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Employee Benefit Guide

Employee Plan

2013

http://www.ormcnewhospital.org/

1

We encourage you to read the entire enrollment guide before you enroll.

This is a summary of your benefits only. Certain restrictions and exclusions apply. If

information in this summary differs from the legal contract/documents, the legal

contract/documents will govern.

Note – All benefits information such as forms, Summary Plan Descriptions (SPDs), Summary

of Benefits and Coverages (SBCs) and any required plan notifications can be found on the

ORMC intranet page at http://info/HR/OpenEnrollment/Default.aspx.

Overview ......………………………………………………………………….……….

2

Medical Benefits .………………………………………………………………..…….

3

Dental Benefits ......…………………………………………………………….…...... 4

Employee Contributions ……………………………………………….……………..

5

Vision Benefits ...………………………………………………………………………

6

Basic and Voluntary Life and AD&D ………………………………………..………

7

Disability Benefits ………………………………………………………..…………… 8

Flexible Spending Account ..……………………………………………..………….

9

Individual Voluntary Benefits ..………………………………………………..……..

11

Other Benefits ..…………………………………………………………………..……

Contact Information …………………………………………………………………..

Forms …………………………………………………………………………………..

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Table of Contents

WHO IS ELIGIBLE

All active full-time and part-time employees for

most benefit offerings. Eligible dependents may

also participate. Eligible dependents are your

spouse* and dependent children up to the

following ages:

Medical:

• Up to age 26, regardless of marital status

Dental:

• Up to age 19 or if they are a qualified full-

time student up to age 23

*Spouses may not participate in the ORMC health

plan if they have other group health coverage

available through their own employer. The

dependent eligibility guidelines are as follows:

• If your spouse is employed either full-time

or part-time, and that employer offers

group health coverage as a benefit of

employment, they are not eligible for

coverage under the ORMC health

plan. Cost of that employer’s plan is not a

factor, even if the cost is a greater expense

than the ORMC plan.

• If your spouse is unemployed, self-

employed without access to group health

coverage, or employed by a company

which does not offer group health

coverage, they may be covered under the

ORMC health plan.

• Spouses currently enrolled with Medicare

or Medicaid may be covered under the

ORMC health plan.

Medical and dental coverage become effective

the first of the month following 3 months of

employment.

MAKING CAREFUL CHOICES

The annual enrollment period is the only time you

can change benefit plans or add/drop dependents

during a plan year, unless you have a qualified

family status change. Such changes include birth,

death, marriage, divorce, adoption, ineligibility of a

dependent, unpaid leave of absence by you or your

spouse because of your spouse’s employment. So

please choose your benefits carefully.

BENEFIT

Medical Coverage Employee Contribution

Dental Coverage Employee Contribution

Basic Life and AD&D Company Paid

Voluntary Life and AD&D Employee Paid

Short Term Disability Company & Employee Paid

Long Term Disability Company Paid

Flexible Spending Accounts

Health Care

Dependent Care

Employee Paid

Employee Paid

Individual Voluntary Benefits Employee Paid

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Overview

Benefit Questions?

Contact your Benefits Department at (845) 695-5844

YOUR BENEFIT CHOICES

Orange Regional Medical Center provides a wide

variety of benefits. Some are provided

automatically at no cost to you. Other benefits are

available if you choose them. Check the guide

below to see which benefits you need to make a

successful program designed just for you.

BENEFIT ORMC / Affiliate

Providers

In-Network

Providers

Out-of-Network

Providers

Calendar Year Deductible

Single

Family

$250

$500

$500

$1,000

$1,500

$3,000

Out-of-Pocket Maximum

Single

Family

$250

$500

$1,500

$3,000

$6,000

$12,000

Lifetime Maximum Benefit Unlimited Unlimited Unlimited

Preventive Care

Exams / Immunizations

Routine Screenings

Routine Mammogram

Routine Colonoscopy

Not Applicable

Not Applicable

100%, no deductible

100%, no deductible

100%, no deductible

100%, no deductible

100%, no deductible

100%, no deductible

60%, after deductible




Office Visit Not Applicable 100%, after $25 copay 60%, after deductible

Diagnostic Lab / X-ray 100%, no deductible 100%, no deductible 60%, after deductible

Complex Imaging 100%, no deductible 100%, after $250 copay 60%, after deductible

Inpatient Hospital Services 100%, after deductible 90%, after deductible 60%, after deductible

Outpatient Hospital Surgical 100%, after $50 copay 100%, after $250 copay 60%, after deductible

Urgent Care Not Applicable 100%, after $25 copay 100%, after $25 copay

Emergency Room 100%, after $75 copay 100%, after $75 copay 100%, after $75 copay

Ambulance Not Applicable 90%, after deductible 90%, after deductible

Mental Health

Inpatient Services

Outpatient Services


100%, after $15 copay





Chemical Dependency

Inpatient Services

Outpatient Services







Chiropractic Care Not Applicable 100%, after $25 copay 60%, after deductible

Prescription Drugs

Retail (30 day supply)

Generic

Brand Formulary

Brand Non-Formulary

Not Applicable

Not Applicable

Not Applicable

$5 copay

$30 copay

$55 copay

Not covered

Not covered

Not covered

Mail Order (90 day supply) 2 times retail copayment

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Medical Benefit Summary

Benefit Delta Dental

PPO / Premier Dentist

Non-Participating

Dentist

Calendar Year Deductible

$50 Single / $150 Family $50 Single / $150 Family

Diagnostic and Preventive

Services

100%, no deductible 80%, after deductible

Basic Services 80%, after deductible 60%, after deductible

Endodontics 80%, after deductible 60%, after deductible

Periodontics 80%, after deductible 60%, after deductible

Oral Surgery 80%, after deductible 60%, after deductible

Major Restorative 50%, after deductible 40%, after deductible

Prosthetics Repairs &

Adjustments

50%, after deductible 40%, after deductible

Prosthetics 50%, after deductible 50%, after deductible

Annual Maximum $1,500 per person $1,500 per person

Orthodontics 50%, no deductible 50%, no deductible

Lifetime Maximum for

Orthodontia

$2,028 per person $2,028 per person

Orthodontic coverage for dependent children to age 19.

Dental Plan

Orange Regional Medical Center offers dental benefits under the Delta Dental of New York program. The

Delta Dental of New York program offers a choice of networks for your dental care.

• Delta PPO

• Delta Premier

Enrolling in the plan allows you the freedom to choose your dentist when

you or your covered dependents need dental care. Your provider selection

determines your coverage level.

Delta PPO Dentists have the highest discount rate, followed by Delta Premier Dentists. Non-participating

Dentists do not accept discounts and may balance bill for services over usual and customary. The total

you pay will be based on the remaining cost after negotiated discounts are applied.

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Dental Benefits

FULL TIME EQUIVALENT (FTE) Single Single + 1 Family

1.0, 0.9, 0.8, 0.7 Per Pay Period Contribution

Your Annual Cost

$1.55

$40.30

$4.20

$109.20

$8.11

$210.86

0.6 Per Pay Period Contribution

Your Annual Cost

$5.70

$148.20

$10.58

$275.08

$17.77

$462.02


Your Annual Cost

$7.12

$185.12

$13.22

$343.72

$22.21

$577.46


Your Annual Cost

$8.54

$222.04

$15.87

$412.62

$26.65

$692.90


Your Annual Cost

$9.97

$259.22

$18.51

$481.26

$31.09

$808.34


Your Annual Cost

$11.39

$296.14

$21.16

$550.16

$35.53

$923.78

FULL TIME EQUIVALENT (FTE) Single Single + 1 Family

1.0, 0.9, 0.8, 0.7 Per Pay Period Contribution

Your Annual Cost

$17.31

$450.06

$31.04

$807.04

$46.15

$1,199.90


Your Annual Cost

$139.01

$3,614.16

$248.21

$6,453.50

$370.27

$9,626.93


Your Annual Cost

$173.76

$4,517.70

$310.26

$8,066.88

$462.83

$12,033.66


Your Annual Cost

$208.51

$5,421.24

$372.32

$9,680.26

$555.40

$14,440.39


Your Annual Cost

$243.26

$6,324.78

$434.37

$11,293.63

$647.97

$16,847.12


Your Annual Cost

$278.01

$7,228.32

$496.42

$12,907.01

$740.53

$19,253.86

MEDICAL CONTRIBUTIONS

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DENTAL CONTRIBUTIONS

Employee Contributions

Vision Plan

Vision coverage is included with your medical plan election and medical plan contributions.

• One vision and eye health evaluation including but not limited to eye health examination, dilation,

refraction, and prescription for glasses;

• Costs for any covered services/materials will be deducted from the annual plan maximum.

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COVERAGE IN-NETWORK

PLAN COVERAGE

OUT-OF-NETWORK

PLAN

REIMBURSEMENT

FREQUENCY

Exam Copay $0 N/A

Exam Allowance

(one per frequency)

Covered In Full $45 Calendar Year

Materials Allowance (per

frequency)

Applied towards the purchase

of frame, lenses and contact

lenses

$100 Allowance $100 Allowance 24 months

In-Network Coverage Includes:

• Minimum 20% savings on additional purchases of frames and/or lenses, including lens options,

with a valid prescription; offered savings does not apply to contact lens materials. Check with your

CIGNA Vision Network Eye Care Professional for details.

Vision Network Savings Program:

Vision Benefits

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DESCRIPTION COMPANY PAID

LIFE BENEFIT

COMPANY PAID

AD&D BENEFIT

Non-Union & Security 1x annual earnings to $500,000 1x annual earnings to $500,000

Retirees Flat $5,000 No Coverage

BASIC LIFE & ACCIDENT INSURANCE

For full-time employees, Orange Regional Medical Center offers Basic Life and Accidental Death and

Dismemberment (AD&D) Insurance and pays 100% of the cost for this coverage.

DESCRIPTION LIFE COVERAGE GUARANTEE ISSUE

Employee Increments of $10,000 to a maximum

of $500,000

$100,000 to age 65;

$10,000 age 60 - 69

Spouse Increments of $10,000 to a maximum

of $500,000

$30,000

Child 14 days to 6 months: $1,000

6 months to 20 or 26: $4,000

$4,000

Guarantee issue means you may elect a benefit up to the listed amount without evidence of insurability. Guarantee

issue is available to new hires or during the one time open enrollment in December 2012 for existing employees. Any

election over the guarantee issue or outside the one time open enrollment will require proof of good health.

AD&D coverage may be elected for the same amounts as the life election. AD&D cannot be purchased without first

purchasing voluntary life.

Basic and Voluntary Life and AD&D

VOLUNTARY LIFE & ACCIDENT INSURANCE

Effective January 1, 2013, Orange Regional Medical Center is pleased to make available an optional

Voluntary Life and Accidental Death and Dismemberment (AD&D) Insurance for employees working at

least 15 hours per week. If elected, this coverage is in addition to the Basic Life and AD&D Insurance

outlined above.

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DESCRIPTION COVERAGE ELIMINATION PERIOD BENEFIT DURATION

Non-Union &

Security

New York State

Short Term Disability

(DBL)

7 days illness / injury 50% of weekly

earnings to $170

26 weeks

Full-time and Part-

time Non-Union &

Security*

Short Term Disability 14 days illness / injury 60% of weekly

earnings to $1,000

26 weeks

Salaried Non-

Union and Security

Long Term Disability 180 days 60% monthly earnings

to $15,000

To age 65

Definition of disability:

As a result of an illness or injury, during the elimination period and thereafter you are unable to perform all of the material

and substantial duties of your own occupation.

*Note: Short Term Disability will offset from DBL Coverage

DISABILITY INSURANCE

Orange Regional Medical Center’s disability plans work together to help you pay your household expenses

if you become disabled and cannot work. These disability plans are:

Disability Benefits

FLEXIBLE SPENDING ACCOUNTS

Orange Regional Medical Center’s Health and Dependent Care Flexible Spending Accounts (FSAs) allow you to use

tax-free dollars to reimburse yourself for a wide variety of health and/or dependent care expenses that aren’t covered

through your other benefit plans. The annual amount you elect to contribute to each account will be divided into

equal amounts and deducted from your paycheck before federal and state income taxes are withdrawn.

Rules and Regulations

Plan your annual FSA contribution amounts carefully; the election you make when you enroll is binding for the entire

plan year (January 1 to December 31) unless you have a qualifying status change. Additionally, the IRS imposes

some rules and restrictions on the way you can use FSAs:

• You must incur eligible expenses during the plan year.

• If you incur fewer expenses than you expected, you forfeit any money remaining in your FSAs at the end of the year; you can’t roll money over from one plan year to the next.

• You can’t transfer money from one account to another; money in your Health Care FSA can’t be used for dependent care expenses, and money in your Dependent Care FSA can’t be used for health care expenses.

• You can only make changes to your contribution amounts with a qualified status change. These include: marriage, divorce or legal separation, death of a spouse or dependent, change from part-time to full-time or full-time to part-time employment, termination or commencement of spouses employment, unpaid leave of absence, significant change in health coverage due to spouse’s employment.

Health Care FSA

Health care expenses for yourself and your dependents – such as

deductibles, coinsurance, copays – are eligible for reimbursement from

your Health Care FSA.

The maximum contribution is $2,500. This is a change effective January

1, 2013.

Dependent Care FSA

Expenses for dependent care services for children under age 13, a

disabled spouse, or incapacitated parent are eligible for reimbursement

from your Dependent Care FSA as long as you incur them while you and

your spouse work or attend school full-time.

The maximum contribution is $5,000.00 ($2,500.00 if you are married and

filing a separate income tax return).

Filing a Claim for Reimbursement

To file a claim for reimbursement, complete the Reimbursement Request Claim Form and submit it with itemized

receipts to CieloStar (formally OutsourceOne, Inc.), Orange Regional Medical Center’s FSA administrator. Use of

your debit card is also an option and eligible health care expenses from approved providers will be automatically paid

to the provider at time of service directly from your flexible spending balance. Follow up documentation may be

requested.

Access to online claim submission is available at www.benefitspaymentsystem.com. Access to claim forms and

information is available at http://www.outsourceone.com/Employees-Participants/FSA-Contact.asp or contact their

customer service at 877-491-5979, during the hours of 7:30 am – 5:30 pm CST Monday through Friday.

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Flexible Spending Account

Your

Expenses

Expenses for

Your Spouse

and Dependents

MEDICAL EXPENSES (not covered by insurance):

Deductibles and Co-Insurance $ $

Office Visit Co-Pays $ $

Prescription Drug Co-Pays $ $

Chiropractic Treatment/Acupuncture $ $

Infertility Treatments $ $

Birth Control Pills, Devices, and Surgical Procedures $ $

Medical Equipment and Supplies

(Wheelchairs, Braces, Crutches, Oxygen, etc.)

$ $

Transportation

(mileage, lodging and meals if necessary to obtain health care)

$ $

Christian Science Practitioner $ $

Over the Counter Medication (with a written prescription) $ $

Other (See IRS Publication 502 for Listing of Deductible Medical Expenses)

$ $

VISION AND HEARING CARE (not covered by insurance):

Eye Exams $ $

Frames and Lenses $ $

Contact Lenses, Cleaning Solutions and Supplies $ $

Hearing Aids and Batteries $ $

Radial Keratotomy Surgery to Correct Vision $ $

DENTAL EXPENSES (not covered by insurance):

Deductibles and Co-Insurance $ $

Exams, Cleanings and X-rays $ $

Fillings $ $

Fluoride Treatments $ $

Crowns, Bridges and Dentures $ $

Orthodontia (Please see “Orthodontic Treatment” worksheet) $ $

Other Eligible Dental Expenses (See IRS Publication 502) $ $

TOTAL ESTIMATED UNINSURED MEDICAL EXPENSES (Sum of

Your Expenses and Expenses for Your Spouse and Dependents):

$

Estimating Your Covered Expenses

10


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Personal Cancer Indemnity Plan

• First-Occurrence – pays $1,500 for the insured, $1,500 for the spouse, and $2,250 for children

to assist in the costs associated with travel, lodging, household costs, and other living

expenses when a covered individual is first diagnosed with Cancer (after a 30-day wait period).

• Hospital Confinement – pays $200 per day when a covered person is confined to a hospital

for cancer treatment. This benefit increases to $400 per day on the 31st day of continuous

confinement

• Radiation and Chemotherapy – pays $200 per day for a covered person who receives one or

more of the specified radiation and chemotherapy treatments for the purpose of modification or

destruction of abnormal tissue.

• Other benefits such as: Medical Imaging, Immunotherapy, Cancer Screening Wellness, plus

many more

• Premiums payments are conveniently made for you through pre-tax payroll deductions.

You have the option of purchasing a Personal Cancer Indemnity Plan which is a specified-disease

insurance plan administered by Aflac New York. This option provides the following benefits:

INDIVIDUAL VOLUNTARY BENEFITS

Orange Regional Medical Center provides you with several individual voluntary benefit offerings

designed to meet the specific needs of their members.

Individual Voluntary Benefits

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Voluntary Short Term Disability Insurance

You have the option to purchase additional Short Term Disability coverage administered by Unum. This

coverage is designed to replace a portion of your income if an illness or an accident prevents you from

working for a short period of time, or if you suffer a loss of income due to disability.

You have a choice of selecting between 25% to 40% of your basic monthly earnings to a maximum benefit

of $3,000 per month. Your benefit is tax-free and will not be reduced by any other sources. You may select

a maximum benefit period of 3, 6, 12, or 24 months.

Premium payments are conveniently made for you through payroll deductions.

The following criteria pertains to your coverage:

Elimination Period

• The number of days that you must wait from the time you become disabled until your benefits begin.

• You may choose from a 7, 14, 30, 60, 90 or 180 day elimination period.

Definition of Disability

• During the first year you are “unable to work at your job and not, in fact, working at any job for pay or

benefits and are under the care of a doctor”

• After the first year, if applicable, you are “unable to work at any job for which you are qualified by

reason of education, training, or experience; not, in fact, working at any job for any pay or benefits

and under the care of a doctor”.

Pre-Existing Exclusion

• An illness or injury for which you received medical treatment, consultation, care or services including

diagnostic measures, or took prescribed drugs or medicines during the 12 months prior to your

effective date of coverage on this plan. Benefits for disabilities due to pre-existing conditions will not

be paid unless the disability begins after you have been on the plan for 12 months.

Individual Voluntary Benefits

Orange Regional Medical Center offers the following additional benefits to all eligible employees. Please

contact your Benefits Department for eligibility requirements, or assistance with any of the Orange

Regional Medical Center offered benefits.

403(b) Retirement Savings Plan

Orange Regional Medical Center has established a defined contribution 403(b) retirement savings plan

through Principal Financial Group. All employees are eligible to save for retirement through pre-tax payroll

deduction. Maximum employee contributions for 2013 are $17,500 or $23,000 if 50 or older.

In addition to employee contributions, an employer base contribution of 1% of compensation after one

year, increasing by 1% each year to a maximum of 5% of compensation after 5 years. Employer matching

contributions equal to 100% of the employee contribution up to a maximum of 4% of compensation.

Contributions are vested immediately upon deposit.

Paid Time Off (PTO)

Full-time and Part-time employees begin accruing paid time off as of the date of hire and are eligible to use

the accrued time after three months of employment.

Hourly Employees receive:

• Twenty days accrued during first year

• Twenty-five days accrued after three years

• Thirty days accrued after seven years

• Accrues per pay period

Salaried Employees & Supervisors Receive:

• Twenty-five days accrued during first year

• Thirty days accrued after three years


Department Heads & Physicians Receive:

• Thirty days accrued during first year


- Part-time employees receive prorated days based on actual hours worked each pay period.

- Payout upon termination is 50% of one year’s annual accrual.

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Other Benefits

Long-term Illness Bank (LTIB)

Full-time and Part-time employees begin accruing paid time off as of the date of hire and are eligible to use the

accrued time after three months of employment.

Employees receive:

• Four days accrue each year

• Maximum accrual is 975 hours

- Part-time employees receive prorated days based on actual hours worked each pay period.

- There is no payout upon termination

Direct Deposit

Orange Regional Medical Center offers you the opportunity to have paychecks automatically deposited into

your bank account. Please contact your Benefits Department for more information.

Tuition Reimbursement

For Non-union and Security employees who hold a position of 0.8 FTE or greater and have been employed for

at least one year, Orange Regional Medical Center offers you reimbursement up to $7,500 per calendar year

for further education that is pre-approved and offered by nationally accredited universities and colleges. Non-

union and Security employees who hold a position below 0.8 FTE are eligible for a pro-rated tuition benefit.

Please refer to the tuition reimbursement policy or contact your Benefits Department for more information.

Section 529 – College Savings Program

This program allows employees to save for higher education purposes for their children or beneficiaries

through payroll deduction. The minimum bi-weekly payroll deduction is $15.00. Visit www.ny529atwork.com or

call 800-420-8580 to sign up for this program.

Employee Assistance Program

Orange Regional Medical Center offers access to an employee assistance program through The Workplace.

This program provides employees and their families with information on a variety of topics such as financial

counseling or family/work-life issues. Contact the EAP at 800-724-0917 for more information or assistance.

Employee Discount Program

Orange Regional Medical Center employees are eligible for the Working Advantage discount program.

Exclusive discounts include movie tickets, theme parks, hotels, museums, Broadway shows, concerts, sporting

events, online retailers and more. You can also earn rewards to be redeemed for movie tickets, gift cards and

more.

Register free at www.workingadvantage.com. Simply click the Register button, select Employees Click Here

and enter Member ID # 596231713. Call 800-565-3712 for assistance.

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Other Benefits

Orange Regional Medical Center, in partnership with the following carriers, strives to meet your benefit needs. If you

have any questions regarding your benefits, please contact the corresponding carrier listed below or Orange

Regional Medical Center.

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CARRIER CUSTOMER SERVICE WEBSITE

Cigna (Medical) (800) 244-6224 www.mycigna.com

Cigna (Vision) (877) 478-7557 www.mycigna.com

Delta Dental of NY (Dental) (800) 932-7083 www.deltadentalins.com

First Reliance Standard (Basic

and Voluntary Life and AD&D)

(800) 353-3986 www.rsli.com

Matrix Absence Management

(Disability and Leaves)

(877) 202-0055 www.matrixeservices.com

CieloStar (Flexible Spending

Accounts)

(877) 491-5979 www.outsourceone.com/Emp

loyees-Participants/FSA-

Contact.asp

CieloStar (COBRA

Administration)

(877) 491-5980 http://www.outsourceone.co

m/Employees-

Participants/COBRA-

Participants.asp

Principal Financial Group

(403b)

(800) 547-7754 www.principal.com

Unum (Voluntary Short Term

Disability)

(800) 421-0344 www.unum.com

Aflac (Individual Cancer) (800) 992-3522 www.aflacny.com

Section 529 (College Savings) (800) 420-8580 www.ny529atwork.com

The Workplace (EAP) (800) 724-0917

Working Advantage (Discount

Program)

(800) 565-3712 www.workingadvantage.com

BENEFITS CONTACT TITLE CONTACT INFORMATION

Nancy Tannini Benefits Supervisor (845) 695-5844 ext. 3

[email protected]

Christine Goodhart Director, Benefits (845) 695-5844 ext. 5

[email protected]

Contact Information

Forms

IMPORTANT INFORMATION

In order to prevent delay of your health and/or dental benefits, the following is necessary when submitting your

enrollment form:

• Marriage License (when enrolling a spouse)

• Birth Certificate for each enrolled dependent

• Proof of full-time student status when electing dental for dependents age 19 to 23

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INSTRUCTIONS:

• Employer completes all shaded

areas.

• Employee completes all other

sections.

• Please print with ball-point pen.

TO BE COMPLETED BY EMPLOYER ONLY

Effective Date Of Transaction: __________________

Enrollment Termination Change

o New Employee

o Rehire

o Open Enrollment

o Special Enrollment Period

o COBRA Continuation

o Terminating Employee

o Layoff/Leave of Absence

o Canceling Coverage

o COBRA Continuation

o Death

o Add Dependent

o Remove Dependent

o Address Change

o Other ____________

Employee Information

Social Security Number: Last Name First Name MI Employee Number:

Employee Address: Date of Birth: Mo. Day Year

Home Phone: Work Phone: Date of Hire: Mo. Day Year

Medical and Dental Insurance

Medical Coverage – Group # 3334119 Dental Coverage – Group # 2516

Medical Plan Election – Cigna Dental Plan Election – DeltaPreferred Option with POS

Employee Plan RN Plan Professional Bargaining Plan Employee Plan RN Plan

Employee Employee + 1 Family Employee Employee + 1 Family None

If you are declining Medical coverage, please check the appropriate boxes. (If you wish to decline coverage for yourself, you must also decline coverage for your dependents.)

I wish to waive/cancel medical coverage for : Myself & Dependents Dependents

Reason: We ARE covered under another plan My dependents ARE covered under another plan

My dependents ARE NOT covered under another plan

I understand that if I decline enrollment for myself or my dependents (including my spouse) because of other health coverage, I may in the future be able to enroll myself or my

dependents in this plan, provided that I request enrollment within 30 days after such coverage ends. In addition, if a new dependent relationship forms as a result of marriage,

birth, adoption or placement for adoption, I may be able to enroll myself and my dependents provided that I request enrollment within 30 days after such marriage, birth, adoption,

or placement for adoption.

Dependent Information

List Individuals for whom you are adding/changing coverage, including yourself.

NAME (Last, First, MI)

Medical Add - A

Change - C

Remove - R

Dental Add - A

Change - C

Remove - R

SS# Relationship Gender DOB Full Time

Student?

Handicap

Dependent?

Other

Coverage

?*

SELF NA NA

Does any dependent listed above live at a different address than the employee? List which dependent(s) and the address(es).

*If “yes” to Other Coverage above, identify which coverage and provide effective dates, name & policy number of carrier insurance carrier, HMO or other source and your

Member ID number.

Acknowledgements / Authorizations

I understand that misstatements, material misrepresentations or omissions may result in my coverage being void as of its effective date with no benefits payable. I hereby request

the group coverage for which I am eligible and authorize payroll deductions from my earnings to serve as payment for any required contributions. I authorize any physician, other

health professionals, hospitals and other health care institutions, to provide the carriers (Cigna, Delta Dental NY, First Reliance), contracted physicians, consulting health

professionals, utilization review organizations, and independent claim administrators with whom the carriers have contracted, information concerning health care advice, treatment

or supplies, provided me and/or my dependents, relating to coverage under these plans. This information will be used for coordinating patient care, evaluating and administering

claims for benefits, and for fulfilling obligations imposed on the carriers by federal or state law. The carriers may provide the employer named below with any benefit calculation

used in the payment of these claims for the purpose of reviewing the experience and operation of the policy or contract. My signature below affirms that all information and

statements provided on the form are full, complete and true to the best of my knowledge.

_____________________________________ _____________________________ __________________________________

Employee Signature Date Email Address

Benefits Enrollment / Change Form

Employee Name: __________________________________ Employee #:____________________ Please Print

AFFIDAVIT OF SPOUSE STATUS

FOR HEALTH COVERAGE

Check and complete whichever of the following applies to you:

1. _____________________________ [insert name] is my spouse, but he/she is not employed.

2. _____________________________ [insert name] is my spouse, but he/she is self-employed and does not have an

employer group health plan.

3. _____________________________ [insert name] is my spouse, but he/she has insurance through Medicare or

Medicaid.

4. _____________________________ [insert name] is my spouse,

and is employed by _____________________________ [insert name of employer]. If you checked this box, you

must also complete the following:

Spouse Employer Group Health Coverage Information: Check whichever of the following applies to

your spouse:

The employer identified above does not offer group health coverage for which my spouse is eligible. I

understand that my spouse will be covered under the ORMC health plan.

The employer identified above offers group health coverage, but my spouse does not meet eligibility

requirements for their employer’s health plan. I understand that my spouse will be covered under the

ORMC health plan.

The employer identified above offers group health coverage. My spouse currently has health coverage

through this plan or is eligible for this plan. I understand that my spouse will not be covered under

the ORMC health plan.

I understand that ORMC is relying on my representations made in this affidavit in enrolling my spouse for coverage

under ORMC’s health plan. I understand and agree that in the event of a false declaration of information in this affidavit,

or failure to provide timely notice of a change in the information provided in this affidavit, ORMC and its health plan

may be entitled to recover from me any benefit payments that were made on behalf of my spouse who was not actually

eligible for coverage under the ORMC health plan, and any costs of recovering such payments. I also understand that

ORMC may take appropriate disciplinary action, up to and including termination, if I have made a false statement in this

affidavit. I am providing this information for the sole use of ORMC (and its agents) in administering its health plan and

determining eligibility of my spouse. I understand that if I do not complete this affidavit, my spouse will not be eligible

for coverage under the health plan.

________________________________ __________________________________ _________________

Print name of employee Signature of employee Date

Orange Regional Medical Center

2013 Flexible Spending Benefits Enrollment Form

Name: Social Security #:

Address: Date of Birth:

Phone Number:

Date of Hire:

Dependents

List below your spouse and/or dependents that are defined by IRC section 105(b) as eligible for tax free health

benefits and only domestic partners who are dependents for income tax return purposes.

Name SSN Birth Date Relationship Gender

Enrollment Election

I elect to enroll in the Flexible Spending Benefits Program and hereby authorize the following salary

reduction. I understand that:

• I may not change my election during the year except for a change in family circumstance.

• I may not transfer money between options.

• I will forfeit any balance remaining 90 days after the Plan Year end.

• I understand that this reduction of my cash compensation could affect my Social Security Benefits.

2013 Plan Year

Maximum

Employee Plan

Year Election

Per Pay Period (Office Use)


$2,500 $ $

Dependent Care Account

$5,000 $ $

Total

$7,500 $ $

Signature Date

Orange Regional Medical Center I 707 East Main Street

Middletown I NY I 10940

(845) 695-5844

Thank you to Hays Companies for donating the copying cost for this booklet.

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