Welcome to Your Benefits Choices for 2017!

November 1, 2016

The Open Enrollment period for NYSHIP members is November 1 – December 31, 2016.

If you choose to continue your current health insurance plan, no action is necessary unless:

 Based on age or disability, you will become eligible for Medicare in 2017. See page 4 of the Summary of Health Benefits.

This Summary of Health Benefits packet provides the information you need to make the best decisions.

Information on the following will be mailed to you separately:

 2017 NYSHIP Employee Contribution Rates available in December  Medical Insurance Opt-Out Program Brochure from the MTA

Dates to remember …  The Annual Enrollment period is November 1 – December 31.  The Opt-Out Program is available November 1 – 30.  The Flexible Spending Account (FSA) period is November 1 – December 15.

The MTA Business Service Center is available to answer your questions and provide assistance.

MTA Business Service Center 646-376-0123 8:30 a.m. to 5 p.m., Monday-Friday [email protected] www.mymta.info

Summary of Health Benefits & Tax-Favored Programs

2017 Open Enrollment

Health Benefits: November 1 – December 31, 2016 Flexible Spending Accounts: November 1 – December 15, 2016 Medical Opt-Out Program: November 1 – November 30, 2016

MTA NYC Transit - NYSHIP

MTA Business Service Center

Summary of Health Benefits & Tax Favored Programs

CONTENTS

I. INTRODUCTION 3 A) 2017 Health Benefits Open Enrollment Period B) Sources of Information

II. HEALTH BENEFITS CHOICES 3 A) Electing/Changing Medical/Dental/Vision Coverage B) Medical Opt-Out Program

III. HEALTHCARE REFORM REQUIREMENTS 5 A) Coverage for Children from Age 19 to 26 B) Social Security Number Requirement

IV. TAX-FAVORED PROGRAMS 6 A) Flexible Spending Account (FSA) B) MTA Deferred Compensation Program C) New York’s 529 College Savings Program D) Premium TransitChek

V. IMPORTANT TELEPHONE NUMBERS & WEBSITES 8

Business Service Center 2 2017 Open Enrollment

I. INTRODUCTION

A) 2017 Health Benefits Open Enrollment Period

Your Open Enrollment Period for Benefit Plan Year 2017 is November 1 through December 31, 2016.

MTA Business Service Center (BSC) staff and various plan administrators will be available to explain your benefit plan choices and answer questions at informational meetings. Watch for announcements that will be posted at your place of work and on the BSC Self-Service Portal www.mymta.info

B) Sources of Information

 My MTA Portal at www.mymta.info provides information and links to providers’ websites. You can also check and update your personal information online and view your benefits and payroll information by clicking on the “My Benefits” ribbon.

 The BSC Customer Management Center (CMC) provides assistance at 646-376-0123 from 8:30 a.m. to 5 p.m., Monday – Friday, or send an email to [email protected].

 The 180 Livingston Street Walk-in Center is open 8:30 a.m. to 5 p.m., Monday – Friday.

 Section V Important Telephone Numbers and Websites in this packet provides contact information for your benefits providers.

II. HEALTH BENEFITS CHOICES

A) Electing/Changing Medical/Dental Coverage

The BSC processes all medical benefits enrollments and changes. You need to complete and submit the appropriate enrollment/change form(s) to the BSC to do the following:

 Change plans and/or  Add/terminate dependents and/or  Provide a social security number for a covered dependent who is at least age 45, as required by federal legislation (see Section IIID)

Business Service Center 3 2017 Open Enrollment

Members of the New York State Health Insurance Program (NYSHIP) include the following groups: 1. Managerial 2. Non-Represented 3. TWU Local 106 - Transit Supervisors Organization (TSO Operating and Queens Division) 4. Subway Surface Supervisors Association (SSSA) 5. Organization of Staff Analysts (OSA) 6. Doctors Council (medical only) 7. Special Inspectors represented by UFLEO hired on or after 01/30/08

To assist with your decision making, see the 2017 NYSHIP Choices Guide listing your plan choices. To change your insurance online, click here for information on MyNYSHIP, a new secure website where active New York State employees can get online access to their own health insurance record.

The 2017 Employee Contribution Rates will be posted on My MTA Portal in December. These include the following options:

 The Empire Plan Rates (Preferred Provider Organization (PPO)  The NYSHIP-approved Health Maintenance Organizations Rates (HMO)

 No action is required if you choose to continue your current health insurance plan.

Note to employees planning to retire in 2017: If you and/or your covered dependent(s) are at least age 65 when you retire, Medicare will be your primary medical coverage on the first of the month coincident with your retirement date or the following month. Enrollment in Medicare generally takes about three months so please contact the Social Security Administration well enough in advance so that you will be enrolled in Medicare Part A (hospitalization) and Medicare Part B (medical) upon retirement.

B) Opt-Out Program (Medical/Hospital and Prescription Drugs)

The MTA Opt-Out Program provides an incentive to employees who opt out of medical/prescription drug coverage.  Please note that your dental and vision coverage will remain in effect if you elect the Opt-Out Program. You will find complete information on how the program works and the incentive payments in the 2017 Opt-Out Brochure, available on My MTA Portal; the brochure will also be mailed to you. Following are general guidelines for the opt-out process.

Business Service Center 4 2017 Open Enrollment

1) If you opted out for 2016 and wish to opt-out for 2017: DO NOTHING. Your opt-out status will remain in place for 2017 provided you remain eligible to participate in the program. 2) If you opted out for 2016 and wish to enroll for medical coverage for 2017: Submit a NYSHIP Open Enrollment/Change form no later than the open enrollment deadline, November 30, 2016. 3) If you did not opt out for 2016 and wish to opt out for 2017: Submit an Agreement to Decline (Opt-Out) Medical Coverage Form (HR-BEN-036) no later than the opt-out deadline, November 30, 2016. A lump sum incentive payment will be issued to you during the first quarter of 2018. If you wish to defer all or part of the incentive payment, submit the Medical Opt-Out Deferred Comp Form (HR-BEN-075).  Your election to opt-out remains in effect until you change your election during a future Open Enrollment period or you experience a Qualified Family Status Change

III. HEALTHCARE REFORM REQUIREMENTS

A) Coverage for Dependent Children from ages 19 to 26

A dependent child age 19 to the end of the month of the 26th birthday is eligible for medical, hospital and prescription drug coverage, regardless of their student or marital status. If you wish to enroll a dependent child age 19 to 26, add the child’s name on the NYSHIP Open Enrollment/Change Form (HR-BEN-060k) and submit the required documentation listed on page 2 of the form.

 Note that this extended dependent child coverage does not apply to dental and vision coverage. For more information see the BSC Self-Service Portal Benefits section under My MTA FAQ >> Benefits >> Student Certification.

B) Social Security Number Requirement

The Medicare, Medicaid, and State Children’s Health Insurance Extension Act of 2007 (MMSEA) requires that the MTA report Social Security Numbers to the Federal Centers for Medicare and Medicaid Services (CMS) for all dependents who are at least age 45. You can check to see if your covered dependent’s Social Security Number (SSN) is missing from your benefits record by logging on to My MTA Portal at www.mymta.info. Click the My Benefits ribbon to view your benefits information. If your dependent’s Social Security Number is not shown under SSN (only the last four digits will show), please submit a copy of your dependent’s Social Security Card with your name and BSC ID number noted on the copy, along with the Open Enrollment/Change Form to the BSC.

Business Service Center 5 2017 Open Enrollment

IV. TAX-FAVORED PROGRAMS

A) Flexible Spending Account (FSA) You may enroll in the FSA Program during the FSA Open enrollment period, November 1 – December 15, 2016, by contacting the P&A Group (see Section V and information posted on the BSC Self-Service Portal).

FSA is a program that allows you to set aside part of your paycheck on a pre-tax basis through automatic payroll deductions for eligible Health Care and Dependent Care expenses. This program allows you to reduce your taxable income, thereby reducing your tax liability. Keep in mind that your FSA account cannot be used to pay for the cost of over-the-counter (OTC) medicines (such as ibuprofen and antacids) unless accompanied by a physician’s prescription. The FSA Health Care Account limit is capped at $2,550 for 2017. The Dependent Care FSA annual maximum allowance per household is $5,000.

 If you enrolled in FSA for 2016, please note that you will not be automatically re- enrolled in FSA for 2017. You must re-enroll by contacting the P&A Group during this Open Enrollment Period.

Examples of Eligible Expenses

 Health Care FSA o Medical, dental, vision and prescription drug deductibles and copayments o Eyeglasses, contact lenses, contact lens supplies, and prescription sunglasses

 Dependent Care FSA o Child care costs o Elder care costs (dependent must meet the definition of a qualifying relative per the IRS, based on a tax year) o Before-school and after-school programs o Summer day camp

B) MTA Deferred Compensation Program

You may enroll or make changes at any time by contacting Prudential (see Section V).

401(k)/457 Participating in the 401(k) and/or the 457 MTA Deferred Compensation Program may help you achieve a more comfortable and secure financial future. The program helps supplement your existing retirement/pension benefits by allowing you to save and invest before-tax dollars through the convenience of automatic payroll deductions. You are offered diversified investment options, access to local service representatives, financial education services, and planning tools that can

Business Service Center 6 2017 Open Enrollment

help you better prepare for retirement. Contributions and any earnings are tax deferred until money is withdrawn, usually at retirement, when you may be receiving less income and are in a lower income tax bracket.

401(k)/457 Roth In addition to the traditional pre-tax contributions, both the 401(k) Plan and 457 Plan now allow you to make after-tax contributions (also known as Roth contributions). The Roth contribution option combines the savings and investment features of a traditional retirement plan with tax-free distribution features of a Roth IRA.

While income taxes on pre-tax contribution amounts are deferred until your account is distributed (for example, at retirement), Roth contributions are made on an after-tax basis so the amount contributed is included in your W-2, just like regular income, in the year you make the contribution. However, earnings on Roth contributions may be distributed tax-free in retirement if you meet certain requirements.

C) New York’s 529 College Savings Program

You may enroll at any time by contacting the College Savings Program (see Section VI).

This program is designed to assist families saving for college. You can elect to contribute to a choice of funds on a post-tax basis through automatic payroll deductions. If you use the money for higher education, earnings will be distributed tax-free

D) Premium TransitChek You may enroll at any time by contacting the TransitChek Center (see Section VI).

This program allows you to set aside money on a pre-tax basis through automatic payroll deductions for commuting expenses for you and your family, up to certain limits established by the IRS. Eligible expenses include using public transportation such as commuter trains, subways, buses, ferries, van-pool services, and/or commuter parking for travel to and from work.

Business Service Center 7 2017 Open Enrollment

V. IMPORTANT TELEPHONE NUMBERS & WEBSITES

Carriers Telephone Website Medical/Hospital Options NYSHIP Health Plans/Choices Guide 877-769-7447 www.cs.ny.gov Dental Options Healthplex/Dentcare 800-468-0600 www.healthplex.com MetLife 800-942-0854 www.metlife.com Vision Options EyeMed 800-334-7591 www.eyemedvisioncare.com Savings Programs P&A Group (FSA) 800-688-2611 www.padmin.com Prudential (401k/457) 877-756-4682 www.prudential.com/mta College Savings 800-420-8580 www.ny529atwork.com TransitChek 888-618-2435 www.transitchek.com COBRA & Government P&A Group (COBRA Administrator) 800-688-2611 www.padmin.com Medicare 800-633-4227 www.MyMedicare.gov Social Security Administration 800-772-1213 www.ssa.gov

Submit Open Enrollment/Change Forms by email, fax, mail, or Walk-in Center: Email: [email protected] Fax: 212-852-8700 Mail: MTA Business Service Center, 333 W. 34th Street, 9th Floor, New York, NY 10001- 2402 Walk-in Center: 180 Livingston Street, 8:30 a.m. to 5 p.m., Monday – Friday

Contact the MTA Business Service Center (BSC) for assistance: Phone: 646-376-0123. 8:30 a.m. - 5 p.m., Monday – Friday

All Open Enrollment information and documents can be accessed on My MTA Portal: www.mymta.info

Please have your BSC ID ready when you contact us and be sure to include your full name and BSC ID on all emails and documents you submit.

Business Service Center 8 2017 Open Enrollment

2017 Open Enrollment Meeting Schedule OCTOBER-NOVEMBER 2016

SUNDAY MONDAY TUESDAY WEDNESDAY THURSDAY FRIDAY SATURDAY 16 17 18 19 20 21 22 METRO-NORTH Annual Health & Safety Fair Vanderbilt Hall Grand Central Terminal 9 am – 2 pm

23 24 25 26 27 28 29 BRIDGES & TUNNELS Randall’s Island (B&T) 10 am – 12 pm

Manhattan Plaza (B&T) 1:30 pm – 3 pm

Bronx Plaza (B&T) 3:30pm – 5 pm

30 31 1 2 3 4 5 BRIDGES & TUNNELS 2 Broadway 22nd Floor, Conference Room A New York, NY 9 am – 12 pm

NYC TRANSIT 2 Broadway 4th Floor, Room D4.00A New York, NY 12 pm – 4 pm

(continued)

2017 Annual Enrollment Meeting Schedule NOVEMBER 2016

SUNDAY MONDAY TUESDAY WEDNESDAY THURSDAY FRIDAY SATURDAY 6 7 8 9 10 11 12 BRIDGES & TUNNELS Verrazano Narrows Bridge 1 Verrazano Bridge Plaza Staten Island, NY 10 am – 12 pm

13 14 15 16 17 18 19 BRIDGES & TUNNELS LONG ISLAND RAIL ROAD NYC TRANSIT Queens Midtown Tunnel Jamica JCC Location 180 Livingston Street 10 am – 12 pm 144-41 94th Avenue Room 6008 Jamaica, NY Brooklyn, NY LONG ISLAND RAIL ROAD 10 am – 1 pm 8:30 am – 5 pm Hillside Support Facility 93-59 183rd Street Hollis, NY 10 am – 1 pm

2017 NYSHIP Open Enrollment/Change Form HR-BEN-060K

State of New York EMPLOYEE BENEFITS Department of Civil Service INSTRUCTIONS FOR THE PS-404 Alfred E. Smith State Office Bldg. NYS HEALTH INSURANCE TRANSACTION FORM Albany, NY 12239 PS-404-

Page 1 Boxes 1 - 9 All enrollees must complete boxes 1 – 9 with their personal information. Note: Marital Status Date is used to show date of marriage, separation or divorce when those marital statuses are selected.

Box 10 (A – I) Complete appropriate sections. The employee is entitled to make separate choices regarding their medical, dental and vision coverages. They may decline any of the three, all of the three, or none of the three different coverage options. Also, they many enroll in family coverage in one benefit and individual coverage in another.

Reminder: Enrollees with a Benefit Fund (CSEA, UUP and DC-37) receive their dental and vision benefits through that Fund. Do not enter dental and vision information on NYBEAS for these enrollees.

New Enrollees (also complete 10.G for family coverage)

Note: for new enrollments in a Health Maintenance Organization (HMO), complete an HMO form in addition to this form.

10.A Request Enrollment – Individual Check box to enroll in individual coverage. Check Medical, Dental and/or Vision boxes for coverage being enrolled. 10.B Request Enrollment – Family Check box to enroll in family coverage. Check Medical, Dental and/or Vision boxes for coverage being enrolled. 10.C Elect Pre-Tax Status? New Enrollees choose to enroll in or decline the Pre-Tax Contribution Program for medical coverage. 10.D Decline Coverage Check box to decline coverage. Check Medical, Dental and/or Vision boxes for coverage being declined.

Cancellation or Change in Coverage

10.E Voluntarily Cancel The enrollee is entitled to make separate decisions regarding their Coverage medical, dental and vision coverages. Enrollees may cancel or change their dental and/or vision coverage(s) at any time during the year. Pre-tax medical enrollees may only cancel coverage during the Pre- Tax Open Enrollment Period, or with a qualifying event (enter the qualifying event). If you are going on Leave Without Pay, also complete Box 12. 10.F Change Coverage Check this box to change from Individual to Family, or from Family to Individual coverage. Pre-tax medical enrollees may only change their coverage from Family to Individual during the Pre-Tax Open Enrollment Period, or with a qualifying event (check the qualifying event and enter the Date of Event). Check Medical, Dental, and/or Vision boxes for coverage being changed. 10.G Add/Change/Delete Check the box to add or delete dependents or to change dependent Dependents information. Check Medical, Dental, and/or Vision boxes that apply. Complete all dependent information including date of birth. Additional documentation may be required to add the dependent. 10.H Change Medical Complete during annual Option Transfer Period or with a qualifying Benefit Plan event (for example, change of address outside of HMO area.) 10.I Change Pre-Tax Status Existing enrollees can only change pre-tax status during the annual Pre-Tax Open Enrollment Period in November.

State of New York EMPLOYEE BENEFITS Department of Civil Service INSTRUCTIONS FOR THE PS-404 Alfred E. Smith State Office Bldg. NYS HEALTH INSURANCE TRANSACTION FORM Albany, NY 12239 PS-404 I (1/07)

Page 2 Box 11 Complete previous coverage information, if applicable.

Box 12 LEAVE WITHOUT Enrollees going on leave without pay who request cancellation of coverage at PAY SECTION the time they leave the payroll must complete this section. To request permanent cancellation of coverage, check the appropriate box and cross out the sentence which reads “I wish to resume my coverage upon return to the payroll.” RETIREMENT Enrollees leaving the payroll due to retirement must complete this section to SECTION indicate their decision to either defer or continue health insurance coverage as a retiree. A PS-406.2 must be completed for enrollees requesting deferment of medical coverage, prior to retirement.

Box 13 Request for Empire Plan Cards Only – complete this section to order a duplicate or replacement Benefit Card. Do not complete this section if requesting a change to your health insurance coverage. A new card will be issued automatically.

AUTHORIZATION Employees must SIGN and DATE this form.

AGENCY/EBD USE ONLY This section is for Agency and/or EBD use only and is provided to assist in updating the enrollee’s record on NYBEAS. Action/Reason Transaction that will be inputted into NYBEAS by HBA. Date of Event Date the event took place, which resulted in the enrollee requesting a change to benefits. Example: first day worked, first day on leave, date of birth, date of marriage. Hire Date Original date of hire or rehire. (Only needed for new enrollment). Date of 1st Eligibility (PE only) The first day the enrollee is eligible for coverage. Percentage Working Enrollee’s percentage on payroll. Agency Code Enrollee’s agency code. Neg. Unit Enrollee’s negotiating unit. Ret. System The retirement system for the enrollee (ERS, TRS or PFS) Retirement Tier Tier 1, 2, 3 or 4. Sick Leave Information - # Hours Number of sick leave hours for enrollee at time of retirement. Sick Leave Information - Hourly Enrollee’s hourly rate of pay based on annual salary at the time of retirement. Rate of Pay (See Hourly Rate Calculation memo NY99-22). Date Entered on NYBEAS Date HBA processes the transaction on NYBEAS. Effective Date The effective date assigned to the transaction by NYBEAS.

Note: When updating NYBEAS, use Date in Authorization Box as Date of Request. Legal changed EXAMPLES OF DOCUMENTATION REQUIRED TO PROCESS YOUR TRANSACTION Employees Spouse/Domestic Partner Children Copy of Birth Certificate Copy of Birth Certificate Copy of Birth Certificate Copy of Social Security Card Copy of Social Security Card Copy of Social Security Card Copy of Marriage Certificate or Complete Completed PS-451 – Statement of PS-425 series Domestic Partner, if Applicable Disability and Required Documentation, if Applicable For Changes of Coverage, copy of Marriage Completed PS-457 – Statement of Certificate, Divorce Order, Death Certificate, Dependence and Required PS-425.4 (Domestic Partner), as appropriate Documentation, if Applicable

State of New York Department of Civil Service Alfred E. Smith State EMPLOYEE BENEFITS DIVISION Office Bldg. Albany, NY 12239 NYS HEALTH INSURANCE TRANSACTION FORM For Participating Employers PS-404 - OE2014

INSTRUCTIONS: READ AND COMPLETE BOTH SIDES/PAGES. PLEASE PRINT AND CHECK THE APPROPRIATE CHOICES. EMPLOYEE INFORMATION (All employees must complete) 1. Last Name First Name MI 2. Social Security Number 3. Sex Male Female 4. Street Address City State Zip

5. Date of Birth 6. Telephone Numbers 7. Work location and address Home ( ) Work ( ) 8. Marital Status Married Divorced Marital Status Date Single Widowed Separated

9. Covered under Medicare? Self Yes No Spouse/Domestic Partner/Dependent? Yes No

10. ENTER REQUEST(S) BELOW

A. Request Enrollment- (Select Empire Plan or HMO) Individual Empire Plan HMO* Code Name B. Request Enrollment- (Select Empire Plan or HMO) Family (Complete G) Empire Plan HMO* Code Name

C. Elect Pre-Tax Status for Note: pretax deductions may not be offered by all Yes No Premium deduction? agencies. Verify eligibility with your agency.

D. Decline Coverage For Agency Use: (Process WAV/BEN transaction)

E. Voluntarily Cancel Coverage

F. Change Coverage Date of Event

Change to FAMILY (Complete G) Change to INDIVIDUAL I voluntarily cancel coverage for my dependents Marriage I voluntarily cancel coverage for my domestic partner Domestic Partner Only dependent died Only First dependent child acquired dependent married Only Dependent returned to full-time student status dependent graduated Request coverage for dependents not previously covered Divorce Newborn Only dependent disqualified by age Previous coverage terminated (Complete Section 11) Termination of domestic partnership (Attach Completed PS-428.4) Other Other

G. DEPENDENT INFORMATION (use additional sheets if necessary)

Check One: A (Add), D (Delete) or C (Change) Date of Event

Social Security Last Name First Name MI Relationship Date of Birth Sex Address (if different) Number A D C A D C A D C A D C A D C * A completed HMO form must be attached. NYS Department of Civil Service Health Insurance Transaction Form For Participating Employers Albany, NY 12239 PS-404 PE OE2014 Page 2 10. Continued. ENTER REQUEST(S) BELOW Change to: Empire Plan HMO * Code HMO Name H. Change Medical Benefit Plan * A completed HMO form must be attached.

11. PREVIOUS COVERAGE INFORMATION If you were previously covered under NYSHIP Previous ID Number Date Coverage or another health insurance plan (attach proof, Terminated i.e. insurance bill or letter stating former Enrollee’s Name Under Last First Middle Initial coverage), please complete this section. Which Previously Covered

12. LEAVE WITHOUT PAY AND RETIREMENT STATUS I wish to continue coverage while I am on authorized leave. LEAVE I understand that I will be billed for this coverage. WITHOUT PAY I do not wish to continue coverage while I am on authorized leave. I wish to resume my coverage upon return to the payroll. I understand the requirements for continuing medical insurance coverage as a retiree and wish to continue my coverage. RETIREMENT I understand the requirements for continuing medical insurance coverage as a retiree and wish to defer my coverage. (A completed PS-406.2 must be attached.)

13. REQUEST FOR EMPIRE PLAN CARD ONLY For Health Maintenance Organization (HMO) cards, contact your HMO.

ENROLLEE DUPLICATE CARD FOR (Previously issued card remains valid.) ENROLLEE AND ALL DEPENDENTS REPLACEMENT CARD INDIVIDUAL DEPENDENT (Previously issued card(s), lost or stolen, become invalid.) Name

Personal Privacy Protection Law Notification This information you provide on this application is requested in accordance with Section 163 of the New York State Civil Service Law for the principal purpose of enabling the Department of Civil Service to process your request concerning health insurance coverage. This information will be used in accordance with Section 96 (1) of the Personal Privacy Protection Law, particularly subdivisions (b), (e) and (f). Failure to provide the information requested may interfere with our ability to comply with your request. This information will be maintained by the Director of the Employee Benefits Division, NYS Department of Civil Service, Albany, NY 12239. For information concerning the Personal Protection Law, call (518) 457-9375. For information related to the Health Insurance Program, contact your Agency Health Benefits Administrator. If, after calling your Agency Health Benefits Administrator, you need more information, please call (518) 457-5754 or 1-800-833-4344 between the hours of 9:00 a.m. and 3:00 p.m. AUTHORIZATION I have read the Pre-Tax Contribution Program memorandum and have made my selection on Page 1 of this document, if applicable. I understand that if I voluntarily decline or cancel my coverage, I may subject myself and/or my dependents to waiting periods if I decide to enroll at a later date, and I may be forfeiting the right to such coverage after leaving State service (vest, retirement, etc.). I certify that the information I have supplied is true and correct. I understand that my failure to provide required proof(s) within 28 days (30 days for newborns) may delay the availability of benefits for me or any dependent for whom I fail to provide such proof. Any person who makes a misstatement of fact or conceals any pertinent in formation, commits a crime which is subject to a $5,000 penalty and the stated value of the claim for each violation. I hereby authorize deduction from my salary or retirement allowance of the amount required, if any, for insurance indicated above. This authorization shall be in effect until I revoke it in wri ting. Employee’s Signature (Required) Signature Date (Required)

AGENCY/EBD USE ONLY

Date of 1st Percentage Neg. Action/Reason Date of Event Hire Date Agency Code Ret. System Eligibility Working Unit

Sick Leave Information Date Entered on Retirement Tier Registration # Effective Date # Hours Hourly Rate of Pay NYBEAS

HBA Signature: Date:

2017 Open Enrollment/Change Form Active Subway Surface Supervisors Association (SSSA), Non Rep Operating Supervisors (MS II), TWU Local 106 Transit Supervisors Organization (TSO) Operating and Queens Supervisory, Coin Retriever Employees, SSII and Special Inspectors

HR-BEN-368A

Section 1 - Information and Instructions The purpose of this form is to enroll in or change health insurance, effective January 1, 2017. Please email a signed copy of the form to [email protected] or fax to 212-852-8700 or drop off at the 180 Livingston Street Walk-in Center 8:30 a.m. to 5 p.m., Monday – Friday. If you have any questions, please contact the Business Service Center (BSC) at 646-376-0123.

Section 2 - Employee Information

BSC ID Print Name Last First M.I. Suffix Pass #

Phone (H) Phone (W) Email If your address on your pay stub is incorrect, contact the Business Service Center OR log onto www.mymta.info and change your address online OR complete HR-HRIS-012 Employee Data Change Form. An incorrect address will delay receipt of your new health insurance cards.

Section 3 – Coverage Election – Effective January 1, 2017

Medical Individual Family

Check One

METLIFE (Fee Schedule) METLIFE PPO DENTCARE (HEALTHPLEX)

PLAN A – AMERICAN DENTAL CENTER PLAN B – THE DENTAL SHOP

Section 4 – Dependent Information If you are found to be covering an ineligible dependent, coverage will be terminated retroactive to the date of the ineligibility and NYC Transit will pursue financial restitution for claims and/or premiums for the ineligible dependent. 1. Please fill in all information for new dependents you wish to enroll and submit required documentation (see Section 6). 2. Please fill in all information for any dependents you wish to delete. 3. Please contact the Business Service Center for the Domestic Partnership Package if you wish to enroll a domestic partner.

NOTE: Your domestic partner will not be enrolled in health coverage unless an application is submitted and approved by the Benefits Department. Check One - Indicate (A) Add or (D) Delete Check One - Relationship Gender Date of Birth A D Name SSN Spouse Domestic Partner Child F M Mo Day Year

Section 5 - Authorization

My signature and date on this form certifies and warrants that all dependent eligibility information is true, correct, and current. I also certify that dependent children from age 19 to 26 that I have enrolled in coverage are not eligible for another employer-sponsored coverage.

Employee Signature Date

Business Service Center Last Revised: 10/24/2016 Creation Date: 04/01/2012

HR-BEN-368A

Section 6 – Dependent Required Documentation 1. For a Spouse A copy of Marriage Certificate, Social Security card, and, if your date of marriage is more than one year old:

 Your most recent Tax Return—Federal or State (including Puerto Rico Returns) o Your most recent tax return showing “Married Filing Jointly” or “Married Filing Separately”. Your spouse’s name must appear on the tax form on the line provided after the “married filing separately” status (or vice versa). o Only submit page 1 of the tax return. This should include the 1040 form, eFile Confirmation page, Tax Preparer’s Summary, or Federal Return Recap. o Eliminate all financial information. OR  Proof of Joint Ownership Both the enrollee’s and spouse’s name must be listed on the documentation of joint ownership and be dated within the past 90 days. Examples include a copy of:  Homeowners/Renters Insurance Policy  Mortgage Statement  Credit Card Statement  Property Tax Document  Loan Obligation  Rental/Lease Agreement  Bank Account Statement  Utility/phone/internet/cable bills  Pension/life insurance/will designating spouse as beneficiary If you are not able to provide the required documentation, please contact the BSC at 646-376-0123.

2. For Children For a Natural-Born Child, a copy of: For a Stepchild, or Legally Adopted Child, a copy of:  Birth Certificate showing employee’s name  Birth Certificate  Social Security card  Social Security card  Legal documentation concerning adoption

3. Dependent Children Coverage between ages 19 and 25

To continue covering a dependent child from age 19 to 25 on dental, you are required to submit a full-time student verification letter. Students will also be entitled to vision coverage under EyeMed.

Business Service Center Last Revised: 10/24/2016 Creation Date: 04/01/2012

2017 Open Enrollment/Change Form - Dental Active Managers, Non-Rep C/S, OSA and DC 37 with NR Benefits HR-BEN-367A

Section 1 - Information and Instructions The purpose of this form is to enroll in or change dental insurance, effective January 1, 2017. Please email a signed copy of the form to [email protected] or fax to 212-852-8700 or drop off at the 180 Livingston Street W alk-in Center 8:30 a.m. to 5 p.m., Monday – Friday. If you have any questions, please contact the Business Service Center (BSC) at 646-376-0123. Section 2 - Employee Information

BSC ID Print Name Last First M.I. Suffix Pass #

Phone (H) Phone (W ) Email

If your address on your pay stub is incorrect, contact the Business Service Center OR log onto www.mymta.info and change your address online OR complete HR-HRIS-012 Employee Data Change Form. An incorrect address will delay receipt of your new health insurance cards.

Section 3 – Coverage Election – Effective January 1, 2017

Dental Individual Family

Check One

METLIFE DENTCARE (HEALTHPLEX) Section 4 – Dependent Information If you are found to be covering an ineligible dependent, coverage will be terminated retroactive to the date of the ineligibility and NYC Transit will pursue financial restitution for claims and/or premiums for the ineligible dependent. 1. Please fill in all information for new dependents you wish to enroll and submit required documentation (see Section 6). 2. Please fill in all information for any dependents you wish to delete. 3. Please contact the Business Service Center for the Domestic Partnership Package if you wish to enroll a domestic partner. NOTE: Your domestic partner will not be enrolled in health coverage unless an application is submitted and approved by the Benefits Department. Check One - Relationship Gender Date of Birth Check One - Indicate (A) Add or (D) Delete A D Name SSN Spouse Domestic Partner Child F M Mo Day Year

Section 5 - Authorization

Employee Signature Date

Business Service Center Last Revised: 10/24/2016 Creation Date: 04/01/2012

2017 Open Enrollment/Change Form - Dental Active Managers, Non-Rep C/S, OSA and DC 37 with NR Benefits HR-BEN-367A

Section 6 – Dependent Required Documentation 1. For a Spouse A copy of Marriage Certificate, Social Security card, and, if your date of marriage is more than one year old:

 Your most recent Tax Return—Federal or State (including Puerto Rico Returns) o Your most recent tax return showing “Married Filing Jointly” or “Married Filing Separately”. Your spouse’s name must appear on the tax form on the line provided after the “married filing separately” status (or vice versa). o Only submit page 1 of the tax return. This should include the 1040 form, eFile Confirmation page, Tax Preparer’s Summary, or Federal Return Recap. o Eliminate all financial information. OR  Proof of Joint Ownership Both the enrollee’s and spouse’s name must be listed on the documentation of joint ownership and be dated within the past 90 days. Examples include a copy of:  Homeowners/Renters Insurance Policy  Mortgage Statement  Credit Card Statement  Property Tax Document  Loan Obligation  Rental/Lease Agreement  Bank Account Statement  Utility/phone/internet/cable bills  Pension/life insurance/will designating spouse as beneficiary If you are not able to provide the required documentation, please contact the BSC at 646-376-0123.

3. Dependent Children Coverage between ages 19 and 25

To continue covering a dependent child from age 19 to 25 on dental, you are required to submit a full-time student verification letter. Students will also be entitled to vision coverage under EyeMed.

Business Service Center Last Revised: 10/24/2016 Creation Date: 04/01/2012