City Of New York Employee Benefits Program Continuation Of Coverage Application (Page 3 of 8) in pdf

City of New York

Office of Labor Relations

Health Benefits Program

COBRA Premiums

Under the Federal Consolidated Omnibus Budget Reconciliation Act (COBRA), you have the opportunity to continue

health benefits coverage through the City of New York group.

You are responsible for paying the full premium for your plan and coverage. The premium levels indicated on the back of

this page reflect 102% of the current rate (because these rates are subject to change, you should check with the plan to

determine the premium at the time of your COBRA enrollment). Payments may be made monthly on the first of the

month. There is usually a 30 day grace period. The City will not "carve out" benefits provided through your Welfare Fund

that are similar to those available in your plan's Optional Rider. If you decide to purchase the Optional Rider, you must

pay for the entire Optional Rider offered by your chosen plan. If you decide to purchase any of your Welfare Fund

benefits, you should contact the Welfare Fund to determine what benefits are available, and the associated cost.

Health Plan Addresses

Payment should be mailed directly to the plan chosen for COBRA continuation coverage. The plan addresses are:

Aetna HealthCare

Empire BlueCross BlueShield

MetroPlus Health Plan

151 Farmington Ave.

3 Huntington Quadrangle, 3 Fl.

160 Water Street, 3

Fl.

Hartford, CT 06156

Melville, NY 11747

New York, NY 10038

Attn: Michele Wrenn

Attn: Lashern Pendergast

Attn: COBRA/Finance Dept.

CIGNA Healthcare

GHI CBP\EBCBS*

Vytra

499 Washington Blvd, 4

Fl.

EmblemHealth

GHI HMO

Jersey City, NJ 07310

EmblemHealth

55 Water Street

Attn: City of New York

55 Water Street

New York, NY 10041

Attn: Membership Department

DC 37 Med-Team

Attn: Membership Department

125 Barclay Street, 3

Fl.

New York, NY 10007

HIP HMO

Attn: Robert Hasiak

HIP POS

EmblemHealth

55 Water Street

New York, New York 10041

Attn: Membership Department

*The GHI CBP/EBCBS is offered as package under COBRA. The premium should be sent to the EmblemHealth

address indicated above.

CONVERSION CONTRACTS - City Health Plan Benefits

If you do not wish to continue coverage under COBRA you may use the same application to request direct payment

conversion contracts from all plans. Conversion contract payments will be due quarterly. Upon receipt of an application

for conversion, the health plan will send you a direct payment contract and a bill. Generally, conversion contracts will be

more expensive than COBRA for the same benefits or will offer benefits less comprehensive than COBRA, with the

exception of certain Medicare supplemental contracts. Optional benefits are not available under conversion. You may

purchase either Group Health Inc. or Empire BlueCross BlueShield direct payment plan separately. Decide whether direct

payment conversion or COBRA continuation coverage is best to meet your needs. If you decide to continue coverage

under COBRA, you will again be eligible to obtain direct payment contracts when COBRA terminates. Contact the health

plan for more information concerning direct payment contracts.

Welfare Fund Benefits

Contact your welfare fund directly for COBRA rates. If you do not wish to continue coverage of benefits provided by your

welfare fund under COBRA, conversion to private coverage may be available for medical and life insurance benefits within

45 days of termination of coverage. If you intend to obtain welfare fund benefits under COBRA, please so indicate on the

COBRA Continuation of Coverage application.

City Of New York Employee Benefits Program Continuation Of Coverage Application Page 3

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