Niagara Wheatfield Central School District

Achieving Excellence

Important Links

Health Insurance/Flex Information and Forms

Listed below are forms and/or information that may answer questions

you may have regarding your health insurance policy.

If you have questions that cannot be answered from the attached forms, please contact Maureen Mack at (716)215-3028 or mmack@nwcsd.org

CHILDREN'S HEALTH INSURANCE PROGRAM (CHIP):

CHIP Info

AFFORDABLE CARE ACT - SBC (Summary of Benefits and Coverage):

PLAN SUMMARIES:

POS 0011 (All other groups):

POS Summary 0011

Traditional OT61 (Teachers only):

Traditional OT61

POS 0002 (Admin only):

POS Summary 0002

BCBS EyeMed Vision Summary - Basic & Enhanced (Applies to POS Plans ONLY):

Vision Summary - Basic & Enhanced

Delta Dental Plan Summary (ALL groups): Cannot be cancelled mid-year

Dental Plan Summary

CONFIDENTIAL FORMS:

125 Flex Enrollment Form 2013-14:

2013-14 Flex Enrollment Form

TEACHER FORMS:

105h Health Reimbursement Enrollment Form 2012-13:

105H Enrollment Form 2012-13

Flex-HRA Claim Form - Universal Claim Form for

Flex 125, 105h and Self-Insured Plans:

Universal Claim Form

Flex Enrollment Form 2013-14:

2013-14 Flex Enrollment Form

For Teacher Health Insurance Waiver Form,

please contact Barbara LaDuca in Human Resources

SCHOOL RELATED PERSONNEL FORMS:

Flex Enrollment Form 2013-14:

2013-14 Flex Enrollment Form

Flex Claim Form:

Flex Claim Form

For SRP Health Insurance Waiver Form,

please contact Barbara LaDuca in Human Resources

ADMINISTRATOR FORMS:

Flex Enrollment Form 2013-14:

2013-14 Flex Enrollment Form

HRA Flex Claim Form:

HRA Flex Claim Form

For Administrator Health Insurance Waiver Form,

please contact Barbara LaDuca in Human Resources

TEACHERS, SRP, CONFIDENTIAL and ADMINISTRATORS:

Flex Plan Direct Deposit Authorization Form:

Flex Direct Deposit Authorization Form

If you need to cancel your health insurance plan with the district,

please use the form below:

Health and/or Dental Plan Cancellation Form

Delta Dental Enrollment Form:

Dental Enrollment From

If you have questions regarding the Health Reimbursement Account Program,

please refer to the FAQ's below. If your question has not been answered or

if you have questions regarding your claims,please contact

Health Economics at 1-800-666-6690, ext 504:

HRA FAQ's

For questions regarding claims, duplicate cards, plan information, etc.:

Blue Cross Blue Shield Customer Service

1-800-544-2583

For help in understanding and resolving claims:

Health Advocate Service

1-800-359-5465

Blue Cross Blue Shield website:

www.bcbswny.com

Delta Dental website:

www.deltadentalins.com

Health Economics website:

www.heginc.com

Instructions on how to check your FLEX, 105h and Benny card balances:

Benefits on how to check your balances

Health Economics Group Flex Spending Account Changes:

List of eligible and ineligible items

Niagara Wheatfield Central School District

Achieving Excellence

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Health Insurance/Flex Information and Forms

Niagara Wheatfield Central School District

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