Benefit Information & Forms

Help

Handouts

Required Notices

The Notices include:
  • Consolidated Omnibus Budget Reconciliation Act (COBRA)
  • Prescription Drug Coverage and Medicare
  • Premium Assistance Under Medicaid and the Children's Health Insurance Program (CHIP)
  • Mental Health Parity Act (MHPA)
  • Michelle's Law
  • Newborns' and Mothers' Health Protection Act
  • Patient Protection Act
  • The Health Insurance Portability and Accountability Act of 1996 (HIPAA) 
    • Privacy and Security Rules
    • Special Enrollment Rights
  • Uniformed Services Employment and Reemployment Act of 1994 (USERRA)
  • Women's Health and Cancer Rights Act of 1998 (WHCRA)
 
Please review the attached Notices carefully and contact the Human Resources Department if you have any questions; otherwise please retain the Notices for future reference.
(.pdf, 215K)
Download Annual Required Notices

Additional Massachusetts Paid Family and Medical Leave Act information:

Private plan summary information / FAQ's.

  1. What Is This Benefit?
  2. Am I Eligible For Benefits?
  3. Waiting Period
  4. Benefit Year
  5. Medical Leave
  6. Family Leave
  7. Combined Leave
  8. Weekly Benefit
  9. What is my cost?
  10. What is my employer’s cost for me?
  11. How do I apply for benefits?
(.pdf, 133K)
Download MA Paid Family and Medical Leave (MAPFML)

Employee Benefit Enrollment/Change Form

This election form is to be completed when enrolling in or declining of group medical, dental, group term life insurance and/or voluntary term life insurance.

To be completed when:

  • Enrolling for benefits during open enrollment
  • Changing existing benefits (restrictions and limitations may apply)
(.pdf, 190K)
Download Employee Benefit Enrollment/Change Form

Health Equity - Health Savings Account

The Health Equity Authorization Form needs to be completed by employees who:

  1. are enrolling in the HNE health plan for the first time OR
  2. are currently enrolled in the HNE health plan but have not been eligible to participate in the HSA (i.e., enrolled in a Health FSA or other medical plan) but have now met the eligibility requirements.

IMPORTANT:  Once you have completed the Statement of Health and/or Health Equity Authorization Form, you must submit the form(s) to kbradway@bfpassociates.com for processing.  Please note: Your full election amount will not be approved until your Statement of Health is received and approved by Principal.

(.pdf, 119K)
Download Health Savings Account Form

Dental Insurance Information - Altus Dental

Just a few items available when using Altus Dental Online.

  • View Usage Summary
  • Print ID Cards
  • Look up Claim Status
  • Customer Services
(.pdf, 64K)
Download Altus Dental Online
  • What are pre-treatment estimates?
  • Why are pre-treatment estimates important to me?
(.pdf, 22K)
Download Importance of Pre-Treatment Estimates
This Certificate, along with the Benefits Summary describes the Plan. It describes the dental services covered by your Plan. It also explains how each is paid for and tells you how to use the Plan. If you have any questions, please contact Customer Service.
 
Altus customer service number is: 1-877-223-0588
(.pdf, 1205K)
Download Altus Dental Certificate of Coverage

Health Reimbursement Account (HRA)

Flexible Spending Account

Information in this section relates to

  • Health Flexible Spending Accounts, HFSA (Not Health Savings Account)
  • Dependent Care Assistance Plan, DCAP
(.pdf, 242K)
Download Flexible Spending Account Summary Plan Description FY21

Benefits through Principal Financial

Available to eligible employees
As an employee covered by a group term life insurance policy from Principal Life Insurance Company, you are eligible for travel assistance services provided by AXA Assistance.
 
You, your spouse and dependent children (whether traveling together or separately) have access to travel, medical, legal and financial assistance plus emergency medical evacuation benefits when traveling domestically or internationally 100 or more miles away from home for up to 120 consecutive 
(.pdf, 322K)
Download Travel Assistance

Vision coverage that gives you choice of provider options for exams, eyewear and other discounts

(.pdf, 1731K)
Download Group Voluntary Vision Coverage
From simple concerns like decreasing stress to complex issues such as losing a loved one, your
Employee Assistance Program (EAP) provides recommendations and information to help you with life's everyday, and not so everyday, challenges. With short-term or long-term disability coverage from Principal Life Insurance Company, you and your immediate family have access to free, confidential services offered through your EAP.
(.pdf, 653K)
Download Employee Assistance Program
The state of Massachusetts now requires that employees be provided with an accelerated benefits disclosure form pertaining to their group term life and group voluntary term life insurance coverage.
 
 
(.pdf, 71K)
Download Disclosure Statement for Accelerated Benefit, Group Life Insurance

Use these discounts to help improve your life - financially, mentally and physically. These discounts are available through your group benefits from Principal. 

These discounts are not insurance.

(.pdf, 328K)
Download Discounts and Services

The Statement of Health is to be completed by employees who are:

  1. Electing voluntary term life coverage for the first time and requesting over $20,000.00 in coverage OR
  2. Increasing their current level of voluntary term life coverage by more than $20,000.00
(.pdf, 250K)
Download Principal Health Statement

Educational Assistance & Tuition Exchange Programs

  • This form is required annually from students who currently receive a Tuition Exchange scholarship and wish to renew the scholarship for another year. Failure to submit this form will result in the termination of the scholarship.
(.pdf, 92K)
Download Tuition Exchange Program (TEP)- Recertification Form for Academic Year 2022-2023

Doctoral Programs Only

Please see the Operations Manual for more information.

(.pdf, 168K)
Download Educational Assistance Program Application - Doctoral Program

Doctoral Programs Only

Please refer to the Operations Manual for more information.

(.pdf, 20K)
Download Doctoral Tuition Educational Assistance Agreement