Who pays the Fund for my benefits?
Actually, your employer does. The money contributed to the Fund on your behalf is made bi-monthly and the amount is determined through contract negotiations between the County of Suffolk and the Suffolk County Association of Municipal Employees, Inc.. These benefits are afforded you in addition to your annual salary and, with the exception of the Legal Service Fund, are made with non-taxable dollars.
There are no contributions made by anyone for the Fund’s retired members.
How do I keep my child’s Fund coverage while they attend college?
Full-Time Student Status
The Fund requires proof from the student’s school each semester*. Student proof must be signed by the school registrar and for an undergraduate must state that the student is enrolled for 12 or more credits; for a graduate student 9 or more credits is required. If you have already sent college proof to Suffolk County to continue health coverage, you must still forward proof to the Fund. The Benefit Fund is not a Suffolk County department.
* Proof for the Spring Semester covers the dependent from January 1st to September 30th or the date classes are terminated, whichever comes first. The Fall semester covers the dependent from September 1st to January 31st or the date that classes end, whichever comes first. To keep your dependent’s coverage active between semesters you must file with the Fund a statement of intent (a school bill or a listing of tentative classes is acceptable). However, if the Statement of Dependency is not received by the Fund within 30 days of the beginning of the semester, coverage will be terminated. You will be billed for any reimbursement that the Fund has made in the interim. Failure to remit payment will result in a suspension of all Fund benefits until such time as payment is made.
How do I add a new dependent to my Fund coverage?
To add a spouse to your Fund coverage, you must file with the Fund a new enrollment card accompanied by a sealed marriage certificate.
To add a new baby to your coverage you must file with the Fund a new enrollment card accompanied with a sealed birth certificate.
How do I keep the Fund coverage for my child who is handicapped?
Adding a Dependent or Requesting Age Extension
If you are adding a dependent to you coverage or think that your dependent might qualify for age extension benefits, telephone the Fund at 631-319-4099 and request a Statement of Dependency form. Remember that you must file a new enrollment card whenever you are making a change to your list of covered dependents.
What if I need to make a changes to my dependents on file with the Fund?
Changes to filed Dependents
In the event of a divorce, you are required to provide a divorce decree* to the Fund immediately upon the issuance of the decree. (The decree becomes legal once it has been entered by the County Clerk. The page showing the entered date must be included with your submission.) Any expenses that the Fund has incurred for a dependent no longer covered (coverage is terminated upon the date of the event) due to the member’s failure to provide the required documentation is the responsibility of the member. Failure to compensate the Fund for those expenses will result in a suspension of all Fund benefits until such time as payment has been received. All time limitations and exclusion apply. The Fund can not add a new spouse to your coverage until such time as the previous spouse has been legally removed from your coverage.
The Fund can not remove a spouse from coverage without having received a divorce decree or a signed and notarized waiver releasing the Fund from it’s obligation to provide benefits.
It is the member’s responsibility to reimburse the Fund for any expenses it has incurred due to ineligibility. Failure to reimburse the Fund will result in a suspension of benefits until such time as reimbursement is made.
Am I supposed to pay a participating dentist any money?
The Fund has contracted with many local dentists to provide dental services for Fund members. What this means is that, if the Fund covers the service, and you are eligible for benefits for that service (frequency or time limitations may be something that might make you ineligible for reimbursement for a particular service), there should be no out-of-pocket expense for you.
A participating dentist may not charge you any money before the Fund has had an opportunity to look at the claim and see exactly what will be paid or not paid. If, for some reason, a particular service is not paid by the Fund, you are responsible for making payment to the dentist for the service. Once you receive your copy of the EOB (Explanation of Benefits), the amount that you owe the dentist will be shown in the column marked “Fee Requested”. Make sure you look at the EOB to see if any additional comments have been added for that particular service. For instance, sometimes the Fund will not make payment on a particular service because it is included in another service that the Fund has already paid for. In cases like this, you are not required to pay anything additional.
If the dentist’s office is asking you to make payment for something that you have not seen on an EOB, let them know that they cannot ask you for payment until the charge is first submitted to the Fund.
When does my coverage terminate?
Termination of Coverage
The Fund receives notification of your employment status each payroll period directly from your employer. If for any reason you receive a notice of termination from the Fund and you dispute the Fund’s termination, you must first contact your payroll office since the information the Fund receives is initially generated there.
If you are considering leaving employment prior to collecting a pension or before reaching the age of 55, you should contact the Fund regarding what steps you must take to make sure that you remain eligible for Fund Retiree Benefits. When making your inquiry request to speak to someone in the Fund’s eligibility department. They will go over your employment history with you to help you determine if you qualify and advise you of the Fund’s self-payment requirements.
What does coordination of benefits mean?
Coordination of Benefits
If the primary carrier requires that a specific dental office must be used in order for the expenses to be covered and the choice is made not to utilize those services the Fund will not cover those expenses. In essence, when you choose not to use the services of the provider required by the primary carrier you are selecting which carrier will be primary. The “Birthday Rule ” has been established to determine which carrier is primary so that neither the insurer or the insured can be selective in which coverage comes first. If there is some reason that prohibits you from using the designated provider you must take the matter up with the insurer that has established that requirement. The Fund can not help you with another carrier’s rules and regulation.
Some insurer’s have made arrangements with providers that there will be no charge for certain services, such as periodic exams. If the EOB (Explanation of Benefits) that is submitted to the Fund from another insurer states on it that there is no charge to the patient for a particular service the Fund will not make payment regardless of what the provider requests. Remember – the Fund reimburses for expenses that you owe. If the primary insurer states that there is no charge for the service, the provider can not bill you for that service.
How do I appeal a decision of the Fund?
Appealing a Decision of the Fund
Every now and then you get the unpleasant news that an expense you had was denied. You’ve called the Fund office and still have not been able to work it out. Is there any avenue left for you to take? Sometimes, the answer is yes.
First you need to answer a few questions:
- Is the benefit normally covered?
- Am I sure there are no exclusions that apply?
- Did I meet all of the requirements to be eligible and if not, were my circumstances unique?
- Did I receive the denial less than 180 days ago?
If the answers to all of these questions are yes, then you may want to consider sending in a letter of appeal.
Now, you need to do your homework. Make sure that what you are putting in writing is factual. Attach supporting documentation attesting to those facts. If it’s a dental appeal, have your dentist help you by supplying you with a written narrative explaining why your situation is unique . If all is in order your appeal will be reviewed by the Funds’ Trustees at their next quarterly meeting. Your request needs to be timely, so make sure that you’ve included everything that you think might be helpful.
The Trustees can only entertain the facts surrounding your particular situation. Many times the Fund receives a letter that simply states “I’m appealing the denial of ……”. Well, logically thinking – what could you do with this? Be precise and lay out your case so that the Trustees can clearly see your point. The Trustees can’t help you if your only basis for the appeal is what you think should have happened.
Don’t confuse your request for new benefits with an appeal for denied benefits. The Trustees periodically review your plan of benefits, and when circumstances are right to add something new, it’s done in a manner consistent with fairness for all. A forward-looking effective date is the first thing established so that all members of the Fund will have equal access.
(In order for your appeal to be heard by the full Board you must direct them to: The Board of Trustees, SCMEBF, 30 Orville Drive, Suite D, Bohemia, New York 11716)
What does limiting the number of payments mean?
Limiting the Number of Payments
There are certain instances when payments for a particular service will be limited. In most cases, the limitations are based on the similarity of the services. For example: You may have received a benefit for a crown in 1999 and your dentist used the dental code 2752 (crown-porcelain fused to noble metal). If your dentist places a new crown in 2002 using dental code 2792 (crown-full cast noble metal) you will not be eligible for it because of the 5 year frequency limitation. If you have a dental code 0330 (a panoramic x-ray) done and then have a 0210 (complete series x-rays) done before the 3 year frequency limit is up for the 0330, the 0210 will be denied benefits. Even though the dental codes are dissimilar – the services are not. It’s always a good idea to check with the Fund office before the services are done to be sure that the services do not overlap with other services previously performed.
What is the difference between my Fund Benefits and my medical benefits?
Fund Benefits vs. Medical Benefits
We realize that it’s very confusing to figure out who handles what when it comes to your benefits. The first thing you need to know is that the Fund is not a County or a Union department. This is one of the reasons why we are unable to “transfer” your call to the right department when we can’t help you with your medical questions. The Fund covers your dental, optical and legal needs directly as well as the Survivors Benefit and Bereavement Benefit. The Fund is secondary for your hearing aid and reimburses prescription co-pays according to our schedule. When you have questions regarding doctors, your prescription/medical card, where to file a medical claim, information about your end-of-the-year prescription statement or any other medical information you need to call Employee Benefits at the department of Civil Service at 631-853-4866.
Why can’t I make a claim for expenses I paid out for my mother?
Even though you personally paid for an expense that is covered by the Fund, you can not be reimbursed for it unless the expense was incurred by a covered beneficiary of the Fund. For instance, you might pay for the will preparation of a relative. However, if that person is not one of your covered dependents, that expense cannot be benefitted since it was incurred by a non-beneficiary of the Fund.