health-forms-and-downloads

Office of Labor Relations


EmployeeNon-Med RetireeRetireePlans & Rates

Health Benefits Videos
Attend a Health Benefits Seminar
Forms and Downloads
Responsibilities & Health Benefits Assistance
Choosing a Health Plan
Enrollment
PICA
Changes in Status
Flexible Spending Accounts Programs
Effective Dates of Coverage
Health Plan Premiums
Transfer to Another City Agency
Change Union/Welfare Fund
Termination and Reinstatement
Leave of Absence Coverage
COBRA
Special Continuation of Coverage
Disability Benefits
Medicare-Eligible Employees
Coordination of Benefits (COB)

Health Benefits Videos

Attend a Health Benefits Seminar

Forms and Downloads

Responsibilities & Health Benefits Assistance

Choosing a Health Plan

Enrollment

PICA

Changes in Status

Flexible Spending Accounts Programs

Effective Dates of Coverage

Health Plan Premiums

Transfer to Another City Agency

Change Union/Welfare Fund

Termination and Reinstatement

Leave of Absence Coverage

COBRA

Special Continuation of Coverage

Disability Benefits

Medicare-Eligible Employees

Coordination of Benefits (COB)


NYC Health Benefits Program

Important Notice

The Health Benefits Retiree client service walk-in center is closed. Due to the closure of the office, if you mailed or faxed forms or correspondence March 11, 2020 or after, we cannot access or process that form. Please resubmit your documents as follows:

1) Forms and documents can be submitted electronically using the following link: https://nycemployeebenefits.leapfile.net

For detailed instructions on how to submit your form/document securely through LeapFile and to view a short video, click here.

Please do not submit your form/document more than once. This will only delay processing.

You will immediately receive notification stating "Success! Your file has been received" upon completion of your document upload. You will not receive a separate email confirmation.

Please allow 30-45 days from the day you submit your document(s) for them to be processed.

Also, please do not send forms or documents via express mail. The office is closed and the package cannot be accepted.

2) Inquiries and questions can be emailed to healthbenefits@olr.nyc.gov

3) For questions regarding the PICA prescription drug benefit program please call 1-800-467-2006.

4) If you are a HIP-HMO member turning 65 or on Medicare due to a disability, please contact HIP at (800) 447-9169 to enroll over the phone. Please identify yourself as a City of New York retiree or dependent of a retiree. For all other members enrolled in a HMO plan, please contact your health plan at the customer service numbers on the back of your ID card.

Please check our website periodically for updates.

Health Benefits Forms & Downloads

Health Benefits Summary Plan Description (SPD)

Employee Health Benefits Application/Change Form (Not for use by NYCAPS Agencies)

Health Plan Rate Chart for Employees

COBRA Form, Notice of Rights and COBRA Rates

Young Adult Option, Through Age 29, (NYS Law Chapter 240)

Dependent Eligibility Required Documentation (DEVA)

Dependent Eligibility Required Documentation (DEVA) FAQs

Domestic Partner Enrollment Information

Case Management Program (for GHI-CBP/EBCBS Members)

Creditable Coverage Notice (Employees Age 65 or Over)

Form 1054 (For Use By Authorized Personnel Only)

Health Insurance Marketplace (Exchange) Notice

List of Services Requiring Pre-Certification