Frequently Asked Questions

General FAQs
• Do I need to have a company in order to obtain health insurance or other benefit programs from Benefit Specialists of NY? | answer
• What size companies are eligible? | answer
• What are monthly premiums? | answer
• I am a sole proprietor. Can I still get health insurance? | answer
• What is considered an emergency? | answer
• What do I do when an emergency occurs? | answer
• What if I’m admitted? | answer
• When can I use an Urgent Care facility? | answer
• Am I covered when traveling? | answer
• What if I need to add or drop someone from my policy? | answer
• What is an Rx Formulary? | answer
• Why are formularies necessary? | answer
• What is an open, closed formulary? | answer
• What does Mandatory Generic mean? | answer
• Are there participation requirements? | answer
• Does Benefit Specialists of NY offer health insurance programs other than MultipleChoice? | answer
• What is a qualifying event? | answer
• How does COBRA work? | answer

Cafeteria Plans FAQs
• Since participants do not pay Social Security taxes on the money put into these accounts, will their Social Security benefits be lower when they receive them? | answer
• Do employees have to include any special reporting on their tax return (1040 Form) about their contributions to the Flexible Benefit Plan? | answer
• What happens if a participant has a claim at the end of the Plan year and does not get it in by the last day of the Plan year? | answer
• Can a participant use a Medical FSA to pay for a spouse’s and/or dependent’s deductibles and co-payments? | answer
• Are day care center expenses eligible for reimbursement from a Dependent Care FSA? | answer
• What happens if a participant submits a claim and his/her Dependent Care FSA balance is less than the amount of the claim? | answer
• Are day care expenses for before-school and after-school care eligible under the Dependent Care FSA? | answer
• Can day care services be provided by a relative? | answer
• Once an election is made, can the participant change his/her Flexible Spending Account election during the year? | answer
• What kind of supporting documents need to be submitted with the claim form? | answer
• If a participant has pre-paid for a medical or dependent care service, can they be reimbursed immediately? | answer
• Can money in a Medical FSA be used for Dependent Care expenses and vice versa? | answer
• What happens to account balances if participants do not use all the money deposited for the current Plan Year? | answer
• What is your reimbursement schedule for calendar year 2003? | answer
• Where can I go for more information? | answer

General FAQs

Q: Do I need to have a company in order to obtain health insurance or other benefit programs from Benefit Specialists of NY?
A: Yes. You need to be a sole proprietor, partnership or corporation in order to be eligible. We do not provide “individual” coverage, only “group” coverage.

Q: What size companies are eligible?
A: The size of the group can be as little as one or as large as 5000 employees.

Q: What are monthly premiums?
A: Monthly premiums can vary by carrier, plan type, employer size and other factors. Contact us by phone at 315-470-1930 or by email for more information.

Q: I am a sole proprietor. Can I still get health insurance?
A: Yes. We have several choices available from our wide selection.

Q: What is considered an emergency?
A: An emergency is a life-threatening situation such as profuse bleeding, extreme abdominal pain, choking, difficulty breathing, chest pain, unconsciousness and broken limbs, etc.

Q: What do I do when an emergency occurs?
A: Immediately go to the nearest hospital. HMO members are required to contact their Primary Care Physician within 24-48 hours of their ER visit. Co-pays apply for each ER visit.

Q: What if I’m admitted?
A: If admitted, there is no cost to the member for the ER visit. Co-pays may then apply for the inpatient admission. BC/BS members (indemnity) are required to notify BC/BS within 48 hours of their admission or you are subject to a $500 penalty.

Q: When can I use an Urgent Care facility?
A: Use Urgent Care facilities on non-life threatening situations after contacting your Primary Care Physician for a referral.

Q: Am I covered when traveling?
A: With all carriers, there is worldwide coverage for life threatening situations. With BC/BS (indemnity members), non-emergency situations are covered the same as they would be locally. With HMOs/Point of Service plans, non-emergency situations require the prior approval of your Primary Care Physician.

Q: What if I need to add or drop someone from my policy?
A: If you are adding a spouse due to marriage or a new baby to your policy, it is required that it be done within 30 days of the event. If you are removing a spouse or dependent it should be submitted prior to the date it takes effect. Other qualifying events may apply.

Q: What is an Rx Formulary?
A: A formulary is a list of preferred drugs. The list is typically developed by doctors and pharmacists compiled by the carriers.

Q: Why are formularies necessary?
A: Carriers have established formularies to control the rapidly escalating cost of prescription drugs. Most drugs are members of a class with similar “biological or therapeutic” effects and therefore makes no difference which drug a person takes. More than likely the lower cost drug will be on the formulary.

Q: What is an open, closed formulary?
A: A closed formulary won’t pay for drugs not on the list unless your doctor wins a medical appeal. An open formulary allows drugs not on the list, but will generally charge a higher co-pay for that drug.

Q: What does Mandatory Generic mean?
A: Mandatory generic means that if a generic version of a brand name drug is available, you must use the generic version. If you still want to use the brand name drug, you will pay the entire difference in cost between the generic and brand name drug, plus any co-pay.

Q: Are there participation requirements?
A: Maybe. Some plans/carriers require 50% or 75% participation. For our exclusive MultipleChoice product offering we require 75% participation of eligible employees.

Q: Does Benefit Specialists of NY offer health insurance programs other than MultipleChoice?
A: Yes. MultipleChoice is one product within our total offerings. We also offer customized plans to our clients when MultipleChoice is not preferred or an option. These customized plans come from a wide range of carriers.

Q: What is a qualifying event?
A: A qualifying event is an event that occurs outside the open enrollment period that would allow an employee to make a change in coverage. Examples would be:

• marriage
• divorce
• birth of a child
• spouse’s loss of coverage
  

An employee has 30 days from the date of the qualifying event to contact his or her employer, so that the employer can forward the necessary paperwork to process the change to Benefit Specialists of NY.

Q: How does COBRA work?
A: All New York State employers with three or more employees are required to offer their employees continuation of coverage through COBRA (Consolidated Omnibus Budget Reconciliation Act).

Once employees or their dependents become ineligible for coverage through their employer, they would become eligible to elect COBRA coverage. The employer would be responsible for notifying the employees of their option to elect COBRA and provide the employees with COBRA’s monthly premium information.

The eligible employees or dependents would have 60 days from the date of notification to fill out the appropriate paperwork and pay the first month’s premium. Once this occurs, their coverage will be reinstated without a lapse in coverage.

Employees eligible for COBRA may continue their coverage typically for 18 months. Dependents coming off of an employee’s policy are eligible for COBRA for 36 months. Once members are no longer eligible for COBRA, then they would have the option of enrolling in a Direct Bill policy.

Cafeteria Plans FAQs

Q: Since participants do not pay Social Security taxes on the money put into these accounts, will their Social Security benefits be lower when they receive them?
A: If they contribute over a long period of time, their contributions to Flexible Spending Accounts will reduce their Social Security benefit by a minimal amount.

Q: Do employees have to include any special reporting on their tax return (1040 Form) about their contributions to the Flexible Benefit Plan?
A: An employee who elects a Dependent Care FSA needs to attach a Child and Dependent Care Expenses form to his/her tax return (form 2441 for a 1040 return; Schedule A for a 1040A return). Box 10 on the employee’s W-2 form should indicate the total annual amount of Dependent Care FSA deductions. The participant should contact a tax preparer for more details.

Information about a Medical FSA does not need to be reported for income tax purposes. The total earnings reported on the W-2 from will exclude any pre-tax payroll deductions.

Q: What happens if a participant has a claim at the end of the Plan year and does not get it in by the last day of the Plan year?
A: Participants will have a grace period after the end of the Plan Year (90 days) to file claims for eligible expenses that have been incurred during the Plan Year.

Q: Can a participant use a Medical FSA to pay for a spouse’s and/or dependent’s deductibles and co-payments?
A: Yes. However, this account cannot be used to pay for a spouse’s insurance premiums or premium contributions.

Q: Are day care center expenses eligible for reimbursement from a Dependent Care FSA?
A: Day care expenses are eligible whether provided by an individual or by an established day care center. If the provider is a day care center which regularly provides care for more than 6 people, the center must comply with state and local laws and regulations.

Q: What happens if a participant submits a claim and his/her Dependent Care FSA balance is less than the amount of the claim?
A: The claim will be paid up to the amount available in the account. The participant will be reimbursed for the rest of the claim once the money is deposited in the account.

Q: Are day care expenses for before-school and after-school care eligible under the Dependent Care FSA?
A: Yes, for children under age 13.

Q: Can day care services be provided by a relative?
A: Yes, as long as the relative is not the participant’s child under 19 years of age and is not someone who can be claimed on the participant’s (or spouse’s) federal tax return as a dependent.

Q: Once an election is made, can the participant change his/her Flexible Spending Account election during the year?
A: An election, once made, is irrevocable for that Plan Year. New elections are made prior to beginning of each subsequent Plan Year. However, certain situations, known as changes in status, can arise during the plan year which allow the participant to change an election. These situations include:

• Marriage of the participant.
• Divorce of the participant.
• Death of a spouse or child of the participant.
• Birth or adoption of child (pregnancy does not constitute a change in family status).
• Termination of a spouse’s employment
• Employment of the spouse.
• Changing from part-time to full-time employment by participant or spouse.
  

Q: What kind of supporting documents need to be submitted with the claim form?
A: A statement from the provider and/or explanation of benefits (EOB) from the insurance carrier which shows the name of the provider, type of service provided, who the service was for, the date the service was provided and the amount of the service. Canceled checks are not acceptable as sufficient supporting documentation. Cash register receipts are not acceptable except when submitting claims for over-the-counter contact lens supplies.

Q: If a participant has pre-paid for a medical or dependent care service, can they be reimbursed immediately?
A: No. A participant can only be reimbursed for a medical or dependent care service after that service has been performed. A participant does not need to pay for a service before being reimbursed for it through a Flexible Spending Account.

Q: Can money in a Medical FSA be used for Dependent Care expenses and vice versa?
A: No. Money directed to one type of account can be used only for expenses relating to that account. This is true even if all the money in one account is not used and the other account runs short.

Q: What happens to account balances if participants do not use all the money deposited for the current Plan Year?
A: Participants will forfeit any money left in the account after they have submitted claims for the entire year. Reminders are sent to the employee to minimize this risk.

Q: What is your reimbursement schedule for calendar year 2003?
A: Reimbursement checks for the 2003 Plan Year will be cut on Friday each week, unless a different schedule has been selected by your employer.

Q:Where can I go for more information?
A: Go to EZFlexPlan for detailed information, forms and personal account information.