The City University of New York

NYS HEALTH INSURANCE PROGRAMNYSHIP

Student Employee Health Plan (SEHP)

Office of Human Resources Management

University Benefits

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ELIGIBILITY

TO BE ELIGIBLE FOR NYSHIP BENEFITS YOU MUSTMEET ALL OF THE FOLLOWING CRITERIA:

Matriculate in a Doctoral Program at the CUNY Graduate Center or the Engineering Ph.D. Program at City College

Work in an eligible title (Graduate Assistant A, B, C, Adjunct Instructor, Adjunct Lecturer, Adjunct College Laboratory Technician And Non- Teaching Adjunct I, II)

Make a minimum $4,122 per year or $2,061 per semester

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ENROLLMENT

Complete the Health Benefits Enrollment Form (PS-404) and submit it along with supporting documentation to the NYSHIP

Coordinator at your college:

CUNY Graduate Center – Scott Voorhees - Office of Student Affairs, Room 7301.05

Phone number 212.817.7406

City College - Kim Ferguson - Office of Human ResourcesShepard Hall, Room 50 – (212) 650-7963

NOTE: Refer to the “SEPH Eligibility Requirements” sheet for list of required documentation:

www.cuny.edu/doctoralstudenthealthplan

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ENROLLMENT… (Cont’d)

YOU MAY ENROLL IN NYSHIP BENEFITS:

Within 45 days of your appointment - Late enrollments will be subject to a 30-day waiting period

Within 30 days of a qualifying event Within 30 days following involuntary loss of other

coverage .

During the Annual Open Enrollment Period – November 1st – November 30th

*Note: Employees of the CUNY Research Foundation are not eligible for these benefits.

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EFFECTIVE DATE OF COVERAGE

FOR NEWLY ELIGIBLE EMPLOYEES:

If you apply within 45 days of your date of appointment in a NYSHIP

eligible title, coverage for you and your eligible dependents will

generally be effective as of the date of your appointment.

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EFFECTIVE DATE OF COVERAGE

LATE ENROLLMENT:

If you apply for NYSHIP coverage more than 45 days after your date of

appointment in a NYSHIP eligible title, your coverage will begin 30 days from the date that your enrollment form is

received by the NYSHIP Coordinator at your college

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COVERAGE OUTSIDE OF THE USA

Services provided outside of the USA are treated as out-of-network services. You must complete a claim form to obtain reimbursement.

Download this claim form at:http://www.cs.ny.gov/ebd/ebdonlinecenter/pof/images/OutOfStateForm.pdf

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INSURANCE CARDS

You should expect to receive your insurance card within 3-4 weeks following your enrollment.

You will receive 3 cards:

Medical/Hospitalization Dental Vision Care

Note: In case of an emergency, the carrier may use your SSN or NYSHIP card number to verify

your coverage. Contact the NYSHIP Coordinator at your college if you need to obtain your NYSHIP

card number.

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ELIGIBLE DEPENDENTS

Spouse Domestic Partner Dependent Children - Up to age 26 (natural children,

adopted children, dependent step children). Disabled Dependents

Notes: Refer to the “SEHP Eligibility Requirements” on the

CUNY website for a list of required documentation.

www.cuny.edu/doctoralstudenthealthplan

[Note: Parents are not considered eligible dependents.]

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NYSHIP BENEFITS PROVIDERS

Medical Benefit – UnitedHealthCare Hospital Benefit - Empire BlueCross

BlueShield Dental Benefit – GHI Vision Care Benefit – Davis Vision Prescription Drug Benefit -

UnitedHealthCare / Medco Health Solutions Mental Health/Substance Abuse Benefit -

UnitedHealthCare / OptumHealth

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NYSHIP BIWEEKLY PREMIUM RATES

[AS OF JANUARY 1, 2012]

INDIVIDUAL – $7.95 PER PAY PERIOD

FAMILY – $55.52 PER PAY PERIOD

Pre-tax bi-weekly health insurance premiums will be automatically deducted from your paycheck.

You may elect to have post-tax health insurance premium deduction by completing the appropriate section on the Health Benefits Enrollment Form

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CHANGES TO COVERAGE

You may make changes to your coverage:

Within 30 days of a Qualifying Event

During the Annual Open Enrollment Period

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QUALIFYING EVENTS

Marriage

Birth of a child

Becoming a child’s legal guardian, step-parent or adoptive parent

Arrival of an eligible dependent to the United States

Completion of the six month waiting period for attainment of Domestic Partner Status

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ANNUAL OPEN ENROLLMENT PERIOD

Generally held in November. For calendar year 2012 it is

November 1st - November 30th.

During the annual open enrollment period you may:

Enroll in health benefits or add eligible dependents without the 30-day waiting period for late enrollments

Change from individual to family coverage Change from family to individual coverage You may change from pre-tax to post tax status You may change from post-tax to pre-tax status

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TERMINATION OF COVERAGE

Coverage will cease when you no longer meet both of the requirements indicated below:

1. Matriculated in a Doctoral Program at the CUNY Graduate Center or in the Engineering Ph.D. Program at City College

2. Working in an eligible title (Graduate Assistant A, B, C, Adjunct Instructor, Adjunct Lecturer, Adjunct College Laboratory Technician And Non- Teaching Adjunct I, II)

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TERMINATION OF COVERAGE… (Cont’d)

Coverage will terminate when you cease working in a NYSHIP eligible title or when you graduate or take a leave from your doctoral program (whichever comes first).

Since you will have pre-paid for two pay periods of coverage, your coverage will end 28 days following the last date of the pay-period that your termination date falls within.

You must notify the University Benefits Office immediately once you no longer meet the eligibility requirements. Otherwise, it may result in unanticipated cost to you.

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CONSOLIDATED OMNIBUS BUDGET RECONCILIATION ACT OF 1985 (COBRA)

NOTIFICATION

Under COBRA you and your dependents may continue group health coverage at a monthly premium of 102% of the group rate. The maximum period of coverage will vary depending on the reason for continuation.

The COBRA application process begins once the University Benefits Office is notified of your loss of eligibility. The NYS Department of Civil Service will send a COBRA package to your home address once the University Benefits Office has terminated your NYSHIP benefits.

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COBRA APPLICATION

Complete and return the COBRAenrollment application to the

addressindicated on the COBRA application

formon a timely basis

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COBRA MONTHLY PREMIUM RATES

[AS OF JANUARY 2012]

INDIVIDUAL - $176.70

FAMILY - $600.29

You will receive a monthly bill from the NYS Department of Civil Service for your COBRA premium payments

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TO FIND A LIST OF PARTICIPATING PROVIDERS…

Medical - www.empireplanproviders.com

Dental - www.ghi.com

Vision Care – Davis Vision – 1-888-588-4823

General Information - 1-877-7-NYSHIP

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FILL OUT A NYSHIP TRANSFER FORM (NYSHIP001 TRF-UBO) IF YOU ARE:

Transferring to a new college

Changing title

Both transferring and changing title

DOWNLOAD THE FORM FROM:http://www.cuny.edu/administration/ohrm/university-benefits/

dshp.html

TRANSFERS

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ONLINE HOME ADDRESS CHANGE

To update your home address online:

Go directly to www.cs.state.ny.us/mynyship Choose a Civil Service ID and password You will receive an Activation Code in the mail

within 3 to 5 business days .

Once you receive your Activation Code, return to MyNYSHIP and log in with the Civil Service ID and password

Then go to Employee Self Service and update your home address

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If you are working at a CUNY Community College, contact the NYSHIP Coordinator at your college to

be transferred to the Graduate Center payroll.

CUNY Graduate Center – Scott Voorhees - Office of Student Affairs, Room 7301.05 - Phone number

212.817.7406

City College - Kim Ferguson - Office of Human Resources

Shepard Hall, Room 50 – (212) 650-7963

COMMUNITY COLLEGES

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PSC/CUNY WELFARE FUND ADJUNCT HEALTH INSURANCE

If you are eligible for NYSHIP coverage, you will no longer be eligible for adjunct health insurance through the PSC/CUNY Welfare Fund.

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SUMMER COVERAGE

Graduate Assistants - Coverage continues for all who remain on payroll and receive paychecks during the months of June, July and August.

Adjunct Instructor, Adjunct Lecturer, Adjunct College Laboratory Technician and Non- Teaching Adjunct I, II - Coverage continues if: a) you have or are expected to have a Fall 2012 appointment; and b) you prepay premiums to cover health insurance deductions for the summer months in which you are not expected to receive a paycheck.

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CONTACTS

CUNY Graduate Center – Scott Voorhees - Office of Student Affairs, Room 7301.05 - Phone number

212.817.7406

City College - Kim Ferguson - Office of Human Resources

Shepard Hall, Room 50 – (212) 650-7963

You may also contact the University Benefits Office at (646) 313-8232

You may contact NYSHIP at 1-877-7-NYSHIP