New York City Health + Hospitals
Benefits & Forms
- Membership Forms are available on individual hospital pages. Select your hospital from the Benefits page.
- 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)
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. The card acts like a debit card. 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. Members are highly encouraged to submit any out of pocket cost for reimbursement.
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:
- Find a Provider
- Benefits Demo
- WorkLife Matters Employee Assistance Program: overview, details, and website
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
- Major Medical – Supplemental
- Obstetrical – Supplemental
- Newborn Expenses
- 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
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
- 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 70% of your monthly salary, up to a maximum of $3,500 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.
- Life Insurance Conversion Form – When you terminate employment, you will have the option to convert this benefit to an individual policy, subject to certain conditions.
- Continuing Learning Program (CLP) Claim Form 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.Effective July 1, 2020-June 30, 2021, you can put your CLP balance towards your Professional Education Plan (PEP).
- Professional Educational Plan (PEP) Claim Form 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.Effective July 1, 2020-June 30, 2022, you can be reimbursed for work-from-home-related equipment like tables, computers, monitors and printers under PEP.
- 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:
Regional Vice Presidents
Noah Berland, Emergency Medicine, Kings County Hospital Center
Linelle Campbell, Emergency Medicine, Jacobi Medical Center
Oluyemi Omotoso, Emergency Medicine, Lincoln Medical & Mental Health Center