Westchester 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 (both same-sex and opposite-sex partners are 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.
Effective May 1, 2018, the supplemental RX benefit is $750.
Davis Vision benefits:
Guardian Dental benefits:
- Mental Health Claim Form
- Major Medical – Supplemental
- Obstetrical – Supplemental
- Newborn Benefit Claim Form
- 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: email@example.com.
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 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.
- 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.
- For an overview of the differences between porting and converting, click here.You have up to 31 days from your date of termination to submit one of these forms directly to Guardian:
- 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.
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.
Who qualifies for premium assistance?
The American Rescue Plan Act of 2021 (ARP) provides temporary premium assistance for COBRA continuation coverage. The premium assistance is available to certain individuals who are eligible for COBRA continuation coverage due to a qualifying event that is a reduction in hours or an involuntary termination of employment.
If you qualify for the premium assistance, you need not pay any of the COBRA premium otherwise due to the plan. This premium assistance is available from April 1, 2021 through September 30, 2021.
Due to the employment as an House Staff Officer, it is very unlikely that you would qualify to be treated as an Assistance Eligible Individual based on the IRS guidance below. As such, if you request to be treated as an Assistance Eligible Individual, it is very important that you also include any details to support why you believe there was an involuntary termination of employment and why you have a situation that is different from the example provided in the IRS guidance below.
Please note the following guidance in Internal Revenue Service Notice 2021-31, clarifying what is considered an involuntary termination of employment:
Q-34. Does an involuntary termination of employment include an employer’s decision not to renew an employee’s contract, including for an employee whose employer is a staffing agency?
A-34. Generally, yes. An employer’s decision not to renew an employee’s contract will be considered an involuntary termination of employment if the employee was otherwise willing and able to continue the employment relationship and was willing either to execute a contract with terms similar to those of the expiring contract or to continue employment without a contract. However, if the parties understood at the time they entered into the expiring contract, and at all times when services were being performed, that the contract was for specified services over a set term and would not be renewed, the completion of the contract without it being renewed is not an involuntary termination of employment.
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:
Regional Vice Presidents & Delegates
Regional Vice Presidents
Linelle Campbell, Emergency Medicine, Jacobi Medical Center
Jessica Bloomfield, Neurology
Michelle Bravo, Neurology
Michael Diamond, Psychiatry
Urvashi Hooda, Internal Medicine
Jennifer Kaswick, Pediatrics
Vishnupriya Samarendra, Psychiatry (Alternate)
Matthew Seplowe, Internal Medicine (Alternate)
Questions about your contract? Contact: Lalit Clarkson | Lclarkson@cirseiu.org | (917) 902-7253