Who is Eligible for Health Benefits?
DOE employees are eligible for health benefits if they work on a regular schedule, at least 20 hours per week, and work on an appointment that is expected to last for more than six months. F-status employees are eligible for health benefits; occasional per diem substitutes are not.
Eligible employees may cover their spouse, domestic partner, and/or dependent children under their New York City Employee Health Benefits Program.
Health Benefits Application Process
The application process is dependent upon the employee population to which you belong:
Administrative employees (H/ZBank) and Pedagogues (QBank)
All other pedagogical and non-administrative employees (EBank, TBank, and Custodial Payroll)
Effective Date of Coverage
For provisional, temporary, and non-competitive employees, who have no experience or education requirements, coverage begins on the first day of the pay period following the completion of 90 days of continuous employment, provided that the health benefits application was submitted within 31 days of hire.
For appointed teachers and specified school-based personnel, coverage is retroactive to the first day of employment, provided the health benefits application was submitted within 31 days of hire.
For individuals transferring from another New York City agency with no break in service and individuals appointed from a Civil Service list, coverage is retroactive to the first day of employment, provided the health benefits application was submitted within 31 days of hire.
All employees should receive a health insurance card from their provider within six weeks of enrolling in a health insurance plan. Once you enroll, inquires regarding your benefits should be directed to your health care provider.
Late Enrollment Coverage
An enrollment is considered late if an application is filed more than 31 days after the event that made the employee eligible. In cases of late enrollment, coverage will begin on the first day of the payroll period following the receipt of the application by the agency payroll or personnel office.
Useful Information Regarding Your Health Benefits
As a participant in the New York City Employee Health Benefits Program it is important that you know how your health plan works and what is required for you. Please keep in mind the following:
- Within 31 days of the qualifying event, employees must submit the appropriate health benefits application and supporting documentation in order to add or drop dependents.(See Health Benefits Application Process above)
- When your address changes, notify HR Connect by calling (718) 935-4000. If you are moving out of your provider’s coverage area, you must also notify your provider.
- Review your payroll/pension check to ensure appropriate premiums are deducted
- Report Medicare eligibility to your health plan and the New York City Employee Health Benefits Program
Know your rights and responsibilities under COBRA continuation coverage. Visit the U.S. Department of Labor Web site
How To Choose Your Provider
In making your decision on the health benefits plan you select, you may want to consider the following four factors:
- Coverage: The services covered by the plans differ. For example, some plans offer preventive services while others do not cover them at all; some plans cover routine podiatric (foot) care, while others do not.
- Choice of Doctor: Some plans provide partial reimbursement when non-participating providers are used. Other plans only pay for or allow the use of 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 the physicians’ offices and hospital affiliations
- Cost: Some plans require payroll and pension deductions for basic coverage. The costs of Optional Riders also differ. These costs are compared in the Summary Program Description. Some plans require a copayment 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 must also consider the out-of-pocket cost of these services.
Available Health Plan Options
Following is a summary of the types of health plans provided by the New York City Department of Education. You can access more information regarding available health plans by visiting the New York City Office of Labor Relations Web site, and viewing their Health Benefits Program Summary Program Description.
Point of Service Plans (POS)
Point-of-Service (POS) plans offer the freedom to use either a network provider or an out-of-network provider for medical and hospital care. If the subscriber uses a network provider, health care delivery resembles that of a traditional HMO, with prepaid comprehensive coverage and little out-of-pocket costs for services. When the subscriber uses 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. Providers that offer POS plans are:
• Aetna Point-of-Service
• HIP Prime Point-of-Service
Participating Provider Organizations/Indemnity Plans (PPOs)
Participating Provider Organization (PPO)/Indemnity plans offer the freedom to use either a network provider or an out-of-network provider for medical and hospital care. Participating Provider Organization (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. When the subscriber uses a non-participating provider, the subscriber is subject to deductibles and/or coinsurance. The provider that offers a PPO/Indemnity Plan is GHI-CBP/Empire BlueCross BlueShield Hospital Plan.
Exclusive Provider Organization (EPO)
Exclusive Provider Organization (EPO) plans offer a higher level of choice and flexibility than many other managed care plans. Members can see any provider in the EPO network, which contains family and general practitioners as well as specialists in all areas of medicine. There is no need to choose a primary care physician and no referrals are necessary to see a specialist. An EPO provides members with an extensive local, national and worldwide network of providers. There are no claim forms to file and members will never have to pay more than the co-payment for covered services. There is no out-of-network coverage. The provider that offers the EPO plan is Empire EPO.
Health Maintenance Organizations (HMOs)
A Health Maintenance Organization (HMO) is a system of health care that provides managed, pre-paid hospital and medical services to its members. An HMO member chooses 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. Individuals and/or families who choose to join an HMO can receive health care at little or no out-of-pocket cost, provided they 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. The providers that offer HMO plans are:
• Aetna HMO
• CIGNA HealthCare
• Empire HMO (NY & NJ)
• GHI HMO
• Health Net Health Plan
• HIP Prime HMO
Coverage By Multiple Insurance Plans
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 New York City Employee Health Benefits Program 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.
Health Benefits Buy-Out Waiver Program
The New York City Heath Benefits Buy-out Waiver Program allows eligible City employees to receive an incentive payment for waiving their New York City Employee Health Benefits Program coverage. If you are eligible to enroll in the New York City Employee Health Benefits Program, and are covered under their spouse's or domestic partner's non-City group health insurance, or through other employment, or under Medicare Part A and Part B, you may enroll in the Heath Benefits Buy-out Waiver Program. You may only enroll in the Health Benefits Buy-Out Waiver Program at specified times and under specific conditions:
- Within 31 days of becoming eligible for health benefits coverage;
- During the annual Open Enrollment transfer period; or
- As a result of a qualifying event.
The incentive payment is distributed in two equal, semiannual payments, as part of the first June paycheck and the first December paycheck. A prorated payment is given if you enroll in the Heath Benefits Buy-out Waiver Program less than six months prior to a scheduled incentive payment.
Flexible Spending Accounts Program
The City of New York offers its employees a Flexible Spending Accounts (FSA) Program. The Program allows City employees to deposit a portion of their pre-tax income into accounts maintained for certain health and dependent care expenses. With an FSA program, you can pay for your health expenses with pre-tax dollars, saving you money. To learn more please visit the New York City Office of Labor Relations Flexible Spending Accounts Program Web site. You can enroll in the FSA program during the annual Open Enrollment transfer period. The annual Open Enrollment transfer period is determined by the New York City Office of Labor Relations each year, and typically occurs from mid-October through mid-November.
Making a Change to Your Health Plan
You may make a change to your health plan (by adding or dropping a dependent, adding or dropping an optional rider, or enrolling in the Heath Benefits Buy-out Waiver Program) during the annual Open Enrollment transfer period or as the result of a qualifying event. You may only change your health care provider during the annual Open Enrollment transfer period. The annual Open Enrollment transfer period is determined by the New York City Office of Labor Relations each year, and typically occurs from mid-October through mid-November.