aetna QPOS
- 800-445-8742
- www.aetna.com
Aetna HMO
- 800-445-8742
- www.aetna.com
CIGNA HealthCare
- 800-832-3211
- www.cigna.com
Empire HMO (NY)
- 800-767-8672
- www.empireblue.com/nyc
Empire HMO (NJ)
- 888-476-6986
- www.empireblue.com/nyc
Empire EPO
- 800-767-8672
- www.empireblue.com/nyc
GHI-CBP/Empire BlueCross/BlueShield:
- GHI: 212-501-4444 | www.ghi.com
- Empire: 800-433-9592 | www.empireblue.com/nyc
- NYC Healthline: 800-521-9574 (for emergency hospital admission)
GHI HMO
- 877-244-4466
- www.ghihmo.com
HIP Prime POS
- 800-447-6929
- www.hipusa.com
HIP Prime HMO
- 800-447-6929
- www.hipusa.com
HIP/HMO
- 800-HIP-TALK
Heath Net
- 800-441-5741
- www.healthnet.com
Vytra Health Plans
- 800-448-2527
- www.vytra.com

Catastrophic Insurance, Seabury & Smith/Marsh Affinity

Phone: Customer Service 1-800-503-9230
Phone: Ariel, 1-800-229-5227 x.324
- Fax: 1-847-503-9230, 1-847-803-1653
1440 Renaissance Drive, Park Ridge, Illinois 60068-1400
Hours: M-F, 8:15am-5:00pm
e-mail: custsvc2@seaburychicago.com
Web: www.seaburychicago.com/plans/ufa (applications/brochures)