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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 ......………………………………………………………………….……….
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Medical Benefits .………………………………………………………………..…….
3
Dental Benefits ......…………………………………………………………….…...... 4
Employee Contributions ……………………………………………….……………..
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Vision Benefits ...………………………………………………………………………
6
Basic and Voluntary Life and AD&D ………………………………………..………
7
Disability Benefits ………………………………………………………..…………… 8
Flexible Spending Account ..……………………………………………..………….
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Individual Voluntary Benefits ..………………………………………………..……..
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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
60%, after deductible
60%, after 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 deductible
100%, after $15 copay
90%, after deductible
100%, after $25 copay
60%, after deductible
60%, after deductible
Chemical Dependency
Inpatient Services
Outpatient Services
100%, after deductible
100%, after $15 copay
90%, after deductible
100%, after $25 copay
60%, after deductible
60%, after deductible
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
0.5 Per Pay Period Contribution
Your Annual Cost
$7.12
$185.12
$13.22
$343.72
$22.21
$577.46
0.4 Per Pay Period Contribution
Your Annual Cost
$8.54
$222.04
$15.87
$412.62
$26.65
$692.90
0.3 Per Pay Period Contribution
Your Annual Cost
$9.97
$259.22
$18.51
$481.26
$31.09
$808.34
0.2 Per Pay Period Contribution
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
0.6 Per Pay Period Contribution
Your Annual Cost
$139.01
$3,614.16
$248.21
$6,453.50
$370.27
$9,626.93
0.5 Per Pay Period Contribution
Your Annual Cost
$173.76
$4,517.70
$310.26
$8,066.88
$462.83
$12,033.66
0.4 Per Pay Period Contribution
Your Annual Cost
$208.51
$5,421.24
$372.32
$9,680.26
$555.40
$14,440.39
0.3 Per Pay Period Contribution
Your Annual Cost
$243.26
$6,324.78
$434.37
$11,293.63
$647.97
$16,847.12
0.2 Per Pay Period Contribution
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
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Flexible Spending Account
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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
• Accrues per pay period
Department Heads & Physicians Receive:
• Thirty days accrued during first year
• Accrues per pay period
- 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
Christine Goodhart Director, Benefits (845) 695-5844 ext. 5
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)
Flexible Spending Account
$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.