Health care and mental hygiene workers that meet each of the following criteria will be eligible for the bonus:

• The employee works for a qualified employer.
  • A qualified employer is defined in SOS § 367-w(2)(b) and (c).
  • Qualified employers include many, but not all, types of health care providers.
• An employee working for a qualified employer must be:
  • Work in one of the eligible titles listed in SOS §367-w(2)(a)(i)-(iii).
  • Must receive an annual base salary of $125,000 or less (excluding any bonus or overtime pay paid by the employer).
  • Must be employed by a qualified employer at all times during the "vesting period" as defined in SOS § 367-w(2)(d).
  • Must not be excluded or suspended from participation in the Medicaid program.
  • Must have worked the required minimum number of hours (at least 20 hours per week) during the vesting period to be eligible for the bonus.

• The employer must evaluate whether they and/or their employees meet the criteria, and complete a separate attestation.
• If the Employer is a qualified employer and has eligible employees, the employer must make this attestation form available to them.
• The employer must make this attestation form available to its employee for each vesting period for which they may be eligible.
• Eligible employees must complete this Employee attestation form in order to receive a bonus.
• The Employer must maintain contemporaneous records for all claims related information and any other data or documents used to demonstrate that an employee was eligible to receive such bonus, including but not limited to employee attestations. All records, data and other information will be made available for review upon request.

Section A - The Employer must complete the Employer Name, Employer MMIS number, and identify the HWB vesting period.

Section B - The Employee must:

• Provide their name;
• Provide their Federally issued Social Security number (SSN) or Federally issued Individual Taxpayer Identification number (ITIN)
• Attest that during the selected six-month vesting period that their gross wages were not more than $62,500.
• Including wages, salaries or fees from ALL employers or from contract work, not limited to wages from qualified employers.
• Do not account for any deductions or allowances.
• Exclude any bonuses or overtime pay.
• Attest that they have not previously received HWB payments:
  • totaling three thousand dollars ($3,000) from any employer;
• for two (2) or more vesting periods from the qualified employer named on this form.
• Sign and date the attestation.

For more information about the bonus, please visit the NYS Health Care and Mental Hygiene Worker Bonus webpage: {insert webpage}