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”:
- Your termination of employment (except for gross misconduct)
- A reduction of your hours so that you or your dependent(s) no longer meet the eligibility requirements for coverage
- In the event of your death
- In the event of your divorce or legal separation
- 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:
- Up to l8 months in the event of your termination of employment or a reduction in your hours.
- 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.
- This Benefit Fund assumes first responsibility within the limits of our plans for all the member’s covered benefits.
- 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.
- 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.
- 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.
- 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:
- First, the plan of the parent with custody of the child;
- Then, the plan of the spouse of the parent with the custody of the child; and
- Finally, the plan of the parent not having custody of the child.
- 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.
- 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.
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.
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 2015, for example, must be claimed no later than December 31, 2016.
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.