October 1, 2017

Welcome to Your Benefits Choices for 2018!

It’s time to make your choices for health care Open Enrollment. This Summary of Benefits packet provides the information you need to make the best decisions. You will receive even more information throughout the Open Enrollment period.

Note: To remain in your current medical plan, there is no action required by you. If you plan to retire in 2018 and satisfy the requirements of Medicare eligibility, see page 4 of the Summary of Health Benefits.

If you are thinking about making a change, review the information in this packet...

Summary of Health Benefits

Health Plan Highlights

2018 Open Enrollment Meetings Schedule in all five boroughs

2018 Open Enrollment/Change Form

Notice of Creditable Coverage (Does not apply if you or a covered dependent are not yet covered by Medicare.)

Mailed to you separately and/or available online…

Opt-Out Program Brochure

Summary of Benefits and Coverage (SBC) for each medical plan (which will include the prescription drug plan) for which you are eligible as required by the Affordable Care Act (ACA)

Brochures covering plan descriptions and features provided by plan administrators

Dental and Vision information is available through UTU Local 1440 Dates to remember …

Open Enrollment October 15 – November 15

Opt-Out Program November 1 – 30

Flexible Spending Account (FSA) November 1 – December 15

The MTA Business Service Center is available to answer your questions and provide assistance.

MTA Business Service Center 646-376-0123, 8:30 to 5 p.m., Monday-Friday bscservice@mtabsc.org www.mymta.info

Summary of Health Benefits

& Tax-Favored Programs

2018 Open Enrollment

October 15 – November 15, 2017

Active SIRTOA United Transportation Union, Local 1440

& TCU with TWU Local 100 Medical Benefits

MTA Business Service Center

Business Service Center 2

Summary of Health Benefits & Tax-Favored Programs Active SIRTOA United Transportation Union, Local 1440 & TCU

with TWU Local 100 Medical Benefits

CONTENTS

I. INTRODUCTION 3

A) 2018 Open Enrollment Period

B) Sources of Information

II. HEALTH BENEFITS CHOICES 4

A) Choices Grid

B) Electing/Changing Medical–Coverage

C) Opt-Out Program

III. AFFORDABLE CARE ACT & OTHER 6

LEGAL REQUIREMENTS

A) Grandfathered Status

B) Coverage for Children from Age 19 to 26

C) Flexible Spending Account (FSA)

D) Social Security Number Requirement

IV. TAX-FAVORED PROGRAMS 7

A) Flexible Spending Accounts (FSA)

B) MTA Deferred Compensation Program

C) New York’s 529 College Savings Program

D) Premium TransitChek

V. IMPORTANT TELEPHONE NUMBERS & WEBSITES 9

Attachments:

Health Plans Highlights 2018 Open Enrollment Meeting Schedule Notice of Creditable Coverage Open Enrollment Change Form (HR-BEN-372A) Employee or Retiree Affidavit

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I. INTRODUCTION

A) 2018 Open Enrollment Period

Your Open Enrollment Period for Benefit Plan Year 2018 will be from October 15 through November 15, 2017.

During this period MTA Business Service Center (BSC) staff and various plan administrators will be available to explain your benefit plan choices and answer questions at informational meetings held throughout the five boroughs.

See the 2018 Open Enrollment Meeting Schedule enclosed.

B) Sources of Information

My MTA Portal www.mymta.info provides links to provider websites. You can also check and

update your personal information online in the “My Personal Information” tab and view your benefits

and payroll information by clicking on the “My Benefits” and “My Pay” tabs.

The BSC Customer Management Center (CMC) provides assistance if you call 646-376-0123 from 8:30 a.m. to 5 p.m., Monday – Friday, or send an email to bscservice@mtabsc.org.

The 180 Livingston Street Walk-in Center is open 8:30 a.m. to 5 p.m., Monday – Friday.

Important Telephone Numbers and Websites in this packet provides contact information for your benefits providers.

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II. HEALTH BENEFITS CHOICES

A) Choices Grid

Medical/Hospital Prescription Drugs Dental Vision

Aetna CPOS II Basic Option

Express Scripts UTU UTU

Aetna CPOS II High Option (Aetna High Option)*

Express Scripts GHI Preferred Dental UTU

Aetna Select Option For employees who live or work in New York Service area who must seek care from a New York based provider.

Express Scripts UTU UTU

*If you elect to disenroll from the High Option, you will not be able to re-enroll for two years.

Note to employees planning to retire in 2018: If you and/or your covered dependent(s) become Medicare eligible as a result of attaining at least age 65 or being disabled when you retire, Medicare will be your and/or your dependent(s) primary medical coverage. Enrollment in Medicare generally takes about three months, so please contact the Social Security Administration well enough in advance so that as a retiree you and/or your dependent(s) will be enrolled in Medicare Part A (hospitalization) and Medicare Part B (medical). Your medical plan choices at that time will be Aetna Basic Option and Aetna Medicare Advantage Options 1 or 2.

Prescription Drug Plan

Your prescription drug plan is administered by Express Scripts. Your coverage is based on a three-tiered formulary according to the following schedule:

Prescription Drug Retail Mail Order (Mandatory*)

(Up to 30-Day Supply) (Up to 90-Day Supply) Co-payment Co-payment

Generic $0 $0

Formulary Brand $10 $20

Non-Formulary Brand $15 $30

*Mandatory Mail Order means that if you are on a maintenance medication you MUST obtain your medication(s) through Express Scripts Home Delivery Service. Any prescription drug that has been filled two times at a participating pharmacy (original prescription plus one refill) MUST be sent to Express Scripts Home Delivery Service for all additional fills. All initial prescriptions sent to Express Scripts Home Delivery Service must be sent with a new prescription from your physician and should be written for up to a 90-day supply.

Remember, third fills presented at a participating retail pharmacy will be rejected.

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Dental Plan Contact Solstice or Cigna or UTU L1440 except for Aetna CPOS II High Option members, who must contact the BSC or GHI Preferred Dental

Vision Plan Contact Solstice or UTU L1440

Telephone numbers and websites for providers are listed in Section V.

B) Electing/Changing Medical Coverage

The Business Service Center processes all medical benefits enrollments and changes. You need to complete and submit a 2018 Open Enrollment/Change Form (HR-BEN 372A) to the BSC no later than November 15, 2017 to do the following:

Change plans and/or

Add/terminate dependents and/or

Provide a social security number for a covered dependent who is at least age 45, as required by

federal legislation (see Section IIID)

The 2018 Open Enrollment/Change Form HR-BEN-372A is attached.

C) Opt-Out Program (Medical and Prescription Drugs)

You will receive complete information on the Opt-Out Program in a separate mailing from the MTA. Following is a general overview of the opt-out process:

1) If you opted out for 2017 and wish to opt-out for 2018:

DO NOTHING. Your opt-out status will remain in place for 2018.

2) If you opted out for 2017 and wish to re-enroll for medical coverage for 2018:

Submit a 2018 Open Enrollment/Change Form (HR-BEN 372A), no later than the Open Enrollment deadline, November 15, 2017.

3) If you did not opt out for 2017 and wish to opt out for 2018:

Submit an Agreement to Decline (Opt-Out) Medical Coverage Form (HR-BEN-036) no later than the opt-out deadline, November 30, 2017. A lump sum incentive payment will be issued to you by the end of 2018.

Please note that your election to opt-out remains in effect until you change your election

during a future Open Enrollment period or you experience a Qualified Family Status Change.

Information and forms are available on the My MTA Portal at www.mymta.info. You will also receive a brochure in the mail.

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III. AFFORDABLE CARE ACT & OTHER LEGAL REQUIREMENTS

A) Grandfathered Status

NYC Transit’s health plans are “grandfathered health plans” under the Affordable Care Act (ACA). As permitted by the ACA, grandfathered health plans can preserve certain basic health plan benefits that were already in effect when the law was enacted. Grandfathered status also means that our plans may not include certain consumer protections of the ACA that apply to other plans. However, grandfathered health plans must comply with certain other consumer protections in the ACA, for example, the elimination of lifetime limits on benefits.

Questions regarding which protections apply and which protections do not apply to a grandfathered health plan and what might cause a plan to change from grandfathered health plan status can be directed to the BSC by sending an email to bscservice@mtabsc.org or calling the BSC Customer Management Center at 646-376-0123.

B) Coverage for Dependent Children from ages 19 to 26

A dependent child age 19 to 26 is eligible for medical, hospital and prescription drug coverage, regardless of their student or marital status. If you wish to enroll a dependent child age 19 to 26, add the child’s name on the 2018 Open Enrollment/Change Form (HR-BEN-372A), submit the required documentation listed on the back of the form and affirm, by signing the form, that your child is eligible for coverage

C) Social Security Number Requirement

The Medicare, Medicaid, and State Children’s Health Insurance Extension Act of 2007 (MMSEA) requires that MTA New York City Transit report Social Security Numbers to the Federal Centers for Medicare and Medicaid Services (CMS) for all dependents who are at least age 45. You can check to see if a covered dependent’s Social Security Number is missing from your benefits record by signing on to My MTA Portal at www.mymta.info. Log in and then click the “My Benefits” tab to view your benefits information.

If a dependent’s Social Security Number is not shown under SSN (only the last four digits will show), please submit a copy of the dependent’s Social Security Card with your name and BSC ID number noted on the copy, along with the 2018 Open Enrollment/Change Form (HR-BEN-372A) to the BSC.

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IV. TAX-FAVORED PROGRAMS

A) Flexible Spending Accounts (FSA) You may enroll in the FSA Program during the open enrollment period, November 1 – December 15, 2017, by contacting the P&A Group (see Section V).

FSA is a program that allows you to set aside part of your paycheck on a pre-tax basis through automatic payroll deductions for eligible Health Care and Dependent Care expenses. This program allows you to reduce your taxable income thereby reducing your tax liability. Keep in mind that your FSA account cannot be used to pay for the cost of over-the- counter (OTC) medicines (such as ibuprofen and antacids), unless accompanied by a physician’s written approval.

Under provisions of the Affordable Care Act (ACA), the salary reduction contribution made to a Health Care FSA is capped at $2,600 annually. The Dependent Care FSA annual maximum allowance per household is $5,000.

If you enrolled in FSA for 2017, please note that you will not be automatically re- enrolled in FSA for 2018. You must re-enroll by contacting the P&A Group during the FSA enrollment period, November 1 – December 15, 2017.

Examples of Eligible Expenses

Health Care Flexible Spending Account (FSA)

o Medical, dental, vision and prescription drug deductibles and copayments

o Eyeglasses, contact lenses, contact lens supplies, and prescription sunglasses

Dependent Care Flexible Spending Account (FSA)

o Child care costs

o Elder care costs (dependent must meet the definition of a qualifying relative per theIRS, based on a tax year)

o Before- and after-school programs o Summer day camp

B) MTA Deferred Compensation Program You may enroll at any time by contacting Prudential (see Section V).

401(k)/457 Participating in the 401(k) and/or the 457 MTA Deferred Compensation Program may help you achieve a more comfortable and secure financial future. The program helps supplement your existing retirement/pension benefits by allowing you to save and invest before-tax dollars through the convenience of automatic payroll deductions. You are offered diversified investment options, access to local service representatives, financial education services, and planning tools that can help you better prepare for retirement. Contributions and any earnings are tax deferred until money is withdrawn, usually at retirement, when you may be receiving less income and are in a lower income tax bracket.

401(k)/457 Roth In addition to the traditional pre-tax contributions, both the 401(k) Plan and 457 Plan now allow you to make after-tax contributions (also known as Roth contributions). The Roth contribution option combines the savings and investment features of a traditional retirement plan with tax-free distribution features of a Roth IRA.

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While income taxes on pre-tax contribution amounts are deferred until your account is distributed (for example, at retirement), Roth contributions are made on an after-tax basis so the amount contributed is included on your W-2, just like regular income, in the year you make the contribution. However, earnings on Roth contributions may be distributed tax-free in retirement if you meet certain requirements.

C) New York’s 529 College Savings Program You may enroll at any time by contacting the College Savings Program (see Section V).

This program is designed to assist families saving for college. You can elect to contribute to a choice of funds on a post-tax basis through automatic payroll deductions. If you use the money for higher education, earnings will be distributed tax-free.

D) Premium TransitChek You may enroll at any time by contacting the TransitChek Center (see Section V).

This program allows you to set aside money on a pre-tax basis through automatic payroll deductions for commuting expenses for you and your family, up to certain limits established by the IRS. Eligible expenses include using public transportation such as commuter trains, buses, subways, ferries, van- pool services and/or commuter parking for travel to and from work.

Submit Open Enrollment/Change Forms by email, fax, mail, or drop off at Walk-in Center:

Email: bscservice@mtabsc.org Fax: 212-852-8700 Mail: MTA Business Service Center

333 W. 34th Street, 9th Floor New York, NY 10001-2402

Drop off: 180 Livingston Street, Brooklyn, New York, 6th Floor, 8:30 a.m. to 5 p.m., Monday – Friday

Contact the MTA Business Service Center (BSC):

Email: bscservice@mtabsc.org Fax: 212-852-8700 Phone: 646-376-0123 Hours: 8:30 a.m. - 5 p.m., Monday - Friday

Website: www.mymta.info

Please have your BSC ID ready when you contact us and be sure to include your full name and BSC ID on all emails and documents you submit.

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V. IMPORTANT TELEPHONE NUMBERS & WEBSITES

Carrier Telephone Website

Medical/Hospital Options

AETNA Basic/High Option 855-824-5349 www.AetnaNYCT.com

AETNA Select Option 855-824-5349 www.AetnaNYCT.com

Prescription Drug Option

Express Scripts 855-842-9875 www.Express-Scripts.com

TWU Local 100 212 873-6000 www.twulocal100.org/

Dental Options

GHI Preferred Dental 212-501-4444 www.ghi.com

Tax-favored Programs

P&A Group (FSA) 800-688-2611 www.padmin.com

Prudential (401k/457) 877-756-4682 www.prudential.com/mta

College Savings 800-420-8580 www.ny529atwork.com

TransitChek 888-618-2435 www.transitchek.com

COBRA Administrator

P&A Group 800-688-2611 www.padmin.com

Medicare 800-633-4227 www.MyMedicare.gov

Social Security Administration 800-772-1213 www.ssa.gov

AETNA CPOS II

High Option

$13.17 Individual, $26.34 Family

PPO In-Network and Out-of-Network

In- Network Highlights1

$15 copay

$15 copay

$15 copay

$50 deductible, Up to 365 days

$0 copay

$15 copay

$15 copay

$15 copay, 8 visits per year

AETNA

SELECT OPTION

$0

HMO In-Network only

Highlights1

$0 copay

$0 copay

$0 copay

$0 deductible, 365 days

$0 copay

$0 copay

$0 copay

$0 copay, 90 visits per year

SIRTOA UTU Local 1440/TCU/ATDA with TWU Local 100 Health Plan Highlights1

PRESCRIPTION DRUGS

EXPRESS SCRIPTS Retail Up to 30 days supply

Generic $0 copay Name Brand Formulary $10 copay

Name Brand Non-Formulary $15 copay

Mail Order2 Up to 90 days supply Generic $0 copay

Name Brand Formulary $20 copay Name Brand Non-Formulary $30 copay

OPT-OUT PROGRAM Coverage

Opt-out Medical/Hospital/Prescription Drugs

Retain Dental and Vision

Incentive Lump sum at end of plan year

Individual $550

Family $1,100

1-If you are on a maintenance medication that has been filled two times at a retail pharmacy (original prescription plus one refill), mail order is mandatory

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2018 Open Enrollment

MEDICAL AETNA CPOS II

Basic Option

Bi-Weekly Pre-Tax Deductions

$0 Type of plan PPO In-Network and Out-of-Network

In-Network Highlights1

Office Visit $15 copay Specialist Office Visit $15 copay

Diagnostic Service $15 copay Hospital Service $50 deductible, Up to 120 days

Well-Child Care Visits up to

Age 19

$0 copay

Chiropractic $15 copay

Outpatient Mental Health $15 copay Physical Therapy $15 copay, 8 visits per year

SIRTOA TCU/ATDA with TWU Local 100 Health Plan Highlights1 (Continued)

DENTAL Plan A (American Dental Centers)

Plan B (The Dental Shop)

High Option Dental (this is only dental choice for those enrolled in High Option medical plan)

Network Access DMO In-Network only PPO In-Network and Out-of-Network PPO In-Network and Out-of-Network

Highlights In- Network Highlights In- Network Highlights

Deductible $0 $0 $50 per person, per year

Annual Maximum None None $1,200

Orthodontics up to age 19 Up to 20 months Up to 20 months; $1,500 lifetime max $1,500 lifetime max

Oral Examination & Diagnosis Covered in full -- no limitation Covered in full -- two per year Covered in full

X-Rays Covered in full -- no limitation Covered in full -- one series per 3 years

Covered in full

Fluoride Treatment Covered in full -- no limitation Covered in full -- one per year Covered in full

Filling Covered in full Covered in full 80%

Root Canal Covered in full Covered in full 80%

Crowns and Bridges Covered in full Covered in full 50%

VISION UHC

Every 12 months In-Network (General Vision Services GVS) Out-of-Network Maximum Reimbursement

Eye Exam Covered in full $15

Frames Up to $80 See below

Lenses

Single Vision Covered in full $37.44 (includes frames and exam)

Kryptok Bifocal Covered in full $69.12 (includes frames and exam)

Trifocal Covered in full $72.00 (includes frames and exam)

Dependent Coverage When coverage ends Age 19 Age 21 Age 26

MEDICAL/HOSPITAL

Basic/High Option and Select Option N/A N/A End of Month

PRESCRIPTION

Express Scripts N/A N/A End of Month

DENTAL

High Option Dental N/A End of Month N/A

Plan A End of Month N/A N/A

Plan B End of Month N/A N/A

VISION

Vision Plan End of Month N/A N/A

1- UTU L1440 Contact Solstice or Cigna or UTU except for Aetna CPOS II High Option members who must contact the BSC or GHI Preferred Dental

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2018 Open Enrollment

2018 Open Enrollment Meeting Schedule

SEPTEMBER - OCTOBER 2017 Note: This schedule may be expanded to include additional meetings.

Please check the BSC website, My MTA Portal at www.mymta.info, for updated information.

SUNDAY MONDAY TUESDAY WEDNESDAY THURSDAY FRIDAY SATURDAY 24 25

Jackie Gleason Depot 871 5th Ave Brooklyn NY 10 am – 2 pm Manhattanville Depot 666 W 133th Street New York, NY 10 am – 3 pm

26 West 4th St Station New York, NY 12 pm – 3 pm Centralized Electric Shop 33-33 54th Street Woodside, NY 12 pm – 4 pm

27 Grand Avenue Depot 48-05 Grand Ave Maspeth, NY 10 am – 3 pm Yonkers Depot 59 Babcock Place Yonkers, NY 10 am – 3 pm

28 BDFNQ Lines Crew Room Reporting Ctr 2915 Stillwell Ave Brooklyn, NY 10 am – 2 pm Structure & Lighting Southbound Platform, South end of L line 14th St & 6th Ave New York, NY 8 am – 10 am Signal Learning Center West 14th St & 8th Ave New York, NY 12 pm – 3 pm

29 Jamaica Depot (ATU L1056) 165-18 South Rd Jamaica, NY 10 am – 2 pm Castleton Depot (ATU 726) 1390 Castleton Ave Staten Island, NY 10 am – 2 pm

30

1 2 TWU Retiree Meeting 195 Montague Street, 3rd Fl Brooklyn, NY 10 am – 2 pm Jamaica Center – Parson/Archer – E&J Subway Terminal Archer Ave & 153rd Street Jamaica, NY 11am – 4pm

3 Ulmer Park 2449 Harway Ave Brooklyn, NY 10 am – 2 pm West Farms Depot 1100 E 177 St/Devoe Ave Bronx, NY 10 am – 3 pm

4 East 180th St Maintenance Shop 481 Morris Park AVe Bronx, NY 11 am – 3 pm Coney Island Pneumatic Shop 2550 McDonald Av/Z Ent Brooklyn, NY 11 am – 3 pm

5 Kingsbridge Depot, 9th Ave Unit Shop & 240 Street Care Maintenance 4065 10th Ave New York, NY 11 am – 3 pm Charleston Depot (ATU 726) 4700 Arthur Kill Rd Staten Island, NY 10 am – 3 pm

6 207th St Overhaul/Mntce Shop Cafeteria, 2nd Fl 3961 Tenth Ave, New York, NY 10 am – 3 pm

7

2018 Open Enrollment Meeting Schedule

OCTOBER 2017 Note: This schedule may be expanded to include additional meetings.

Please check the BSC website, My MTA Portal at www.mymta.info for updated information.

SUNDAY MONDAY TUESDAY WEDNESDAY THURSDAY FRIDAY SATURDAY 8 9

East NY Maintenance Shop/East NY Depot 1700 Bushwick Ave Brooklyn, NY 11 am – 3 pm Fresh Pond Depot Crew Room, 2nd Fl 66-99 Fresh Pond Ridgewood, NY 10 am – 3 pm

10 ATU 1056 Retiree Meeting New Hyde Park Elks Lodge 901 Lakeville Road New Hyde Park, NY 10:30 am – 2 pm East 180th Structure Maintenance 1151 E. 180th St Bronx, NY 11 am – 3 pm

11 Michael Quill Depot 525 11th Ave New York, NY 10 am – 3 pm JFK Depot 165-25 147th Ave Jamaica, NY 10 am – 2 pm

12 Corona Maintenance Facility Lunch Room, 3rd Fl 126-53 Willets Pt Blvd Flushing, NY 9am – 1pm Staten Island Railroad 845 Bay Street Staten Island, NY 10:30 am – 2:30 pm

13 LaGuardia Depot 85 - 01 24th Ave East Elmhurst, NY 10 am – 3 pm Yukon Depot (ATU L726) 40 Yukon Ave Staten Island, NY 10 am – 3 pm

14

15 16

17 Flatbush Depot 4901 Fillmore Ave Brooklyn, NY 10 am – 3 pm Queens Village Depot (ATU L1056) 97-11 222nd St Queens Village, NY 10 am – 3 pm

18 Tiffany Shop 1170 Oakpoint Avenue Bronx, NY 10474 9 am –3 pm R & M Lines Queens 71st Street Continental Ave (Crew Room) Queens, NY 11 am – 3 pm TWU Active Meeting 195 Montague Street, 3rd Fl Brooklyn, NY 10 am – 12 pm 2 pm – 4 pm

19 Tuskegee 100th St Depot 1552 Lexington Ave New York, NY 11 am – 3 pm College Point Depot 128 - 15 28th Ave Flushing, NY 10 am – 3 pm

20 Gun Hill Depot 1910 Bartow Ave Swing Room Bronx, NY 10 am – 2 pm Maintenance Shop at Jackie Gleason Depot 871 5th Ave Brooklyn, NY 10 am – 2 pm ATU 726 Retiree Meeting 3948 Amboy Road Staten Island, NY 10 am – 2 pm

21

(continued)

2018 Open Enrollment Meeting Schedule OCTOBER - NOVEMBER 2017

SUNDAY MONDAY TUESDAY WEDNESDAY THURSDAY FRIDAY SATURDAY 22 23

Casey Stengel Depot (ATU L1056) 123-53 Willets Point Blvd Corona, NY 10 am – 2 pm Meredith Depot (ATU L726) 336 Meredith Ave Staten Island, NY 10 am – 2 pm

24 Coney Island Overhaul Shop 2556 McDonald Av/Z Ent Brooklyn, NY 12:30 pm – 4:30 pm

25 Baisley Park Depot 114-15 Guy Brewer Blvd Jamaica, NY 11 am – 3 pm Eastchester Depot 3320 Hutcherson Ave Interstate 95, Exit 13 Bronx, NY 10 am – 3 pm

26 Plant & Equipment 1745 Bathgate Avenue Bronx, NY 10457 10 am – 2 pm Far Rockaway MTA Bus Depot 4919 Rockaway Beach Blvd Far Rockaway, NY 11691 10 am – 2 pm

27 Conway St Maintenance 40 Conway Street Brooklyn, NY 8 am – 12 pm Mother Clara Hale Depot 721 Lenox Avenue (146th – 147th Streets) New York, NY 12 pm –4 pm

28

29 30 Zerega CMF Complex Cafeteria 750 Zerega Ave Bronx, NY 10 am – 3 pm

31 Pitkin Maintenance Shop 1434 Sutter Avenue Brooklyn, NY 11 am – 3 pm Spring Creek Depot 12755 Flatlands Ave Brooklyn, NY 11 am – 2 pm

1 Cozine Iron Shop 50 Cozine St Brooklyn, NY 8 am – 11 am 38th Street Yard Lunchroom, 2nd Fl 3801 9th Ave Brooklyn, NY 10 am – 2 pm

2 240th Street Car Maintenance (Lunch Room) 5911 Broadway Bronx, NY 10 am – 2 pm

3 2 Broadway 4th Floor, Room D4.00A New York, NY 12 pm – 4 pm

4

(continued)

2018 Open Enrollment Meeting Schedule

NOVEMBER 2017 SUNDAY MONDAY TUESDAY WEDNESDAY THURSDAY FRIDAY SATURDAY

5 6

7 E 239th St Maintenance Shop Crew Room Reporting Ctr Bronx, NY 10 am – 2 pm Staten Island Rail 331 Bay Street Staten Island, NY 11 am – 3 pm

8 Jamaica Maintenance Shop 7888 Park Drive East Kew Gardens, NY 11 am – 4 pm

9

10

11

12 13 ATU 726 Retiree Meeting 3948 Amboy Road Staten Island, NY 10308 10 am – 2 pm

14 15 180 Livingston Street, Room 6008 Brooklyn, NY 8:30 am – 5:00 pm

16 17 18

OMB 0938-0990

CMS Form 10182-CC Updated August 2011

If you or your family members aren’t currently covered by Medicare and won’t be covered

by Medicare in the next year, this notice does not apply to you.

Important Notice from New York City Transit (NYCT) About

Your Prescription Drug Coverage and Medicare

Please read this notice carefully and keep it where you can find it. This notice has information about your current prescription drug coverage with New York City Transit and about your options under Medicare’s prescription drug coverage. This information can help you decide whether or not you want to join a Medicare drug plan. If you are considering joining, you should compare your current coverage, including which drugs are covered at what cost, with the coverage and costs of the plans offering Medicare prescription drug coverage in your area. Information about where you can get help to make decisions about your prescription drug coverage is at the end of this notice. There are two important things you need to know about your current coverage and Medicare’s prescription drug coverage: 1. Medicare prescription drug coverage became available in 2006 to everyone with Medicare. You can get this coverage if you join a Medicare Prescription Drug Plan or join a Medicare Advantage Plan (like an HMO or PPO) that offers prescription drug coverage. All Medicare drug plans provide at least a standard level of coverage set by Medicare. Some plans may also offer more coverage for a higher monthly premium. 2. NYCT has determined that the prescription drug coverage we offer is, on average for all plan participants, expected to pay out as much as standard Medicare prescription drug coverage pays and is therefore considered Creditable Coverage. Because your existing coverage is Creditable Coverage, you can keep this coverage and not pay a higher premium (a penalty) if you later decide to join a Medicare drug plan.

When Can You Join A Medicare Drug Plan? You can join a Medicare drug plan when you first become eligible for Medicare and each year thereafter during the open enrollment period. For 2018, the open enrollment period will be from October 15th through November 15th 2017. According to the Paperwork Reduction Act of 1995, no persons are required to respond to a collection of information unless it displays a valid OMB control number. The valid OMB control number for this information collection is 0938-0990. The time required to complete this information collection is estimated to average 8 hours per response initially, including the time to review instructions, search existing data resources, gather the data needed, and complete and review the information collection. If you have comments concerning the accuracy of the time estimate(s) or suggestions for improving this form, please write to: CMS, 7500 Security Boulevard, Attn: PRA Reports Clearance Officer, Mail Stop C4-26-05, Baltimore, Maryland 21244-1850.

OMB 0938-0990

CMS Form 10182-CC Updated August 2011

However, if you lose your current creditable prescription drug coverage, through no fault of your own, you will also be eligible for a two (2) month Special Enrollment Period (SEP) to join a Medicare drug plan.

What Happens To Your Current Coverage If You Decide to Join A Medicare Drug Plan? If you decide to join a Medicare drug plan, you will still be eligible to receive retiree medical and prescription coverage. However, NYCT’s plan will pay secondary to Medicare.

When Will You Pay A Higher Premium (Penalty) To Join A Medicare Drug Plan? You should also know that if you drop or lose your current coverage with NYCT and don’t join a Medicare drug plan within 63 continuous days after your current coverage ends, you may pay a higher premium (a penalty) to join a Medicare drug plan later. If you go 63 continuous days or longer without creditable prescription drug coverage, your monthly premium may go up by at least 1% of the Medicare base beneficiary premium per month for every month that you did not have that coverage. For example, if you go nineteen months without creditable coverage, your premium may consistently be at least 19% higher than the Medicare base beneficiary premium. You may have to pay this higher premium (a penalty) as long as you have Medicare prescription drug coverage. In addition, you may have to wait until the following October to join.

For More Information about This Notice or Your Current Prescription Drug Coverage… Contact information is provided below if you need further information. NOTE: You will get this notice each year. You will also get it before the next period you can join a Medicare drug plan, and if this coverage through NYCT changes. You also may request a copy of this notice at any time.

MTA Business Service Center: Call: 646-376-0123 (8:30 a.m. – 5:00 p.m., Monday through Friday) Fax: 212-852-8700 Email: bscservice@mtabsc.org

OMB 0938-0990

CMS Form 10182-CC Updated August 2011

For More Information about Your Options Under Medicare Prescription Drug Coverage… More detailed information about Medicare plans that offer prescription drug coverage is in the “Medicare & You” handbook. You’ll get a copy of the handbook in the mail every year from Medicare. You may also be contacted directly by Medicare drug plans. For more information about Medicare prescription drug coverage: • Visit www.medicare.gov. • Call your State Health Insurance Assistance Program (see the inside back cover of your copy of the “Medicare & You” handbook for their telephone number) for personalized help. • Call 1-800-MEDICARE (1-800-633-4227). TTY users should call 1-877-486-2048. If you have limited income and resources, extra help paying for Medicare prescription drug coverage is available. For information about this extra help, visit Social Security on the web at www.socialsecurity.gov or call them at 1-800-772-1213 (TTY 1-800-325-0778). Remember: Keep this Creditable Coverage notice. If you decide to join one of the Medicare drug plans, you may be required to provide a copy of this notice when you join to show whether or not you have maintained creditable coverage and, therefore, whether or not you are required to pay a higher premium (a penalty).

EMPLOYEE OR RETIREE AFFIDAVIT

STATE OF

COUNTY OF

NAME [ ] being duly sworn, deposes and says: 1. I am an employee of or have retired from [circle appropriate description]

New York City Transit Authority or MaBSTOA or SIRTOA or MTA BUS Co.

2. I make this affidavit based on personal knowledge and under penalties of perjury.

3. My spouse [PRINT SPOUSE’S NAME],

is covered by

my health insurance plan and is currently eligible to receive health benefits as a dependent on my

plan.

4. I am unable to provide a copy of the top half of the front page of my most recent federal tax return

that includes my spouse (with financial information blacked out); and the E-File confirmation page,

Tax Preparer’s Summary, or the Federal Return Recap; nor can I provide any of the following

alternate documentation of joint ownership, dated no earlier than twelve (12) months prior to my

application for coverage for my spouse:

Joint checking or savings account

Mortgage payment or lease agreement

Homeowner’s insurance bill

Property tax bill (home or auto)

Car payment or insurance bill

Credit card bill

Loan payment

Electric, gas, water, trash or sewer bill

Cable, satellite, phone or internet bill

My will designating my spouse as primary beneficiary (or my spouse’s will,

designating me as primary beneficiary)

My employment/retirement plan designating my spouse as primary beneficiary (or my spouse’s

employment retirement plan designating me as primary beneficiary)

Any other acceptable documentation demonstrating current joint ownership.

Despite my inability to produce any of the necessary documentation, I hereby affirm, under penalties of

perjury, that my spouse and I are currently married and that we are not legally separated or divorced.

PRINT EMPLOYEE OR RETIREE NAME

Sworn to before me this

day of 20 Date Month Year

SIGNATURE OF EMPLOYEE OR RETIREE

NOTARY PUBLIC 13333090

EMPLOYEE OR RETIREE AFFIDAVIT

STATE OF

COUNTY OF

NAME [ ] being duly sworn, deposes and says: 1. I am an employee of or have retired from [circle appropriate description]

New York City Transit Authority or MaBSTOA or SIRTOA or MTA BUS Co.

2. I make this affidavit based on personal knowledge and under penalties of perjury.

3. My spouse [PRINT SPOUSE’S NAME],

is covered by

my health insurance plan and is currently eligible to receive health benefits as a dependent on my

plan.

4. I am unable to provide a copy of the top half of the front page of my most recent federal tax return

that includes my spouse (with financial information blacked out); and the E-File confirmation page,

Tax Preparer’s Summary, or the Federal Return Recap; nor can I provide any of the following

alternate documentation of joint ownership, dated no earlier than twelve (12) months prior to my

application for coverage for my spouse:

Joint checking or savings account

Mortgage payment or lease agreement

Homeowner’s insurance bill

Property tax bill (home or auto)

Car payment or insurance bill

Credit card bill

Loan payment

Electric, gas, water, trash or sewer bill

Cable, satellite, phone or internet bill

My will designating my spouse as primary beneficiary (or my spouse’s will,

designating me as primary beneficiary)

My employment/retirement plan designating my spouse as primary beneficiary (or my spouse’s

employment retirement plan designating me as primary beneficiary)

Any other acceptable documentation demonstrating current joint ownership.

Despite my inability to produce any of the necessary documentation, I hereby affirm, under penalties of

perjury, that my spouse and I are currently married and that we are not legally separated or divorced.

PRINT EMPLOYEE OR RETIREE NAME

Sworn to before me this

day of 20 Date Month Year

SIGNATURE OF EMPLOYEE OR RETIREE

NOTARY PUBLIC 13333090

2018 Open Enrollment/Change Form For NYCTA/MaBSTOA/MTA Bus/SIRTOA Actives Except ATU 726 HR-BEN-372A

Section 1 - Information and Instructions

The purpose of this form is to enroll in or change health insurance, effective January 1, 2018.

Please email a signed copy of the form to bscservice@mtabsc.org or fax to 212-852-8700 or drop off at the 180 Livingston Street Walk-in

Center 8:30 a.m. to 5 p.m., Monday – Friday. If you have any questions, please contact the Business Service Center (BSC) at 646-376-0123.

Section 2 - Employee Information

Print Name

Last First M.I. Suffix

BSC ID

Pass #

Phone (H) Phone (W) Email

If your address on your pay stub is incorrect, contact the Business Service Center OR log onto www.mymta.info and change your address

online OR complete HR-HRIS-012 Employee Data Change Form. An incorrect address will delay receipt of your new health insurance cards.

Section 3 – Coverage Election – Effective January 1, 2018

Medical Individual Family

Check One:

AETNA CPOS II BASIC OPTION

AETNA CPOS II HIGH OPTION

(Bi-weekly pre-tax required contribution of $13.17 for Individual Coverage and $26.34 for Family Coverage)

AETNA SELECT OPTION (Live/work in the New York Service area)

OPT-OUT PROGRAM (for Medical/Hospital/Prescription Drugs)

I agree to the Terms and Conditions of the Opt-Out Program on the back of this form. Alternate medical information must be provided below.

Name of Policyholder: Relationship _______________________

Policy #: SS# of Policyholder: _______________________

Name of Insurance Carrier: _ Date of Birth of Policyholder: _______________________

Employer of Policyholder: _______________________________

Section 4 – Dependent Information Changes

If you are found to be covering an ineligible dependent, coverage will be terminated retroactive to the date of the ineligibility and NYC Transit will pursue financial restitution for claims and/or premiums for the ineligible dependent.

ADD/DELETE DEPENDENT(S)

Please fill in all information for dependents you wish to add/delete and submit required documentation (see Section 6). Documentation must be received by the BSC within 90 days from the effective date of coverage. Failure to submit documentation will result in termination of your dependent’s coverage. DOMESTIC PARTNER Please contact the Business Service Center for the Domestic Partnership Package if you wish to enroll a domestic partner. Your domestic partner will not be enrolled in health coverage unless an application is submitted and approved by the Benefits Department.

Check One - Indicate (A) Add or (D) Delete Check One - Relationship Gender Date of Birth

A D Name SSN Spouse Domestic Partner Child F M Mo Day Year

Section 5 - Authorization

My signature and date on this form certifies and warrants that all dependent eligibility information is true, correct, and current. I also certify that dependent children from age 19 to 26 that I have enrolled in coverage are eligible for coverage.

Employee Signature

Date / / 2017

Business Service Center Last Revised: 09/07/2017

2018 Open Enrollment/Change Form For NYCTA/MaBSTOA/MTA Bus/SIRTOA Actives Except ATU 726 HR-BEN-372A

Section 6 – Dependent Required Documentation

1. Spouse A copy of Marriage Certificate, Birth Certificate, Social Security card, and, if your date of marriage is more than one year old:

Your most recent Tax Return—Federal or State (including Puerto Rico Returns)

Your most recent tax return showing “Married Filing Jointly” or “Married Filing Separately”. Your spouse’s name must appear on the tax form on the line provided after the “married filing separately” status (or vice versa).

Only submit page 1 of the tax return. This should include the 1040 form, eFile Confirmation page, Tax Preparer’s Summary, or Federal Return recap.

Eliminate all financial information. .

OR Proof of Joint Ownership

Both the enrollee’s and spouse’s name must be listed on the documentation of joint ownership and be dated within the past 90 days. Examples include a copy of:

Homeowners/Renters Insurance Policy Mortgage Statement

Credit Card Statement Property Tax Document

Loan Obligation Rental/Lease Agreement

Bank Account Statement Utility/phone/internet/cable bills

Pension/life insurance/will designating spouse as beneficiary If you are not able to provide the required documentation, please complete the Employee or Retiree Affidavit, have it notarized

and return it with your Enrollment form.

2. Children

For a Natural-Born Child, a copy of: For a Stepchild, or Legally Adopted Child, a copy of:

Birth Certificate showing employee’s name Birth Certificate

Social Security card Social Security card

Legal documentation concerning adoption

3. Dependent Children Coverage between ages 19 and 26

To enroll a dependent child from age 19 to 26 in your medical, hospital, and prescription drug coverage, add the child’s name on this form, submit required documentation, and affirm by signing this form that your child is eligible for coverage.

Those who enroll in the High Option are not required to submit student verification from age 19 to 21 to cover dependent

children in dental coverage.

**If you did not choose AETNA CPOS II HIGH OPTION, please direct questions about dental and vision coverage to your union.

Section 7 – Opt-Out Program Terms and conditions Incentive for Opt-Out

You may opt out of medical coverage and receive a lump sum incentive payment. Opting out of medical coverage means that you

elect not to participate in medical, hospital, and prescription drug coverage. You will however retain coverage in dental and vision plans. To

be eligible, you must document that you will be covered by another medical plan sponsored by:

a spouse or domestic partner’s employer

another employer

armed forces

Lump Sum Incentive Payment

Payment of the lump sum incentive will be made at the end of the Opt-Out year in the following amount:

$550 for an employee who receives medical coverage through spouse/domestic partner who is also

employed by NYC Transit or another MTA agency

$550 if you opt-out of individual medical coverage

$1,100 if you opt-out of family medical coverage

If you participate in the Opt-Out Program and either re-enroll or retire during that same year, you will not be eligible to receive any part of the

incentive payment.

Terms of Agreement

I understand that this election will be effective from January 1 through December 31, 2018, unless I am no longer allowed by law or as a result

of a qualifying event or such other events as the Authority determines will permit a change or revocation of an election.

I understand that the lump sum payment will be subject to all applicable Federal, State and Local taxes. I also understand that these monies will

not be considered income for pension purposes and will not be included in any calculation therein.

This agreement is subject to the terms of the employer's plan, as amended from time to time in effect, shall be governed by and

construed in accordance with applicable laws, shall take effect as a sealed instrument under applicable laws and revokes any prior election

and compensation agreement relating to such plan. The health benefits waiver will be administered as permissible under IRS section 125.