PLAN YEAR 2021 ENROLLMENT/CHANGE FORM
MEDICAL SPENDING CONVERSION (MSC)
HEALTH BENEFITS BUY-OUT WAIVER PROGRAM
nyc.gov/fsa
Employee (Participant) return completed form to:
Agency Benets Oce, NYCAPS Central or HR Shared
Services Oce. See instructions on reverse side.
INSTRUCTIONS:
Please review the MSC Health Benets Buy-Out Waiver section in the Flexible Spending Accounts (FSA) Program Brochure, which is on the
FSA website at nyc.gov/fsa. Also, see instructions on reverse side of this form before completing.
ENROLLMENT
(Check one):
q Open Enrollment (October 1 - November 13, 2020; eective January 1, 2021) Complete Sections I, II, and IV.
q Mid-Year Enrollment (January 1 - November 12, 2021; eective Qualifying Event date) Complete Sections I, II, III, and IV.
I. EMPLOYEE (PARTICIPANT) INFORMATION (Please Print)
LAST NAME FIRST NAME M.I. SOCIAL SECURITY NUMBER
HOME ADDRESS - NUMBER AND STREET APT
CITY STATE ZIP CODE + FOUR
-
HOME PHONE NUMBER WORK PHONE NUMBER MOBILE PHONE NUMBER E-MAIL
( ) - ( ) - ( ) -
AGENCY NAME (NOT DIVISION):CUNY EMPLOYEES PLEASE SPECIFY THE NAME OF COLLEGE
II. MSC HEALTH BENEFITS BUY-OUT WAIVER PROGRAM SECTION: If completing this section during mid-year, you must also complete Section III below.
A)
To participate in the Buy-Out Waiver Program, complete this form and a Health Benets Application or submit through ESS. Return both forms to your agency’s
Human Resources Department/NYCAPS (if applicable) for approval and completion.
q I wish to participate in the Buy-Out Waiver Program. Check one
Non-City group health plan provider (company name)
q Individual Coverage ($500) q Domestic Partner/Civil Union Coverage ($500) q Family Coverage ($1,000)
Please note: You must attach proof of non-City group health coverage (letter or health insurance card).
B)
To terminate your participation in the Buy-Out Waiver Program, you must complete this form and a Health Benets Application, or submit through ESS, for
reinstating City health benets. Return both forms to your agency’s Human Resources Department/NYCAPS (if applicable) for approval and completion.
q I wish to withdraw from the Buy-Out Waiver Program.
III. MID-YEAR QUALIFYING EVENT: Newly eligible employees or current employees changing their status during mid-year must complete this section.
This is to certify that I incurred the Qualifying Event indicated below and, therefore, wish to modify my benets as indicated. I understand that the change(s)
requested must be consistent with the Qualifying Event and that I must submit this form with legal/supporting documentation of all changes to my agency’s Human
Resources Department/NYCAPS (if applicable) and they must be received by the MSC Administrative Oce within 30 days after the Qualifying Event to take eect.
Date of Qualifying Event: / / 2021 Today’s Date: / / 2021
If Today’s Date is more than 30 days from the Date of Qualifying Event, please note that you are not eligible for Plan Year 2021.
Please check one of the following:
Employment Status: Documentation must be provided by employer/agency Family Status Change: Legal documentation must be provided by participant
q Beginning/termination of employment (q self q spouse)
q Unpaid leave of absence (q self q spouse)
q Return from unpaid leave of absence (q self q spouse)
q Change from P/T to F/T employment or vice versa (q self q spouse)
q Increase in health plan deductions by more than 20%
q Marriage/domestic partner
q Birth or adoption of child
q Divorce
q Ineligibility of dependent (q age q marriage)
IV. Employee Signature
I have read the MSC Program materials and instructions and I attest that I meet the qualications to enroll or withdraw from the MSC Health Benets Buy-Out
Waiver Program.
Signature:__________________________________________________________________________________________________ Date: _____/ _____/____
V. FOR COMPLETION BY EMPLOYING AGENCY’S HUMAN RESOURCES DEPARTMENT/NYCAPS/HR SHARED PERSONNEL ONLY:
Please review the above information and submitted documentation from employee before completing the information below.
Note to Benets/Payroll/NYCAPS/HR Shared Ocer:
Send this MSC Form and the Health Benets Application, along with any legal/supporting documentation, electronically to: https://nyc-fsa.leaple.net
You should retain a copy of this form for your records.
1) For the Health Benets Buy-Out Waiver Program (Section II), I have reviewed and processed the Health Benets Application and certify that the employee
has listed a non-City group health insurance policy under which he/she is covered. I have notied the appropriate health insurance carrier of this change.
2) For mid-year changes, I certify that a Qualifying Event listed in Section III has occurred within 30 days after this request and this form, along with legal/
supporting documentation, have been submitted.
Employee’s Agency Appointment Date: / / Eective Date of Health Benets: / /
A)
MSC Buy-Out Waiver Eective Date: (Check one)
q Open Enrollment: (October 1 - November 13, 2020: eective January 1, 2021)
q Mid-Year Enrollment: / / 2021 (January 1, 2021 - November 12, 2021)
(June 1- June 30, eective July 1, 2021) (December 1- December 31, eective January 1, 2022)
B)
MSC Buy-Out Waiver Withdrawal Date: (Check one)
q Open Enrollment: (October 1 - November 13, 2020: eective January 1, 2021)
q Mid-Year Withdrawal: / / 2021 (January 1, 2021 - November 12, 2021)
AGENCY BENEFITS MANAGER/NYCAPS/HR SHARED PERSONNEL SIGNATURE EFFECTIVE DATE WORK PHONE NUMBER
/ / ( ) -
EMPLOYEE AGENCY CODE CUNY STATE I.D. NUMBER E-MAIL ADDRESS
MSC ADMINISTRATIVE OFFICE USE ONLY
ENROLLMENT EFFECTIVE DATE WITHDRAWAL EFFECTIVE DATE PROCESSING DATE PROCESSOR AGENCY PAYROLL CODE
/ / / / / /
J:FSA\PLYR2021\MSC\MSC_FORM_2021.INDD 9/20 1K
MEDICAL SPENDING CONVERSION (MSC)
PLAN YEAR 2021
INSTRUCTIONS:
HEALTH BENEFITS BUY-OUT WAIVER PROGRAM - SECTION II:
The Medical Spending Conversion (MSC) Health Benets Buy-Out Waiver Program allows you to receive an incentive
payment for waiving your City health benets. Refer to the MSC Health Benets Buy-Out Waiver Program section in the
Flexible Spending Accounts Program Brochure for detailed information.
A. Enrolling:
Please Note: The Internal Revenue Service does not permit any retroactive participation from a previous Plan Year.
If you are covered under your spouse’s/domestic partner’s or parent(s)’ non-City group health insurance, or a group health
plan available through other employment, you may waive New York City health benets. Once your enrollment form has
been processed and approved, you will receive a conrmation letter from the MSC Administrative Oce. Please contact
your agency’s Human Resources Department/NYCAPS/HR Shared personnel if you do not receive a conrmation letter.
Current employees: You may enroll in the Program during the Open Enrollment Period (October 1, 2020 - November 13,
2020) for an eective date of January 1, 2021. You must complete Sections I, II, and IV. Section V is to be completed
by your agency’s Human Resources Department/NYCAPS/HR Shared personnel.
Newly eligible employees: You may enroll in the Program within thirty (30) days after becoming eligible for City health
benets. You must complete Sections I, II, III, and IV. Section V is to be completed by your agency’s Human Resources
Department/NYCAPS/HR Shared personnel.
During mid-year: If you incur a Qualifying Event, you must notify the MSC Program Administrative Oce within thirty
(30) days after the Qualifying Event in order to participate. You must complete Sections I, II, III, and IV and attach legal/
supporting documentation. Section V is to be completed by your agency’s Human Resources Department/NYCAPS/HR
Shared personnel.
Any MSC Form received in June will be eective July1
st
of that Plan Year. Any MSC Form received in December will be
eective January 1
st
of the following Plan Year.
By signing the MSC Health Benets Buy-Out Waiver Program Enrollment/Change Form, you elect to receive $1,000 (family
coverage waived), $500 (individual coverage waived), or $500 (domestic partner/civil union coverage waived) annually
in lieu of New York City health benets. You will receive $500 for family coverage, $250 for individual coverage, or $250
for domestic partner/civil union coverage waived at the end of every six-month calendar period. Please note that same
sex marriage will be treated as family coverage (This amount will be pro-rated for any period less than six months
by the number of days you are in the Health Benets Buy-Out Waiver Program.)
An employee participating in the City’s Deferred Compensation Plan (DCP) in lieu of FICA and participating in the Health
Benefits Buy-Out Waiver Program (taxable income), may need to increase his/her salary deferral percentage to an amount
higher than 7.5% of annual salary in order to account for the increase in income due to the “Buy-Out Waiver Incentive
Payment.” If the 7.5% of total salary income requirement is not met, the participant who is enrolled in the DCP may have
to continue to pay FICA taxes until that requirement is met.
B. Terminating:
Your waiver will remain in eect during the Plan Year unless a) you experience an approved mid-year Qualifying Event or,
b) you reinstate your City health coverage during the Health Benets Program Fall Transfer Period. During the mid-year,
your form must be received by the MSC Administrative Oce within thirty (30) days after the Qualifying Event in order for
the change to be eective. If you are returning from an approved leave of absence or transferring to a new City agency,
you must complete the MSC Health Benets Buy-Out Waiver Program Enrollment/Change Form and the Health Benets
Application within thirty (30) days after such event to be reinstated, or to receive a pro-rated incentive payment.
If you wish to terminate your participation in the Health Benets Buy-Out Waiver Program and reinstate your City health
benets coverage, complete Section II, by indicating your requested change. If you are terminating your participation
mid-year, you must also complete Section III.
Please Note: If you waive City health coverage, you must have other non-City group health coverage available to you.
The Health Benets Application must accompany this MSC Form so that your agency’s benets/payroll manager is able
to verify that you have other coverage. Your agency’s Human Resources Department/NYCAPS/HR Shared personnel
may request additional documentation.
This form is not valid if you have not completed Sections I, II, III (for mid-year Qualifying Event) and IV.
This form is not valid if Section V has not been completed by your agency’s Human Resources Department/NYCAPS/HR Shared
personnel.
Please return the completed form and documentation to:
If your agency is a non-centralized agency - send directly to your agency benets oce.
If your agency is a centralized agency - send directly to: NYCAPS Central, 1 Centre Street, New York, NY 10007
DOE Employee/Payroll/Secretary - send directly to: DOE MSC Unit, 65 Court Street, Rm. 406, Brooklyn, NY 11201
H+H Centralized Agency - send directly to: H.R. Shared Services, 55 Water Street, 26
th
Floor, New York, NY 10041