REQUIREMENTS FOR COVERAGE AND EXTENSIONS   

Enrolling

All employees must file an enrollment card with the Fund office and keep it  updated in order to avail themselves of the benefits provided by the Fund. Obtain a card from your payroll representative. It is essential for the orderly processing of claim forms. After filling out and filing the card, you are required to promptly notify the Fund, in writing, of any of the following:

1. Change of Name

2. Change of Address and/or Telephone Numbers

3. Change of Marital Status

4. Any Addition of Dependents

5. Any Loss of Dependents Due to Marriage, Death, or Their Change of Residence

The Fund reserves the right to request any documents necessary to establish eligibility of a member or dependent.  

1. As an employee, you must be in an active payroll status with an employer who has funded the required contribution. This establishes the period of employment for which contributions are paid or should have been paid to the Benefit Fund by the employer.

2. Eligibility for benefits commences on the first of the month after completion of at least two full months, but not more than three months, of such status. In other words, if you start work on the first of the month, you will be able to participate in benefits in exactly two months. However, if you start on the second day of the month (or later) the remainder of that month must be added to the two full-month minimum. Example: Hired January l, benefits start March l. Hired January 2, benefits start April l.

Benefit Payment Requirements     

Once the waiting period is over, and provided the eligible employee has filed a Fund enrollment card, benefit coverage starts. Before starting payment of benefits to you, the Fund may request confirmation from you or your employer of pertinent payroll, address, and dependent data. Payment of benefits can be put in jeopardy if the employee fails to notify the Fund of changes in marital status, dependent status, or domicile; or neglects to confirm college attendance status of a dependent child of their household. College attendance must be confirmed directly to the Fund each semester. Benefits are payable to those eligible members or their dependents only to the extent of the terms of each benefit as defined in this booklet.

 

Ending of Coverage    

Coverage and eligibility ends upon the effective date of termination of employment for the employee; this includes all spouse and dependent participation except as provided for under Status, Sections 3 and 4. Participation in benefits end for dependents with a change in their status, such as in cases where they cease to be dependents of the employee or otherwise cease to be a dependent as defined by the Fund.

Extension of benefits for a terminated member or dependents under various circumstances may be available under COBRA.

Eligibility For Future Retiree Benefits    

Effective January 1, l998 members who leave or retire from employment with a participating employer and have 20 or more years of service, but have not reached the age of 55, are not eligible for Retiree Benefits until such time as they reach the age of 55 providing the employee has made continuous self-payments for coverage to the Benefit Fund during the period of time since leaving employment until age 55.

The length of time a future retiree may continue benefits under COBRA has been extended to accommodate any additional months needed for retirees' eligibility.

COBRA notifications are mailed directly to the member’s home by the Fund as soon as the employer has advised the Fund of termination of employment. The member has 60 days from receipt of the COBRA notification to choose to continue benefits. Payments must be made continuously, without delinquency, in order to receive retiree benefits at a future date.

Failure to select the self-payment of premium option under COBRA will result in a loss of retiree benefits.

 

Direct Payment Plan (COBRA)    

The plan is required under COBRA to provide continuation of certain benefits for members and dependents that have had their eligibility for benefits terminated. Under this provision you and/or your covered dependent(s) have the opportunity to continue certain coverage, which would otherwise end as the result of any of the following "qualifying events":

1. Your termination of employment (except for gross misconduct)

2. A reduction of your hours so that you or your dependent(s) no longer meet the eligibility requirements for coverage

3. In the event of your death

4. In the event of your divorce or legal separation

5. Your child no longer qualifies as a dependent

Under the qualifying events cited in 4 and 5, it is the dependent’s obligation to notify the Fund within 60-days of the qualifying event that they wish to exercise their COBRA option.

If you and/or your covered dependent(s) elect to continue certain coverage, it would be identical to the coverage provided by the Fund, with the exception of legal, which includes the tax benefit, life insurance and surviving spouse benefits, and would be extended as follows:

1. Up to l8 months in the event of your termination of employment or a reduction in your hours.

2. Up to 36 months for your dependent(s) in the event of your death, divorce, or your child no longer qualifies as a dependent.

You may receive additional information on direct payments by calling or writing the Fund.

Note: No Fund member is compelled to use any of the Fund’s plans.

COORDINATION WITH OTHER DENTAL, OPTICAL AND BENEFIT PLANS   

These plans have been designed to help you meet the cost of dental, optical and other needs. Since it is not intended that you receive greater benefits than the actual expenses incurred, the amount of benefits payable under this plan will take into account any coverage you, your spouse, or dependents have under other group plans. That means, the benefits under this plan will be coordinated with the benefits of other group plans that your family may have.

A spouse or child will not be covered for any benefits from this Benefit Fund if, for any reason, they choose not to, or neglect to enroll in, their employer's group coverage plan, provided the coverage was available at no cost to them.

It is important for you to remember the next few points.

1. This Benefit Fund assumes first responsibility within the limits of our plans for all the member's covered benefits.

2. If your spouse is covered by a group coverage plan, that plan has first responsibility for your spouse's benefit claims. This means that the spouse's plan must pay all the spouse's expenses incurred up to the limit of the schedule in that plan.

3. If the plan covering your spouse does not provide coverage to pay all of the expenses incurred and all of the primary plan’s requirements have been met, the Fund will provide the difference of such expenses within the limits of its coverage. You cannot collect from the Fund and under your spouse's plan in excess of fees charged.

4. For dependent children of parents not separated or divorced, the plan of the parent whose month and day of birth falls earlier in the calendar year pays first, and the plan of the parent whose date of birth falls later in the calendar year will pay second. The word "birthday" refers only to month and day, not the year in which the parent was born.

5. If two or more plans cover a person as a dependent child of separated or divorced parents, the benefits are determined in the following order:

1. First, the plan of the parent with custody of the child;

2. Then, the plan of the spouse of the parent with the custody of the child; and

3. Finally, the plan of the parent not having custody of the child.

4. If the specific terms of a court decree state that one of the parents is responsible for the health care expenses of the child, and the entity obligated to pay or provide the benefits of the plan of that parent has actual knowledge of those terms, the benefits of that plan are determined first. The plan of the other parent shall be the secondary plan. This paragraph does not apply with respect to any claim determination period or plan year during which any benefits are actually paid or provided before the entity is aware such a decree exists.

6. Where husband and wife are both members of the Benefit Fund, the same coordination of benefits apply.

If you have any doubt about coverage for you, your spouse, and your dependent children, please get in touch with the Fund office.

CLAIMING YOUR BENEFITS  

Review Your Enrollment

Review the contents of this information thoroughly. Locate which benefit applies to your needs and provides the best coverage for you. After you are certain that the benefit is due you, check to see that all anticipated claims fall within the allowable claim-time limit; that is, within one year of the calendar year in which the services are rendered. Follow directions for submitting claims.

Claim Forms

Follow all instructions contained on claim forms for completion. All forms or correspondence received by the Fund must contain the following information:

• Name of member

• Address, telephone numbers

• Social Security Number of member

• Original signature and date ( if a non-participating provider is used)

An incomplete form will be returned causing a delay in your benefit payment. If you utilize the services of a non-participating provider, you are required to place your original signature and the current date on all claim forms. The Fund cannot accept photocopied signatures or signature strips.

Payment    

The processes for payment of benefits vary. Payments shall be made either to the member directly or to the establishment that has provided the particular service. Specifics are provided according to each benefit.

Payment will not be made for any benefit that is claimed after a period that exceeds one year from the calendar year in which services were rendered. Dental services performed in 2001, for example, must be claimed no later than December 31, 2002.

The Benefit Fund periodically audits payments made. If, for any reason, the Fund discovers a discrepancy that results in a request for a refund, any failure to comply may place your future benefits in jeopardy.

It should be noted that from time to time the Trustees may, at their discretion, add to, amend, change, delete or modify existing Benefit Fund rules and regulations and benefit allowances. Should a question arise as to benefit coverage, such questions shall be resolved upon review of the Benefit Fund's Trust indentures, plan of benefits and minutes of Trustee meetings. If additional information is desired, call the Fund office where more detailed information is available.

APPEALS   

Appeal Procedure

Within 180 days after receipt of notice that your claim has been denied, in whole or in part, you, or your duly authorized representative, may file a written request for a review of your claim by the full Board of Trustees. Such a request must set forth the basis for the appeal and all pertinent data to substantiate your position. In connection with the appeal, you, or your representative, will be given an opportunity to inspect copies of pertinent documents and to review the information upon which the denial was based.  

The Board of Trustees, at their discretion, may hold a full hearing of the issues presented by you. The Board will act upon a request for a review within 60 days after receipt of all necessary information, except that if a hearing is held, the Board may extend its review period to a maximum of l20 days. You will be notified in writing of the action taken by the Board of Trustees. Such notice shall include the specific reasons for the decision and specific references to the plan provisions on which the decision was based. All such decisions will be final, conclusive and binding.

All appeals must be in writing and addressed to the Board of Trustees at the Suffolk County Municipal Employees Benefit Fund, 30 Orville Drive, Suite D, Bohemia, NY  11716.