Nyperl Form Ebd 542 1 – Fill Out and Use This PDF

New York State Public Employee and Retiree Long Term Care Insurance Plan (NYPERL)

EMPLOYEE NOTICE AND FACT SHEET

With Instructions on Enrolling

EMPLOYING AGENCY SECTION

Employee Name					Date of Birth
		Agency
Date of Hire or		Name &				Salary
Date First Eligible		Agency Code				Grade
Agency Contact				Agency Contact
Name				Phone#

OPEN ENROLLMENT EXPIRATION DATE

(60 CALENDAR DAYS After Date Employee is Hired or First Eligible for Guarantee Issue)

EMPLOYEE SECTION

I have been offered an opportunity to enroll in the NYS Public Employee and Retiree Long Term Care Insurance Plan (NYPERL), and have received a NYPERL fact sheet and instructions on how to receive additional information to enroll in NYPERL.

I understand that I have 60 days from the date I became first eligible for guarantee issue to enroll in NYPERL without having to produce evidence of insurability such as a health statement, an interview, or a physical exam.

I understand that if I decide to apply to participate in NYPERL after the 60-day period has passed, then I will be required to produce evidence of insurability, to be determined by the Insurer at that time.

I understand that I am responsible for contacting the Insurer to obtain additional information and an application to enroll in NYPERL if I decide to enroll in the Plan, and that I am responsible for the completion and submission of the application to the Insurer.

Employee Signature

Date

Employee SSN

Personal Privacy Protection Law Notification The information you provide on this document is being requested in accordance with Article 11-A of the Civil Service Law for the principal purpose of notifying employees of their 60-day open enrollment opportunity for the New York State Public Employee and Retiree Long Term Care Insurance Plan (NYPERL). The information will be used in accordance with Public Officers Law section 96 (1) also known as the Personal Privacy Protection Law. Failure to provide the information requested may interfere with your employer's ability to ensure the proper administration of NYPERL. This information will be maintained by your employer and by MedAmerica Insurance Company of New York, 165 Court Street, Rochester, New York 14647. For information concerning the Personal Privacy Protection Law, call (518) 457-9375. If you have any questions regarding this form, please call your employer’s Personnel Office.

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New York State Public Employee Long Term Care Insurance Plan (NYPERL)

EMPLOYEE NOTICE AND FACT SHEET

With Instructions on Enrolling

NYPERL is your employer's voluntary, employee-pay-all group long-term care insurance plan.

Long-term care is assistance you need if you are unable to carry out the basic activities of everyday living—bathing, continence, dressing, toileting, eating, or transferring, such as from a chair or bed. The need could arise from an accident or a debilitating illness. Or it could simply be the natural result of aging.

Only a small portion of the long-term care services you are likely to need are covered by health insurance or Medicare and long term care is expensive. According to a NYS Partnership study conducted in 2004, the average nursing facility cost in New York State is $95,937 per year.

NYPERL is designed to provide financial protection against the costs associated with long-term care covered services provided by a(n): nursing facility; home health care agency; adult day care center; or assisted living facility.

Premiums are based upon your age when you apply and the benefits you select. The younger you are when you apply, the lower the premium. As in any long term care insurance product, premiums may change, but only if the insurer changes the premium rates for all persons in the same premium payment class, regardless of where you reside at the time of the premium change.

NYPERL is administered and insured by MedAmerica Insurance Company of New York (Home Office: Rochester,

NY) and MedAmerica Insurance Company (Home Office: Pittsburgh, PA) headquartered in Rochester.

You should not buy long term care insurance if the only way you can afford to pay for it is by not paying other important bills. Look closely at your needs and resources, and discuss it with a family member to decide if long-term care insurance is right for you.

INSTRUCTIONS ON ENROLLING

An enrollment kit and more NYPERL information may be obtained by calling MedAmerica’s NYPERL Customer Service toll free number, 1-866-474-LTCI (5824), or by visiting the NYPERL website at www.NYPERL.net. Once you have reviewed the materials in the enrollment kit or the information on the website, Customer Service staff can walk you through the enrollment form and answer any questions you might have.

NYPERL applications are found in the Enrollment Booklet in the enrollment kit or are available on the NYPERL website. Submit your completed application to MedAmerica, not to your employer.

If an eligible employee is actively at work and applies for NYPERL during the 60 day open enrollment period, a health statement, health interview, physical exam or other evidence of insurability is not required. If you are an eligible employee applying under open enrollment, use Enrollment Form 1 found in the Enrollment Booklet of the enrollment kit.

If you are applying after the expiration of open enrollment or if an eligible family member is applying, use Enrollment Form 2 found in the Enrollment Booklet of the enrollment kit. This enrollment form contains a health statement that you must complete with the application.

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