Kings County Medical Center
Benefits & Forms
- Membership Form
- Update Form – To add new dependents to your plan. Requests to add dependents must be received within 30 days of qualifying event (birth/adoption or marriage), and you must attach requested documentation (see form).
- Domestic Partnership Application (same-sex and opposite partners eligible) – To add a partner, download an application and return a notarized copy, along with all requested documentation, to the Plan office. You must also complete an Update Form above.
- Opt-Out Benefits Form – Please fill out this form if you would like to remove yourself and/or your dependent(s) from the CIR Benefits Plan.
- Prescription – Express Scripts (HHC Residents Only)
- Member ID card
- Online registration
- Mobile app – download now
- ScriptVisionSM for digital physician engagement
About this benefit:
This benefit is a supplemental RX coverage that should be used in conjunction with your employer’s primary prescription plan. The Plan highly recommends the member enroll in the employer prescription plan for themselves and their family. Whenever possible use your primary prescription carrier prior to the supplemental debit card. Employees will be mailed two cards per household and informational materials. You may use the cards immediately.
Please note: Employees and their dependents may not be issued a card if a completed enrollment card was not presented to the benefits office. Cards will be issued at $750 per eligible individual in the family. Members can obtain discounts for prescription drugs at any one of ESI’s participating providers nationwide. Cards are presented to the participating pharmacy for eligibility verification. Once eligibility is established, the cost of the prescription will be reduced by a discounted rate. Members will not have to pay any cash/payment upfront. When the balance on the card reaches zero, members can continue to use the cards to fill prescriptions at a discounted price.
In the event the card does not have a sufficient balance to pay for the full prescription, the cost of the purchase will be applied to the card and the remaining balance will be the member’s responsibility.
It is important to note this card does not cover any over the counter drugs or medications. To determine the participating providers, you can logon and register at www.express-scripts.com or call the customer service phone number on the back of your card. ESI’s customer service representatives can also inform you of your card balance.
For additional savings you can use ESI’s mail order program to get a ninety day supply for the cost of two copayments. For replacement of a lost card, please contact ESI @ 1-800-467-2006.
Davis Vision benefits:
Guardian Dental benefits:
Dental Guard Preferred – DGP (This Benefit is insured through HSBP):
If the employee or eligible dependent is enrolled in the DentalGuard Preferred through Guardian or another carrier, this supplement will pay an additional 20% to the member, of the amount reimbursed by the dental carrier for covered services. This 20% supplement will be calculated based on the total reimbursements received under the Dental Plan during the benefit year.
For Example: Managed DentalGuard – MDG
If the employee or eligible dependent is enrolled in the Managed DentalGuard, this supplement will pay 20% of what the employee has paid in connection with receipt of covered Managed DentalGuard. With your claim form, you must submit an itemized statement of covered charges from your primary care dentist with the exact date(s), diagnosis and procedure codes for which services were rendered. Only services that are covered by your dental carrier will be reimbursed by the Plan. Scanned copies of your receipts for eligible dental expenses must be submitted to the Benefits Plan Office with the appropriate claim form. The Managed DentalGuard or DentalGuard Preferred reimbursements in combination cannot exceed the maximum supplement per person per benefit year of $1,000.
- Mental Health Claim Form – Now available through the Member Portal: CLICK HERE
- Major Medical – Supplemental
- Obstetrical – Supplemental
- Newborn Benefit Claim Form – Now available through the Member Portal: CLICK HERE
- Urinalysis Monitoring
The HSBP Transgender benefit gives those who need the ability to receive medical services such as psychology, hormones and surgery to develop the physical characteristics of the desired gender. Transgender benefit coverage includes: culturally appropriate, knowledgeable primary care and prescription care, access to gender specific care, transition-related care and mental health outpatient care. Read more here
The WorkLife Matters Employee Assistance Program offers services to help promote well-being and enhance the quality of life for you and your family. View details.
Connect to a counselor for free support services: 1-800-386-7055 (available 24 hours a day, 7 days a week).
Visit ibhworklife.com and login to “For Employees & Members” (password: wlm70101).
Questions? Email: firstname.lastname@example.org.
For purposes of our disability benefits, “disabled” means you can no longer perform the duties of your occupation due to accidental bodily injury, sickness, or a related medical condition, including pregnancy or childbirth. You must also be under the care of a licensed provider as defined by the state in which you work.
- Disabled Health Premium Reimbursement
- Short-Term Disability (STD) Benefits Claim Form
- If this is your first full-time job, you would have to work four consecutive weeks in order to become eligible for short-term disability. If this isn’t your first full-time job, you will be eligible for short-term disability payments on your first day of employment, unless you worked less than four weeks in previous job.
- Coverage begins on the eighth (8th) day of your disability. The maximum benefit payable is 70% of your weekly salary, up to $875 per week, for up to 26 weeks. See the Summary Plan Description (SPD) for more details.
- If you are going out on a disability leave, contact your employer as soon as possible.
- Long-Term Disability (LTD) Benefits Claim Form
- The LTD plan pays you $3500 per month. LTD benefits typically start if you are still disabled after 26 continuous weeks. For detailed information on Long-Term Disability see the Guardian Certificate.
- INSMED Portable Disability Coverage – Policies offered to you without any medical underwriting requirements or exams.
Guardian Life Insurance:
- If you die, a death benefit of $150,000 will be paid to any beneficiary you name. A death benefit of $20,000 will be paid to you if your legal spouse or domestic partner dies from any cause.
- For instructions on submitting a Group Life Claim, click here.
- When you terminate employment, you will have the option to continue the life insurance coverage as either group term insurance (this is called “porting” and is similar to how you have been covered during training) or you may convert this benefit to an individual policy, subject to certain conditions.
- Whether you decide to port or convert, the availability and pricing of this coverage does not depend on any past or current medical conditions.
- You have up to 31 days from your date of termination to submit one of these forms directly to Guardian:
For an overview of the differences between porting and converting, click here.
- Continuing Learning Program (CLP) Claim Form – Now available through the Member Portal: CLICK HERE – allows reimbursement for medical conferences, board review courses, and online courses. You can still attend conferences or take online courses up to six months after graduation, if you pay for them while on your hospital’s payroll. See the Summary Plan Description (SPD) for more details.
- Professional Educational Plan (PEP) Claim Form – Now available through the Member Portal: CLICK HERE – reimburses costs associated with books, board exams, medical licensure fees, dues, subscription, journals and mobile electronic medical devices. See the Summary Plan Description (SPD) for more details.
- QI Training & Education Application
- QI Training & Education Reimbursement Form (For those who have been previously approved for this benefit)
- Rosetta Stone – opportunity to learn a new language with Rosetta Stone.
Are you a resident or fellow in need of childcare? You’re in luck!
Housestaff with children 13-years-old or younger are eligible for reimbursement of up to $3,500 per calendar year as of July 1, 2019 for childcare expenses.
- You must be a resident or fellow at a New York Health + Hospitals (NYC H+H) facility
- Your child or children must be 13-years- old or younger
- Your expenses must qualify as tax- exempt per IRS Publication 503
- Submit a reimbursement form with paid receipt and other required documentation
You can fill out a reimbursement form and find more info below:
- Summary of Material Modification
- Tax Certification Worksheet
- Childcare Reimbursement Claim Form – Now available through the Member Portal: CLICK HERE
- NYC Childcare Resource & Referral Listings
- Childcare FAQs
What is COBRA continuation coverage?
COBRA continuation coverage allows you to choose to continue and pay for group health benefits provided by CIR for up to 18 months after your termination date.
Who is eligible?
You and your dependents covered under the Plan on the day before you terminated from your employer.
You will receive a COBRA notice mailed to the address we have on file. This notice has important information about your rights related to continued health care coverage in the House Staff Benefits Plan.
COBRA Election forms:
To apply for COBRA, you will need to complete the Election form that corresponds to the Dental Plan you had prior to termination. If you don’t remember which Dental Plan you have, look at your Dental ID card. Here is a sample of what the Managed Dental Guard ID card looks like:
Your Cobra Election includes the following benefits: RX, Supplemental Reimbursements (Major Medical, Dental, Mental Health,Obstetrical and Newborn) Hearing Aid, Vision, Urinalysis Monitoring, Hospitals Detox & Rehab.
The only difference in the benefits is the Dental option you had prior to termination. Please select the Election form (also includes the COBRA Credit Card Authorization Form) that applies to you:
- Individual – Managed DentalGuard Preferred (MDG)
- Individual – DentalGuard Preferred (DGP)
- Family – Managed DentalGuard Preferred (MDG)
- Family – DentalGuard Preferred (DGP)
You have up to 31 days from your date of termination to submit one of these forms directly to Guardian:
- Benefits-at-a-Glance – a comprehensive summary of available benefits.
- HIPAA Notice of Special Enrollment Rights
- View discount programs on the main Members page.
Mental Health Resources:
- NY Project Hope Emotional Support Helpline: 1-844-863-9314
- Crisis Text Line: Text GOT5 to 741741
- National Suicide Prevention Lifeline: 1-800-273-TALK
- Trevor Lifeline: 1-866-488-7386
- Trevor Text: Text START to 678678
- OMH’s Customer Relations: 1-800-597-8481
- NY Office of Mental Health Website
The Benefits Fund Office is pleased to announce the launch of our Member Portal!
Now accepting claims for the Continuing Learning Program (CLP), the Professional Educational Plan (PEP), Supplemental Mental Health, Newborn Nursery, and Childcare Reimbursement, with more benefits coming soon.
Click on Submit Claim if you have already registered to the member portal. If not, please click on the register link and enroll:
Please note: the “View EOB” (Explanation of Benefits) option will be hidden for claims that were processed prior to going live with Member Portal registration.
How it Works:
Member Portal Instructions – First Time
Click the REGISTER button above to get started.
User Details – Enter the following criterions to register:
- Enter Member ID (starting with 900/901) or Last 4 of SSN
- Enter First Name, then Last Name
- Enter Date of Birth (slashes not necessary)
- Click Next
- System navigates to Create Your Password step
- Create New Password and Confirm Password
- Select terms and accept the terms and conditions
- Terms and Conditions box will appear
- Click Submit
- Click Next
- Click Send Authorization code button
- Sent to user registered primary email ID
- Enter code (did not receive code, check box to skip email verification)
- Click Finish
System will display confirmation message and navigate to login page. You will receive a welcome email to the registered email address on file.
Member Portal Instructions
Click the SUBMIT CLAIM button above to open the Member Portal. Then:
- Click on the Login (top right) -> The Member Portal Login section appears
- Enter User Name and Password (created during registration)
- Verification email will appear if skipped during registration
- Click send Authentication code
- Click “I already have a code”
- Enter code sent via registered email address
- No code, request new code
- Click Submit
- Enter code sent via registered email address
Communications details will appear if first time logging into Member Portal:
- Update address/contact information if required.
- Click Submit
- System updates address information on member record
To submit for reimbursements, please see steps below
- Top menu Click Benefits
- Select Reimbursement Type and Employer
- Read the claim submission rules and instructions then Click Continue
- System will display the Claim Form
- Enter all required information and attach proofs (supporting documents) as required
- Click Submit
- Reimbursement claim will be submitted to the Benefit Funds Office
- You will receive an email confirmation of your submission
- Claims are processed between 7 to 10 business days
Advantages of the Self-Serve Member Portal
- You will be able to easily update contact information as needed.
- The Member Portal streamlines the application process by automatically linking to your member and employer details so that you won’t have to enter them on each application. Based on the login information provided, the system will automatically load the applicable reimbursement claim forms.
- The proof needed for each expense submitted will be tied to the expense line itself. This will reduce the number of denials from the Fund Office for lack of proof-of-submission and decrease wait time for payments.
- The claims processing time will decrease. Checks will be mailed out faster than they have been under the old system.
- The rules and guidelines for the reimbursement type are listed on the form’s first page to help you understand what’s allowed and required.
- You will be able to easily submit claims through the browser on your desktop computer, cell phone, or tablet.
- You can take a picture from your device and upload it for proof of payment.
- Coming soon: “View Balance” – view payment information for your individual benefits.
- Coming soon: “My Messages” – communicate with the Benefits Office directly through the Member Portal.
Regional Vice Presidents & Delegates
Regional Vice Presidents
Dina Jaber, Internal Medicine, Kings County Health Care Center
Kaushal Khambhati, Emergency Medicine, Jacobi Medical Center
Jim Yang, Emergency Medicine, Jacobi Medical Center
Nata Cisse, Emergency Medicine
Priyanka Datta, Emergency Medicine
Yvonne Okaka, Ophthalmology
Shane Solger, Emergency Medicine
Zachary Moore, Emergency Medicine
Dina Jaber, Internal Medicine
Roshan Srinivas Srinivasan, Pediatrics
Questions about your contract? Contact: Lalit Clarkson | Lclarkson@cirseiu.org | (917) 902-7253