Index
Dear Colleague:
We are pleased to provide you with a current edition of The Red Apple, a guide to the UFT Welfare Fund benefits. This booklet has been redesigned for easier access to information regarding the medical, dental, disability and other benefits available to our members. This new format also will allow us to bring you updates on administrative or benefit changes in a more timely and efficient manner.
The UFT Welfare Fund has provided members with nearly $1 billion in benefits since we began 30 years ago. Thanks to members like you, who have become cost conscious by selecting generic drugs or by using our prescription drug mail order program, we have been able to maintain an excellent package of benefits in the face of ever increasing medical costs. In that way, both you and the Fund have achieved significant savings.
In this booklet you will find a comprehensive description of your benefits and how to access them. But if you need further information or explanation about any of these services, please contact any of the trained professionals at the UFT Welfare Fund who are always ready to assist you.
The UFT remains committed to providing you and your family peace of mind and security with an extensive and quality array of Welfare Fund benefits.
Sincerely,
Sandra Feldman
Chair
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GENERAL INFORMATION
Oct. 1, 1996
• Eligibility Rules
• Enrolling and Updating Information
• Coverage Rules:
• Special Leave of Absence coverage (SLOAC)
• Leave of Absence without Pay for Restoration of Health or Maternity Leave
• Family and Medical Leave Act (FMLA)
• Coordination of Benefits (COB) Information
• Special Coordination of Benefits (SCOB) Information
• Forms and Claim Submission Information
• General Questions and Answers
• Miscellaneous Information
*Please note, that upon divorce or termination of domestic partnership, the Change of Marital Status-Dependents-Beneficiary Card must be completed to delete a spouse or domestic partner.
GENERAL INFORMATION — ACTIVES
Who is Covered?
Employees of the New York City Board of Education who are “covered” under agreements with the United Federation of Teachers, and for whom the Board contributes monies to the UFT Welfare Fund. “Covered employees” are hereinafter sometimes referred to interchangeably as “employees” or “members.”
ELIGIBILITY RULES
• Covered Members — In general, subject to the requirements pertaining to the definition of “covered employees,” members in covered categories are eligible for benefits so long as they are in Active status.
• Active status is determined by, and runs concurrently with, the period for which contributions are appropriately paid, or should have been paid for the member, by the Board of Education to the UFT Welfare Fund. Members on leave with pay are considered to be in Active status.
• Dependents — Dependents of eligible members as defined below, are eligible for all benefits except life insurance, disability and in some cases supplemental benefits.
1. Legally married husband or wife.
2. A ‘domestic partner’, defined as any individual, eighteen years of age or older, who is not married or related by blood to the member in a manner that would bar marriage in the State of New York, who has a close and committed personal relationship with the member, who lives with the member and has been living with same on a continuous basis, and who, together with the member, has registered as a domestic partner of the member and has not terminated the domestic partnership. Members can obtain details concerning eligibility, enrollment and tax consequences from the New York City Office of Labor Relations Domestic Partnership Liaison Unit 212-306-7336.
3. Unmarried children under age 19 — The term “children” for purposes of this and the following definitions, includes: natural children, children for whom a court has accepted a consent to adopt and for the support of whom a member has entered into an agreement; children for whom a court of law has made a member legally responsible for support and maintenance; and children who live with a member in a regular parent/child relationship and are supported by the member. The coverage termination date for children reaching age 19 will be the end of the month during which the child reached age 19.
4. Unmarried dependent children age 19 to 23 who are full-time students — The termination date will be the end of the calendar year (December 31st) of the student’s 23rd birthday or graduation, whichever occurs first. Qualifying criteria (as described in the City’s Summary Program Description) for coverage must be met for each term attended.
5. Unmarried children who cannot support themselves because of a mental illness, developmental disability, mental retardation, or physical handicap — If the disability occurred before the age at which coverage would otherwise terminate, and the dependent was covered by the City at that time, coverage will be continued, provided medical evidence of the disability is submitted to the Fund before the date the dependent reaches the age limitation.
The following procedure must be followed:
a. Obtain a “Certificate of Disability” from your basic health carrier. Complete the form and mail it directly to your carrier. Your carrier will send you a letter confirming your dependents disability status.
b. Request a “Disabled Dependent Child Affidavit” (DDCA) from the Welfare Fund. Complete the Affidavit and return it to the Fund along with a copy of the letter from your carrier.
c. The Welfare Fund will send you a letter of confirmation.
What are my Welfare Fund benefits?
The UFT Welfare Fund provides:
Prescription Drug,
Dental,
Optical,
Hearing Aid,
Disability,
Life Insurance, and
Supplemental benefits (benefits which specifically supplement the HIP/HMO, HIP Choice Plus, and GHI-CBP/Empire Blue Cross Blue Shield (EBCBS) plans.
See the applicable brochure(s) in this Red Apple for the benefits listed above.
All eligible members are covered by a City basic health plan of their choice. For detailed descriptions of these benefits refer to the NYC Health Benefits Program Summary Program Description booklet. Additionally, members may contact the different plans listed in that booklet for further information.
How do I enroll and update information?
To enroll, all new members must:
1. — complete a UFT Welfare Fund Enrollment Card. (This filing is separate from any filing with the Board of Education regarding your choice of health plan.)
2. — attach applicable documentation (e.g. birth certificate or marriage certificate) to the enrollment card.
To update information, all members must notify the Fund Office of a change in marital status, dependent status or beneficiary by filing a Change of Marital Status-Dependents-Beneficiary Card. When enrolling or changing dependents, the member must attach photocopies of necessary documentation to the Enrollment Card or Change of Marital Status-Dependents-Beneficiary Card. The Fund reserves the right to request additional documentation verifying the bona fide relationship of any dependent to a member.
COVERAGE RULES
When Does Coverage Begin?
Coverage for eligible members begins on their first day of employment, except for the Prescription Drug Plan which begins on the first day of the fourth month after the member has acquired Active status.
Dependents become eligible on the same date as the member, or if acquired later, on the date they first become eligible dependents.
When Does Coverage Terminate?
Coverage for a member terminates when the member is no longer in Active status as defined above in the Eligibility section.
Dependent coverage terminates when a member’s eligibility ends for any reason other than death, or on the date when the dependent no longer meets the definition of eligible dependent, whichever occurs first. In cases of the member’s death, dependent coverage terminates at the end of the month that death occurred.
What do I do when my Coverage Terminates?
Depending upon your situation, there are many different ways to continue your coverage. They are as follows:
1. SPECIAL LEAVE OF ABSENCE COVERAGE
(All Members)
When a member is off payroll due to illness or accident, the member may be eligible to have his or her City basic health insurance continued for up to four (4) months through the Board of Education’s Special Leave of Absence Coverage (SLOAC). To those receiving SLOAC, as an additional benefit the Welfare Fund will pay the premiums directly to your health carrier for continuing City basic health insurance and optional rider, for those who have elected these City coverages, for up to eight (8) additional months. No enrollment forms are necessary.
2. LEAVE OF ABSENCE WITHOUT PAY FOR
RESTORATION OF HEALTH OR MATERNITY LEAVE
Regularly appointed pedagogical members:
a. on authorized sick leave without pay, which commences immediately following cessation of Active status, will be covered for Welfare Fund benefits for a period not to exceed one (1) year from the effective date of the leave.
b. on authorized maternity leave without pay, which commences immediately following cessation of Active status, will be covered for Welfare Fund benefits, but only for the period for which evidence of disability is submitted and accepted by the Welfare Fund as described in the Disability Plan.*
Members on SLOAC maternity leave status will receive Welfare Fund benefits for a maximum of four (4) months .
*Refer to Disability Section for further details.
A signed copy of the Board of Education Personnel Transaction Form (PTF) or Form #OP218 (Leave of Absence without pay for Restoration of Health) must be filed with the Fund Office with each claim submitted for payment.
Paraprofessionals:
The preceding paragraphs concerning coverage while on authorized sick leave without pay (personal illness or pregnancy related), maternity leave, or on an approved leave while receiving Workers’ Compensation, which commences immediately following cessation of Active status, are also applicable to paraprofessionals.
Continuation of coverage, as stated above, is available to a paraprofessional who is on an approved leave while receiving Workers’ Compensation. However, the Board of Education Form #OP218 and Personnel Transaction Form (PTF) are not used for paraprofessionals. Instead, you must submit the “Application for Leave of Absence for Employees in Educational Paraprofessional Title,” issued by the Board of Education with “Approval” indicated in the appropriate section by the Medical director for those on authorized sick leave without pay. For Maternity/Child Care Leave or for Worker’s Compensation, however, the Medical Director’s section is left blank by the Board of Education.
Regularly Assigned Pedagogical Employees — Regular Substitutes:
Since regularly assigned pedagogical members who leave payroll due to illness or maternity during a term are eligible for SLOAC retroactively if they return to the same school during the same term in a covered status, Fund benefits will be provided during the retroactive SLOAC period. Appropriate documentation verifying status must be filed with the Fund Office with each claim submitted for payment to be eligible for benefits.
All Others:
Other members may be eligible for continuation of Welfare Fund benefits for a period not to exceed one (1) year if the member:
1. receives an official leave for restoration of health or maternity from the Board of Education which commences immediately following cessation of Active status and
2. is eligible to receive SLOAC through the Board of Education.
Appropriate documentation verifying your status must be filed with the Fund Office with each claim submitted for payment to be eligible for benefits.
3. THE FAMILY AND MEDICAL LEAVE ACT (FMLA)
The Federal Family and Medical Leave Act of 1993 (FMLA) entitles eligible City employees, after twelve (12) months of employment, up to twelve (12) weeks of family leave in a twelve (12) month period to care for a dependent child or covered family members, and for the serious illness of the member. Members using this leave may be able to continue their City health coverage through the FMLA provisions for unpaid leave.
Contact your payroll or personnel office for details. Upon submission to the Fund of documentation issued by the Board of Education verifying FMLA status, the Fund will provide Welfare Fund benefits during the FMLA period.
4. LAYOFF
Under the terms of the applicable collective bargaining agreement, members may be eligible for 90 days of basic health insurance and UFT Welfare Fund coverage, excluding disability coverage.
5. COBRA*
The Federal Consolidated Omnibus Budget Reconciliation Act of 1985 (COBRA), requires that the City and UFT Welfare Fund offer members, retirees and their families, the opportunity to continue health and certain Welfare Fund benefits at 102% of the group rate (or 150% of the group rate for the 19th through the 29th months in cases of total disability) whereby the coverage would otherwise terminate. The maximum period of coverage is either 18, 29 or 36 months, depending on the reason of termination.
*Refer to the COBRA Section for further details.
COORDINATION OF BENEFITS RULES
Benefits provided by the UFT Welfare Fund are subject to Coordination of Benefits (COB) provisions. COB is applicable when you or your dependents are covered by another group benefit plan. A patient’s basic health coverage will always be primary and the UFT Welfare Fund benefits secondary.
Benefit claims under COB are payable under a primary-secondary formula. The Primary plan determines its benefits first, and pays its normal benefit. The Secondary plan computes its benefit second, and may reduce its benefit payment so that the insured does not receive more than 100% reimbursement of expenses. In no event would the UFT Welfare Fund’s liability exceed the benefits payable in the absence of COB.
The order of payment is determined as follows:
1. If one plan does not have a COB provision, that plan will be primary;
2. If the patient is our (UFT Welfare Fund) member, the UFT Welfare Fund is the Primary plan. However, if the patient is the spouse of our member, and is covered under another group plan, the other group plan is Primary and the UFT Welfare Fund is Secondary.
3. If the patient is a dependent child under both plans, then the plan of the parent whose birthday (month and day) occurs first within the calendar year will be Primary, except that where the parents are separated or divorced, the following rules will apply:
a. If a court order establishes that one of the parents is financially responsible for medical, dental or other health care expenses of a child, the contract under which the child is a dependent of that parent shall be primary;
b. If financial responsibility has not been established by a court order and the parent with custody of the child has not remarried, the contract under which the child is the dependent of the parent with custody will be primary;
c. If financial responsibility has not been established by a court order and the parent with custody has remarried and the child is also covered as a dependent of the step-parent, then the order of payment shall be: 1st contract under which the child is a dependent of the parent with custody; 2nd the contract under which the child is a dependent of the step-parent; 3rd the contract under which the child is covered as a dependent of the parent without custody.
4. If none of the above applies, then the plan under which the patient has been enrolled the longest will be Primary. However, the plan covering you as a laid-off or retired member, or as a dependent of such person, shall be Secondary and the plan covering you as an active member shall be Primary, as long as the other plan has a COB provision similar to this one.
NO-FAULT INSURANCE
The Fund will not pay any benefits that are covered by the New York State or other jurisdiction’s No-Fault Insurance Law.
SPECIAL COORDINATION OF BENEFITS
Members and their spouses or domestic partners who are also members can receive UFT Welfare Fund dental, optical, prescription drugs and hearing aid benefits from each other’s coverages. This is known as Special Coordination of Benefits (SCOB). In addition, their eligible dependents may receive benefits under each member’s coverage. Details are included within each specific benefit description.
HOW TO OBTAIN FORMS, CURRENT PANEL LISTINGS AND INFORMATION
Welfare Fund forms and current panel listings may be obtained through several sources. For forms needing Fund validation such as optical and hearing aid, as well as general information, members should call the Fund at 212-539-0500 during regular business hours. members can also see their UFT Chapter Leader for forms not needing validation.
The Fund Hotline is also available to members who need forms and current panel listings. Members may access the Hotline by dialing 212-539-0539.
Fund representatives are available to members who request assistance with specific health plan related problems. Members should include in any correspondence their full name, address, social security number, and telephone number. Members should always include photocopies of appropriate documentation such as the Health Benefits Application or the claim rejection notice from the health plan.
NOTE: Health Plan claim forms are available directly from the carrier and are not supplied through the Fund.
SUBMISSION OF CLAIMS RULES
Disability Claims (DBL-1) — This form must be submitted no later than 30 days following the 28 day waiting period. The penalty for late filing is a loss of benefits for the period between the 29th day of disability and the date the claim is received at the Fund Office.
Disability Claims (DBL-2) — This supplemental form must be submitted no later than 30 days following the last date of the previous UFT Welfare Fund Disability Payment. The penalty for late filing is a loss of benefits for the period claimed.
Prescription Drug Claims — These claims must be submitted to NPA no later than 90 days from the date the drug is dispensed. The penalty for late submissions will be non-payment of the claim.
Dental Claims — These claims should be submitted within 90 days of completion of treatment. Claims submitted more than one year from the date the covered expense is incurred will not be honored for payment.
Hearing Aid Claims — These claims must be submitted no later than 90 days from the date of service.
Optical Claims — These claims must be submitted no later than 90 days from the date of service.
Generally speaking, no exceptions will be granted for the late submissions of claims. However, physical inability to file within the period e.g., because of hospitalization or like circumstances, will be given consideration. Likewise, there will be no penalties for delays which are beyond the member’s control, such as by a primary carrier or arbitrator. In these cases, appropriate documentation will be required. The late filing of a claim by a dentist, doctor or other provider will not be considered an exception, since it is the member’s responsibility to file claims.
Claim forms must be fully completed, giving all requested information or the claim cannot be processed. Claims which have been rejected and returned to the member for additional information must be resubmitted within 90 days of the date of rejection, or by the original submission deadline, whichever is later. If claims are ultimately rejected by the Fund Office, you may appeal the rejection. you must do so by writing the Board of Trustees within sixty (60) days of the rejection.
With respect to any claims incurred prior to a member’s death, benefits will be made payable, in the absence of (a) named beneficiary(ies), to the first surviving class of the following classes of successive preference beneficiaries:
The deceased member’s:
a. widow or widower/domestic partner;
b. surviving children;
c. estate.
SOME GENERAL QUESTIONS AND ANSWERS
What is the Fund?
The Fund was established to provide certain benefits to supplement City Basic Health Plans. It was created as a result of collective bargaining between the United Federation of Teachers and the Board of Education of the City of New York located at 110 Livingston Street, Brooklyn, New York 11201. Employer contributions are predicated on the amount stipulated in the current Collective Bargaining Agreements and are provided at the annual rates, prorated monthly, on behalf of each covered member. Members do not contribute.
Who Administers The Fund?
The Fund is administered by a Board of Trustees. It consists of five persons designated by the United Federation of Teachers. Current members of the Board of Trustees are listed below and they can be communicated with in writing at the Fund’s address. The Board of Trustees governs the Welfare Fund in accordance with an Agreement and Declaration of Trust. The Board of Trustees employs a Director and staff who are responsible for the day to day operation of the Fund, including the determination of eligibility and the processing of claims.
The Trustees and the Director of the Fund are subject to a body of law designed to protect the beneficiaries of the Fund. Under this body of law, we are mandated to submit our financial records to audit by Certified Public Accountants. We are further mandated to submit reports of these audits annually to the Internal Revenue Service. Copies of these reports are provided to the Comptroller of the City of New York.
Who are the current members of the Board of Trustees?
The current members of the Board of Trustees are:
Sandra Feldman, Chair
Ann Kessler
Ronald C. Jones
Thomas Pappas
Randi Weingarten
What Are My Rights Of Appeal?
Decisions of the Director and the staff are subject to review by the Trustees upon appeal. All rules are uniformly applied by the Fund Office. The action of the Fund Office is subject only to review by the Board of Trustees. An appeal must be filed with the Fund Office within 60 days of denial of the claim, by submitting notice in writing to the Board of Trustees, United Federation of Teachers Welfare Fund, 260 Park Avenue South, New York, New York 10010. The Trustees shall act on the appeal within a reasonable period of time and render their decision in writing, which shall be final and conclusive and binding on all persons. If your appeal has been denied by the Trustees, and you still believe you are entitled to the benefit, you have a right to file suit in the New York State Supreme Court.
Do the contributions to the UFT Welfare Fund become part of the general treasury of the Union?
No. The United Federation of Teachers and the United Federation of Teachers Welfare Fund are two (2) distinct and separate legal entities. Their resources are not comingled.
What becomes of the contributions that the Board of Education makes to the United Federation Teachers Welfare Fund?
Under the Agreement and Declaration of Trust, contributions to the Welfare Fund are used to provide benefits for covered members and their families and to finance the cost of administration.
Does The UFT Welfare Fund Operate Under ERISA?
The Fund may not be legally subject to the requirements of the Employees Retirement Income Security Act of 1974 (ERISA), nevertheless the Fund generally operates in compliance with that law.
MISCELLANEOUS INFORMATION
AMENDMENT OR TERMINATION OF BENEFITS
This booklet and amendments constitute the plan of benefits for members provided by the United Federation of Teachers Welfare Fund and, as such, includes the specific terms and conditions governing the coverage and the benefits provided for members by the Fund. In addition, there are various administrative policies and procedures which are applied on a uniform basis by the Fund, and claimants will be informed whenever such policies and procedures are applied.
The United Federation of Teachers Welfare Fund is maintained for the exclusive benefit of members and retirees of the New York City Board of Education who are “covered” under agreements with the UFT, and for whom the Board contributes monies to the UFT Welfare Fund. The Fund, as well as the plan terms, were established, pursuant to applicable law and regulation with the intention of being legally enforceable and maintained for an indefinite period of time. However, the Fund reserves its rights, under applicable law, to alter and/or terminate the plan of benefits as it currently exists.
The benefits provided by this Fund may, from time to time, be changed, modified, augmented or discontinued by the Board of Trustees. The Board of Trustees adopts rules and regulations for the payment of benefits and all provisions of this booklet are subject to such rules and regulations and to the Trust indenture which established the Fund and governs its operations.
Your coverage and your dependents’ coverage will stop on the earliest of the following dates:
~ When you are no longer eligible.
~ When the Board ceases to make contributions on your behalf to the Fund.
~ When the Fund is terminated.
~ Your dependent’s coverage will also terminate when they are no longer your eligible dependents.
Member benefits under this plan have been made available by the Trustees as a privilege and not as a right and are always subject to modification or termination in the exercise of the prudent discretion of the Trustees. The Trustees may expand, modify or cancel the benefits for members; change eligibility requirements and otherwise exercise their prudent discretion at any time without legal right or recourse by a member or any other person.
THIRD-PARTY REIMBURSEMENT/SUBROGATION
If a covered member or dependent is injured through the acts or omissions of a third party, the Fund shall be entitled — to the extent it pays out benefits — to reimbursement from the covered member or dependent from any recovery obtained from the responsible third party. Alternatively, the Fund shall be subrogated, unless otherwise prohibited by law, to all rights of recovery that the covered member or dependent may have against such third party arising out of its acts or omissions that caused the injury. Subrogation means that the Fund becomes substituted in the injured person’s place to pursue a claim for recovery against the third party. Fund benefits will be provided only on the condition that the covered member or dependent agrees in writing:
To reimburse the Fund, to the extent of benefits paid by it, out of any monies recovered from such third party, whether by judgment, settlement or otherwise;
To provide the Fund with an Assignment of Proceeds to the extent of benefits paid out by the Fund on the claim and to cooperate and assist the Fund in seeking recovery. The Assignment will be filed with the person whose act caused the injuries, his or her agent, the court and/or the provider of services; and
To take all reasonable steps to effect recovery from the responsible third party and to do nothing after the injury to prejudice the Fund’s right to reimbursement or subrogation, and to execute and deliver to the Fund Office all necessary documents as the Fund may require to facilitate enforcement of the Fund’s rights and not to prejudice such rights.
OVERPAYMENT
In the event you receive an overpayment of benefits, on your behalf or on behalf of your dependent, you are obligated to refund said overpayment to the Fund immediately.
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PRESCRIPTION DRUG PLAN
• CARD PROGRAM — NPA
• Obtain drugs at any participating pharmacy
• Copay — $5.00 brand - $2.00 generic
• 30 day or 100 doses supply (whichever is less)
• MAIL ORDER — CFI
• Obtain maintenance drugs by mail
• Copay — $2.00 brand or generic — 90 day
or 100 doses supply (whichever is greater)
• COST CARE PROGRAM
For members that exceed $1200 per year in prescription costs, this program allows members and their dependents to obtain medication in a cost effective manner by utilizing our mail order program combined with local NPAS pharmacies.
The UFT Welfare Fund Prescription Drug Plan
is administered by National Prescription Administrators, Inc
. (NPA), 711 Ridgedale Avenue
East Hanover, NJ 07936
1-800-4NPA-006 • IN NJ 201-503-1000
*For Information covering diabetes, chemotherapy and intravenous/infusion therapy contact your basic health carrier. For additional information regarding diabetes, see page 6.
PRESCRIPTION DRUG PLAN
Who is Covered and When?
All covered members and eligible dependents become covered for prescription drugs beginning with the first day of the fourth month (waiting period) after the member has acquired Active status.
What Types of Prescription Drugs are Covered?
— Prescriptions for legend drugs (drugs which can be dispensed only by a prescription). These drugs must be for specific use(s) as approved by the Food and Drug Administration (FDA), and obtained at a pharmacy. These usages, referred to as “labeled” uses, include conditions, time frames, dosage schedules, etc. for all drugs monitored by the FDA and printed in the manufacturer’s monograph and established industry references as recognized by the Fund. However the Fund’s Medical Advisor may require a justification in order to give authorization for coverage or continued coverage of a particular drug.
— Prescriptions which require compounding and include an approved therapeutic dose of a legend drug.
What is the difference between Brand Name and Generic drugs?
A generic drug is one that is defined by its official chemical name, rather than its advertised brand name. Generic equivalent drugs must meet the same U.S. Food and Drug Administration (FDA) regulations for purity, strength and safety as brand name drugs; they just cost less.
Is There an Annual Maximum?
Yes. Benefits are limited to a $100,000 maximum per family per calendar year, based upon the date the prescription was dispensed.
What is the Prescription Benefit Record (PBR)?
Twice a year, usually May and November, a Prescription Benefit Record (PBR) is sent to all members for verification of each prescription drug obtained and the following items:
— your address and dependent information
(e.g., name, date of birth...);
— where it was obtained;
— patient it was prescribed for;
— cost to the Fund; and
— how much can be saved by utilizing
generic drugs.
If you discover any discrepancies in any of the above items, contact the Fund Office by indicating the discrepancy directly on the PBR and returning same to the Fund.
How are Benefits Obtained?
Members may obtain benefits by using any of the
following:
— through a participating pharmacy network;
— by mail order; and
— direct reimbursement.
What is the Prescription Drug Identification (ID) Card?
Each eligible member is issued an ID card authorizing any participating pharmacy to fill prescriptions that come under the scope of the plan. The plastic card is embossed with your name and the first names of your eligible dependents (not to exceed seven (7) letters), according to the Welfare Fund’s records.
Each member will receive one (1) new card once during the school year. Members with dependents receive a second card. Additional cards are available upon request to the Welfare Fund.
New members will be issued a card automatically at the completion of the waiting period, provided a properly completed Enrollment Card had been previously submitted to the Welfare Fund.
It is the responsibility of the member to update all dependent information. Upon submitting an Enrollment Card or a Change of Marital Status-Dependents-Beneficiaries Card to the Fund Office to change dependents, a new ID card will be issued automatically.
PLEASE NOTE: The front side of the ID card states “Card not valid after employment terminates or retirement.” This statement applies regardless of the expiration date printed on the front.
How do I use the Participating Pharmacy Program (NPAS)?
In order for you to obtain prescription drugs at an NPAS pharmacy, simply present the prescription and your ID card to the pharmacist. You will be required to make a small, out-of-pocket payment (“copayment”) toward the cost of the drug. The copayments are:
— $5.00 for brand name drugs; and
— $2.00 for generic drugs.
Refills authorized on the original prescription can be obtained (subject to the quantity and time period limitations described below) by presenting your ID card together with the Rx number to the NPAS pharmacy that filled the original prescription. However, another copayment will be necessary.
In both cases mentioned above, you must sign, where mandated by law, either a log book, or a Universal Claim Form, verifying the receipt of medication.
Pharmacies affiliated with the plan display an NPAS sticker. These pharmacies have both an agreement with, and a computerized link to, NPA. If you need to locate an NPAS pharmacy, call one of NPA’s telephone numbers shown on the back of your ID card and the information will be provided. NPA has many participating pharmacies located throughout the U.S. This telephone number can also be used if you are traveling and wish to determine if there is a participating pharmacy in the vicinity.
What Quantities are Permitted at an NPAS Pharmacy?
NPAS pharmacies are authorized to dispense, when permitted by law, up to a 30 day supply or 100 unit doses, whichever is less. In addition, if permitted by law, NPAS pharmacies are authorized to dispense a maximum of two (2) refills, if indicated on the prescription, within one (1) year. If further medication is necessary, a new prescription must be obtained from the patient’s prescriber.
For prescription drugs that are pre-packaged by the manufacturer — for example, asthma inhalers — only up to a maximum of two (2) packages will be permitted to be dispensed at a time, regardless of the quantity written by the prescriber.
What is the Mail Order Program?
The Mail Order Program is designed to provide substantial savings and the convenience of receiving prescription drugs at home. The mail order pharmacy is CFI, which is affiliated with NPA. The address for CFI is: Box 141, Lemoyne, Pa. 17043-0141. The phone number is (800) 233-7139. They have a pharmacist on duty 24 hours a day if you have some specific questions.
This program is primarily used for long term maintenance drugs. These include drugs that are being written for chronic ailments such as, but not limited to:
anemia gout
arthritis high cholesterol
asthma hypertension
depression migraine headaches
gastric diseases thyroid diseases
How do I use the Mail Order Program?
Enclose both the original prescription and a $2.00 copayment (personal check, payable to “CFI”) for each prescription or refill and mail it to CFI along with your name, social security number and the address to which the drugs should be shipped. A postage-paid envelope is available as a convenience. Whether you use the postage-paid envelope or your own, the address where you would like the drugs to be sent must be clear to CFI. There is no limit to the number of prescriptions that can be included in one envelope.
Please note that telephone prescriptions and photocopies cannot be accepted and prescriptions on file at a pharmacy cannot be transferred.
Prescriptions are filled within 48 hours, however, you must allow delivery time both ways. Your medication will be delivered to your home or to any location you request within 10-14 business days by first class mail or United Parcel Service (UPS).
Accompanying your medication will be an envelope to order your refill and/or future prescription(s). In addition, your order will be accompanied by a “Patient Counseling” form, which has useful information regarding your medication and a statement that can be used as a paid receipt.
What Quantities are Permitted through Mail Order?
CFI is authorized to dispense up to a 90-day supply, 100 dosage units or multiple package sizes, whichever is greater, with up to three (3) refills, if indicated on the prescription, within one (1) year. If further medication is necessary, a new prescription must be obtained from the patient’s prescriber.
NOTE: If you choose to use the Participating Pharmacy Program (NPAS) you will have to pay three (3) copayments for the same 90-day supply for which you would only have had to pay one (1) copayment, by ordering through CFI.
What is Direct Reimbursement?
Under direct reimbursement, you are required to pay for the full cost of the drug and then submit to the Fund for payment. (Reimbursement is made according to the fee schedule or the actual charge, whichever is less.) This may arise in the following situations:
— if you present a prescription to a partici-
pating pharmacy without your ID card; or
— if the prescription is for a dependent not
imprinted on your ID card; or
— if you use a non-participating pharmacy.
In these cases, the pharmacist is allowed to charge the store’s regular price.
How do I get Reimbursed?
In order to receive any reimbursement, you must submit a UFT/NPA Direct Reimbursement Form (one for each prescription). You must complete and sign the member’s section (upper half) and have the pharmacy complete its section (lower half). It is not necessary to attach receipted bills. The cardmember ID number is your Social Security number.
The completed form should be mailed to NPA at the address preprinted on the form within 90 days from the date the drug was dispensed.
Reimbursement will be made in accordance with the schedule of allowances limited to the same quantity and package rules, less the copayment that is applicable to participating pharmacies. This will most likely result in an out-of-pocket expense to you greater than the copayment.
What is the Diabetes program?
In 1994, a mandatory diabetes program was legislated by New York State law. The law states that all basic health carriers must cover all drugs, ancillary devices and have a diabetes management educational program for all patients. Since the Welfare Fund supplements your basic city health plan, it was no longer necessary for the Fund to cover these items.
The Welfare Fund has instituted a procedure to reimburse you for the difference in drug copays between your basic health carrier and the UFT Welfare Fund.
For reimbursements, you must submit a DIABETES DRUG REFUND FORM completely filled out with all pharmacy receipts attached. For example, if you are a GHI member, it must include NRx receipts, Telepaid pharmacy receipts and/or the Explanation of Benefits that GHI sends to all its subscribers quarterly. For members with other carriers, in addition to the pharmacy receipts, it must include a statement from that carrier that they have paid or denied the claims.
The Welfare Fund will reimburse you so that your out-of-pocket expense remains equal to the out-of-pocket expense you would have incurred had the Welfare Fund continued its coverage of these drugs. The $5 copayment for a brand drug and the $2 copayment for a generic drug is not reimbursable.
WHAT IS THE COST CARE PROGRAM?
The Cost Care Program allows members and their dependents to obtain medication in a cost effective manner while maximizing the resources available to the Fund.
Who is Enrolled in the Cost Care Program?
Those families whose combined prescription drug claim benefits totaled in excess of $1,200 during the past twelve (12) months will be enrolled in this program. For members and their spouses or domestic partners who are also members, this total is $2,400. These members must notify the Fund of this relationship in order for the $2,400 total (Special Coordination of Benefits) to be applied.
How do I know I used that much in prescription drugs?
Your utilization is reflected on the PBR explained previously. In reviewing the PBR, you should be aware that some prescriptions may be dated before the period indicated. The dates used to determine your eligibility in the Cost Care Program are the dates of payment by NPA and not the date the prescription was filled. The column headed “Prescription Date” lists the date that the prescription was filled, not the date it was reimbursed by NPA. Therefore, it is also likely that recent prescriptions may not be listed.
How is the Cost Care Program Different?
The program differs in the following three (3) ways:
1. You will receive a different colored Prescription Drug ID card which will have “Cost Care Program” printed on it;
2. It requires mandatory use of the Mail Order Program for all drugs other than acute (short-term) care prescriptions;
3. Mandatory Generic Price Provision — When a brand name prescription drug has an approved generic equivalent you can still get the brand name drug. However, you will be responsible for the difference between the cost of that brand name drug and the cost of the generic equivalent, plus the applicable copayment, even if the physician has authorized the brand name drug. Therefore ask your prescriber to write your prescriptions generically whenever possible.
A generic drug is one that is defined by its official chemical name, rather than its advertised brand name. Generic equivalent drugs must meet the same Food and Drug Administration (FDA) regulations for purity, strength, and safety as brand name drugs; they just cost less.
Pharmacies have been requested to charge the difference between the brand name average wholesale price, or the posted price, whichever is less, and the generic equivalent price in addition to the copayment.
What if my prescriber insists on a Brand Name Drug?
The Fund has established a procedure whereby members may seek a waiver to its Mandatory Generic Price Provision. Any member seeking such an exception may do so by having a Generic Price Waiver Form completed in full by the member and his or her physician. These forms are available from the Fund Office. Each request will be reviewed by the Fund’s Pharmacist and Medical Advisor, whose decision will be based upon specific medical criteria, other available medications, and other pertinent information. Members will be notified by mail as to whether an exception can be made to have the Fund pay for a brand name drug where a generic equivalent exists.
What brand name drugs, although available generically, may be dispensed by CFI with no price differential?
The UFT Welfare Fund has waived the generic pricing requirement for the following drugs if dispensed by CFI:
Coumadin Provera
Dilantin Slo-Bid
Isordil Tembids 40 Ritalin
Lanoxin Synthroid
Norpramin Tegretol
Persantine Theo-Dur
Prenatal Vitamins
If there is a generic drug available, how will I be charged if I obtain a brand name at a pharmacy?
The Welfare Fund picks up the cost of the generic drug. You are responsible for the difference between the generic’s price and the brand name’s price, plus the copayment. This difference is determined by NPA according to their contractual arrangement with the pharmacies.
How will I be charged for a brand name drug ordered through the mail when a generic is available?
You will get a bill for the difference between the brand name and its generic equivalent, based upon CFI’s discount prices when you receive your prescription(s). It is important that this bill be paid to CFI within ten (10) days of receipt.
How long will I be in the Cost Care Program?
That all depends on your drug expenditures. The Welfare Fund will review your claim experience every six (6) months. At that time it will total the previous twelve (12) months prescription drug history. If your costs fall below $1,200 (or $2,400 for spouses or domestic partners who are also members), you would be re-enrolled in the regular prescription drug plan.
What is not covered under the Prescription Drug Plan?
1. Direct claims for prescription drugs if they are presented for payment later than 90 days from the date on which the drug was dispensed.
2. Drugs, including vitamins, foods, diet and nutritional supplements, homeopathic medicines, etc. which legally can be purchased without a prescription, even if a written prescription is obtained from a prescriber.
3. Drugs used for cosmetic purposes or hair growth.
4. Drugs used for the treatment of diabetes. (See page 6.)
5. Appliances and all companion implements (devices) used in the administration of drugs.*
6. Prescriptions not dispensed by licensed pharmacists when provided by a hospital, physician or dentist, except under certain circumstances, as determined by the Welfare Fund.
7. Experimental and investigational drugs.
8. Legend drugs for unapproved (unlabeled) use(s).
9. Immunizations/vaccines**, except as approved in advance by the Welfare Fund.
10. Prescriptions filled in a foreign country unless required by a covered person in an emergency and the drug is covered in the U.S.
11. Genetically engineered drugs except as approved in advance by the Welfare Fund.
12. Copayments under Coordination of Benefits (COB).
* Many of these items are covered by the Welfare Fund’s Prescription Appliance Benefit for HIP/HMO and HIP Choice Plus enrollees. GHI-CBP and all other health plans cover many of these items in their basic coverage. Check with your individual plan for details.
** Immunizations for dependents up to the age of 19 are covered by your basic carrier. Check with your individual plan for details.
How do I Obtain Claim Forms or Additional Information?
Call or write to the United Federation of Teachers Welfare Fund. For forms, call the Forms Hotline, (212) 539-0539. For other information call (212) 539-0500.
The UFT Welfare Fund will take appropriate action
to recover from the member, any monies paid out
on behalf of, or to, members/dependents for
prescriptions obtained after eligibility terminates
and for drugs used for
non-approved or unlabeled uses.
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DENTAL PLAN
• SCHEDULED BENEFIT PLAN
Members may choose to access either a panel dentist (SIDS — Self-Insured Dental Services)) at little or no out-of-pocket cost or may choose any dentist and submit for reimbursement according to the schedule of covered dental expenses.
• DENTCARE (HMO)
For members who want comprehensive dental services with no out-of-pocket expenses, Dentcare, a dental HMO is available. Members select a participating dentist for each family member. Specialist referrals are made by the primary dentist.
The UFT Scheduled Benefit Plan is administered by Healthsource Provident Administrators, Inc., P.O. Box 182531, Chattanooga, TN 37422-7531, 1-800-577-0576
*Dental benefits are provided only to the extent that the services and supplies and the course of treatment are necessary and appropriate and that they meet professionally recognized standards of quality. Necessity and appropriateness are determined after taking into account the total current oral condition of the patient.
If you elect to receive dental coverage through the Dentcare HMO, the Welfare Fund’s Scheduled Benefit Plan is not applicable. All covered services would be provided by Dentcare.
DENTAL PLAN
Who is Covered?
All eligible members and eligible dependents, as defined in the General Information section, are covered for dental benefits.
What Dental Benefit Programs are Available?
The UFT Welfare Fund offers benefits through a choice of two (2) types of dental programs as follows:
• A “fee-for-service” plan under which the cost of benefits are reimbursed based on a schedule of allowable charges. This is known as the UFT Welfare Fund Scheduled Benefit Plan (Scheduled Benefit Plan).
• A Dental HMO plan under which comprehensive dental services are covered with no out-of-pocket expenses, known as Dentcare.
How do I enroll in either Dental Plan?
Enrollment in the Scheduled Benefit Plan is automatic. If you wish to select the Dental HMO (Dentcare), there is an Open Enrollment Period every year in the fall during which time you may change plans by completing the Dental Transfer Form (DTF).
NOTE: If you elect to receive dental coverage through the dental HMO, you may not receive reimbursement through the Scheduled Benefit Plan.
What are the Benefits Under the Scheduled Benefit Plan?
This plan provides benefits for covered services under a reimbursement schedule. The “Schedule of Covered Dental Expenses,” listing all covered services and the maximum reimbursement amounts, is delineated in a separate document.
Within the Scheduled Benefit Plan there are two (2) options available:
• Participating Panel Program — provided by
Self Insured Dental Services (SIDS).
• Direct Reimbursement.
What is the Participating Panel Program (SIDS)?
Within the Scheduled Benefit Plan there is a dental panel available consisting of over 600 participating dentists. If you use a participating dentist, the reimbursable services will be provided at no cost to you, except for a $50 copayment on selected dental procedures (i.e., crown, root canal, etc.). All services subject to the $50 copayment are highlighted in red in the Schedule of Covered Dental Expenses. A List of Participating Dentists is printed in a separate pamphlet.
What is the Direct Reimbursement Program?
Under direct reimbursement, you are required to pay for the full cost of the service and then submit for payment. Reimbursement is made according to the scheduled amount or the actual charge, whichever is less. This may happen if you utilize a non-participating dentist.
What is a Pre-Treatment Estimate and When is it Required?
A Pre-Treatment Estimate is an advance notice of dental treatment which must be submitted before treatment is commenced in order to determine what benefits are available. A Pre-Treatment Estimate is required for inlays, crowns, laminate veneers, bridges, dentures, periodontal surgery or when expenses for services provided in a 90-day period will exceed $300.
What is an Alternate Course of Treatment?
Due to the element of choice involved in the utilization of many dental services, situations frequently arise where two or more methods of treatment for a particular dental condition could be used, each of which may produce a desirable, professional result. If an equally effective procedure is available, which is also less costly, the allowance to be reimbursed will be based on this alternate course of treatment. Should you elect to follow the original course of treatment, you will be responsible for any charges which exceed the allowances for the Alternate Course of Treatment.
How are Benefits Obtained Under the Scheduled Benefit Plan?
You can obtain benefit payments for services rendered by participating or non-participating dentists only if you file the required dental claim form with Healthsource Provident as described below.
A. Dental Claim Form
The UFT Welfare Fund Dental Form is used for two different purposes. Indicate by checking the appropriate box on the form whether it is a Pre-Treatment Estimate or a Payment Claim.
You should take a dental form with you when you first visit the dentist, and for each new course of dental treatment.
B. Using the Dental Claim Form
1. Submission of Form
When submitting the Dental Form, you must complete all relevant items in the Member Information section. If not applicable, disregard patient and spouse information. The Authorization to Release Information must always be signed whether the form is a Pre-Treatment Estimate or a Payment Claim.
The Dentist completes the Dentist Information section, including patient name. The Dentist must sign the form. In lieu of completing this form, the dentist may attach his or her own standardized form to the UFT Welfare Fund Dental Form, provided that all required information, including the procedure codes, and the dentist’s signature appear.
2. Assignment of Benefits
The benefits to which you are entitled will be paid to you unless you assign them. Sign the Authorization to Assign Benefits if you wish payment to be sent directly to your dentist. If you assign benefits, you will be notified of payments made so that you know the portion of the bill not covered by this plan.
3. Pre-Treatment Estimate
A Pre-Treatment Estimate (which is an Advance Notice of Dental Treatment) must be submitted along with Pre-Treatment X-rays when the dental course of treatment includes one or more of the following:
a. Periodontic Surgery
b. Inlays or Onlays
c. Crowns
d. Bridgework
e. Dentures
f. The expense for services provided in a 90-day period will exceed $300.
The Pre-Treatment Estimate Form must include all services to be provided in the course of treatment within a 90-day period.
The completed Pre-Treatment Estimate, signed by you and your dentist, must be submitted to Healthsource Provident before treatment is commenced in order to determine what benefits are available. If you do not file this form, you will jeopardize your claim; which may result in non-payment of benefits.
You and your dentist will each receive an Explanation of Benefits (EOB) from Healthsource Provident delineating the services authorized. Services requiring a Pre-Treatment Estimate will not be covered under the Dental Plan unless they have been authorized in this manner.
NOTE: The Pre-Treatment Estimate only authorizes the work to be performed. To obtain benefits, a Payment Claim must be submitted after the work has been performed. No payment will be made if the patient is not eligible when services are rendered.
4. Periodic Submission of Claims
Upon completion of treatment, a complete Payment Claim Form must be submitted to Healthsource Provident with appropriate X-rays. If, however, treatment continues over a long period of time, and your dentist wishes payment as the work progresses, it is possible to be reimbursed on an on-going basis by periodically filing a Payment Claim Form, indicating the work that has been performed to date, and the charges. This process can be repeated during the duration of treatment.
5. Important Information Regarding Claim Form
The Payment Claim Form should be submitted within ninety (90) days of completion of treatment. Be sure to sign the claim form. Remember, it is the member’s responsibility to ensure that all claims are submitted in a timely basis. Claims submitted more than one (1) year after completion of treatment will not be honored for payment.
Be sure to inspect the claim before it is submitted to ensure that the listed services were actually performed. Please be advised that your signature authorizes reimbursement for all dental procedures listed.
NOTE: Pre- and post-treatment X-rays must be submitted with the Payment Claim Form for root canal therapy and non-routine extractions.
What if I have questions regarding the status of a claim or payment?
If you have any questions regarding your claim, please contact Healthsource Provident at 1-800-577-0576 or the Fund Office.
How are payments made?
All payments for benefits under the Plan are made by Healthsource Provident. You will receive a check from Healthsource Provident unless you have assigned the benefit to the dentist. If you have assigned the benefit, payment will be made by Healthsource Provident directly to the dentist.
Will I receive a statement of benefit?
Yes. You will receive a statement from Healthsource Provident, delineating the specific services performed and amount(s) paid, regardless of to whom payment was made. Please review for accuracy.
Are Benefits Provided for the Replacement of, or Additions to Prosthetics?
Benefits are provided for the replacement of, or additions to prosthetic appliances only under the following circumstances:
1. when replacement of an existing partial or full removable denture, or fixed bridgework, replaces missing natural teeth by a new partial or full removable denture, or by addition of teeth to an existing partial removable denture; or
2. when replacement of existing fixed bridgework replaces fixed bridgework, or by the addition of teeth to existing fixed bridgework; or
3. when replacement of an existing partial denture, which replaces missing natural teeth by new fixed bridgework but only when, as a result of the existing condition of the oral cavity, a professional result can be achieved only with bridgework; otherwise, the Covered Dental Expenses for the replacement of an existing denture are limited to the Covered Dental Expenses for a new denture.
With regard to 1, 2 and 3 above, satisfactory evidence must be presented that:
a. the replacement or addition of teeth is required to replace one (1) or more missing natural teeth extracted or accidentally lost after the existing denture or bridgework was installed and while the family member was covered under the plan; or
b. the existing denture or bridgework was installed at least five (5) years prior to its replacement, whether or not benefits were paid for it by this Dental Plan, and that the existing denture or bridgework cannot be repaired, duplicated, or made serviceable; or
c. the existing denture is an immediate temporary denture which cannot be made permanent, and its replacement by a permanent denture takes place within twelve (12) months from the installation of the immediate temporary denture.
4. when, in the case of replacement of an existing free standing crown, evidence satisfactory to Healthsource Provident is presented that the existing crown cannot be repaired or made serviceable, whether or not benefits were paid for it under this Dental Plan.
What is Not Covered Under the Scheduled Benefit Plan?
1. Charges made by a practitioner other than a dentist. Exception: Cleaning or scaling of teeth may be performed by a licensed dental hygienist, if such treatment is rendered under the supervision and direction of the dentist.
2. Charges for services and supplies that are partially or wholly cosmetic in nature, including charges for personalization or characterization of dentures.
3. Charges for crowns, inlays, onlays, dentures, bridgework, or other prosthetic appliances, and the fitting thereof, which (a) were ordered under the plan, or (b) which were ordered while the individual was covered under the plan, but are finally installed or delivered to such individual more than thirty (30) days after termination of coverage.
4. Charges for the replacement of a lost or stolen prosthetic device.
5. Charges for any services or supplies which are for the correction or modification of an occlusion, including orthodontic treatment, except to the extent that such benefits are provided for in the Schedule of Covered Dental Expenses.
6. Charges for any duplicate prosthetic device, or other duplicate device or appliance.
7. Charges for dentures, crowns, inlays, onlays, or bridgework intended to increase vertical dimension.
8. Charges for precision or other elaborate attachments or features for dentures, bridgework, or any other dental appliances.
9. Charges for any services or supplies that are not specifically included as Covered Dental Expenses.
10. Charges that would not have been made if no benefit plan existed, or charges that neither you nor any of your dependents are required to pay.
11. Charges for services or supplies which are furnished, paid for, or otherwise provided for by reason of the past or present service, of any person in the armed forces of a government.
12. Charges for services or supplies which are paid for, or otherwise provided for under law of a government (national or otherwise), except where the payments or the benefits are provided under a plan specifically established by a government for its civilian employees and their dependents.
13. Charges for any dental treatment, services or supplies which are not recommended and approved by the attending dentist.
14. Charges for services or supplies which do not meet professionally recognized standards of quality, are not necessary for treatment of existing disease or injury, or are not appropriate treatment, taking into account the total currently existing oral condition.
15. Charges in excess of the allowances authorized by the Fund.
DENTAL HMO PLAN — DENTCARE
What are the Benefits Under the Dental HMO Plan (Dentcare)?
The Dentcare HMO is a pre-paid program of comprehensive dentistry with no deductibles, copayments or other out-of-pocket expenses when provided or authorized by your primary Dentcare dentist. There are no annual or lifetime maximums and they offer 100% coverage on all covered dental services without having to file claim forms.
How do I Enroll in the Dentcare HMO Plan?
Enrollment in the Dentcare HMO is strictly voluntary. If you wish to select Dentcare you must complete the Dental Transfer Form (DTF), available from the Fund Office, during the Fall Open Enrollment Period. Once enrolled, you and your family will continue to be enrolled in Dentcare until the next Fall Open Enrollment Period when you are permitted to change plans.
Can each family member have a different dental plan?
No. If you enroll in Dentcare, your entire family must also be enrolled in Dentcare.
How do I Obtain Benefits Under the Dentcare Plan?
You must choose your dentist from Dentcare’s list of participating providers. That dentist will perform all necessary work or will refer you to one of Dentcare’s specialists.
Specialists must be referred by your primary dentist. There is no coverage without the proper referral.
It is not necessary for the entire family to have the same dentist. Each family member, including children, may choose from the list of Dentcare’s participating dentists.
Specific questions about the level of benefits or about participating dentists may be directed to Dentcare at 1-800-468-0608.
Once enrolled, Dentcare will send you an ID card indicating your primary dentist. Dentcare will also notify the dentist that you are a Dentcare patient. You may call your Dentcare dentist anytime after the effective date of your coverage.
Special Coordination of Dental Benefits
A. SCHEDULED BENEFIT PLAN
Members and their spouses or domestic partners who are also members are entitled to Special Coordination of Benefits (SCOB) when both are covered by the Scheduled Benefit Plan.
SCOB can significantly increase reimbursement for dental work. If you utilize the services of a non-participating dentist whose charges are above the schedule of allowances, you will be eligible for additional reimbursement under your spouse’s or domestic partner’s coverage. You are covered for up to twice the fee schedule not to exceed the dentist’s actual charges.
SCOB does not extend to limitations on time or frequency of treatment. For example, one (1) exam every six (6) months does not become one (1) exam every three (3) months; but the reimbursement for the exam could be higher.
To obtain the special coordinated dental benefit, check the box on top of the form to indicate special coordination of benefit coverage and submit it directly to Healthsource Provident.
CAUTION: Do not assign these benefits to your dentist. Assignment will interfere with the Welfare Fund’s ability to administer your coordinated benefits.
B. SIDS
SCOB is not applicable to SIDS panel dentists. If you utilize the services of a SIDS panel dentist, you would generally have no out-of-pocket costs except for the $50 co-payment for certain procedures. This co-payment would not be reimbursable through SCOB.
C. DENTCARE & SCHEDULED BENEFIT PLAN
1. — You may also elect to have your family covered under Dentcare and the Scheduled Benefit Plan. One member enrolls in Dentcare and the other member stays in the Scheduled Benefit Plan.
Under this option, you and your family members may use either a Dentcare dentist or a non-Dentcare dentist. Services rendered by the non-Dentcare dentist would be reimbursed according to the Scheduled Benefit Plan.
2. — SCOB (additional reimbursement as explained in Part A above) would no longer be applicable.
3. — Out-of-pocket costs incurred under the Scheduled Benefit Plan are not reimbursable through Dentcare.
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DISABILITY PLAN
• The plan provides benefit payments for up to 28 weeks to disabled members.
• Pregnancy and Maternity/ChildCare Coverage
• Benefits are paid based on current income and are paid at the rate of either $275.00 or
$175.00 per week.
*Disability benefits are payable only under the circumstances and in accordance with the procedures and limitations set forth in the Rules and Regulations that follow.
DISABILITY PLAN
Who Is Covered?
All eligible members are covered for benefits under the UFT Welfare Fund Disability Plan.
What are the Benefits?
The benefits are $275 per week to a maximum of 28 weeks, except for Paraprofessionals and other groups within the same salary range, whose benefits are $175 per week to a maximum of 28 weeks.
Is there a waiting period?
Yes. There is a consecutive 28-day unpaid waiting period after you have exhausted your Sick Bank (Cumulative Absence Reserve) and have been removed from the Board of Education payroll. Summer vacation period days are excluded.
The Board’s Grace Period (applicable only to regularly appointed teachers) runs concurrently with the 28-day unpaid waiting period.
However, if you have requested to borrow sick days, these borrowed days are not considered part of the 28-day unpaid waiting period. Therefore, the 28-day unpaid waiting period begins after the borrowed days are exhausted.
Rules and Regulations:
If an eligible member shall become disabled, the UFT Welfare Fund, following the 28-day unpaid waiting period, will pay benefits in the amount and for the period specified below.
A. Disability Defined
Disability shall mean only that period during which an eligible member is prevented from performing the duties of his or her employment in any occupation or employment as a result of injury or mental or physical illness as determined by the Fund.
The Welfare Fund has found that not all members who apply for disability benefits are actually disabled. Therefore, a physician has been retained as the Fund’s Medical Advisor to review all disability claims. The Medical Advisor initially determines whether the member is disabled and, if so, for how long the member is considered by the Fund to be disabled.
After reviewing each claim, the Medical Advisor may take one or more of the following actions:
1. authorize payment for all or part of the period of the disability claim;
2. request additional medical documentation;
3. determine that (an) examination(s) by a physician designated by the Medical Advisor is/are required (at no charge to the member);
4. reject the claim.
All claimants shall be subject to examination(s) by a designated physician and shall furnish such proof of illness or injury as the Fund Office shall, in its discretion, direct.
Pregnancy Related Disability
In the case of pregnancy related disability, experience has shown that disability as defined above usually occurs during the 9th month of pregnancy and in the 6 weeks immediately following the delivery. Therefore, examination by a designated physician will not be required during those periods. If pregnancy related disability is claimed for any other period, the usual rules described above regarding examination will be followed. If you have been removed from the Board of Education payroll, the 9th month of pregnancy is considered your 28-day unpaid waiting period.
B. Amount Payable Defined
The amount payable, subject to the exclusions and limitations set forth below, is as follows:
1. Members, other than those included in 2. below, are eligible for a benefit of $275 per week (Monday through Friday) of disability.
2. Paraprofessionals and other groups within the same salary range are eligible for a benefit of $175 per week (Monday through Friday) of disability.
3. Fractional weeks are payable at a daily rate equal to 1/5 of the weekly benefit.
4. By law, FICA (Social Security Tax) must be deducted from disability payments unless the member is exempt from Social Security taxes. If exempt, the member should submit a copy of a recent pay stub to the Fund Office with the initial claim.
What is the maximum number of weeks I can collect disability?
There is a 28 week maximum per each period of continuous disability. In addition, the following rules apply:
1. Benefits shall be payable commencing with the first day of disability following the expiration of the unpaid waiting period as defined above. The member must have been granted by the Board either:
a. — an authorized Leave of Absence Without Pay for the Restoration of Health; or
b. — an authorized Leave of Absence Without Pay for Maternity/Child Care.
2. Benefits will end when you are no longer disabled, as determined by the Fund, or have been paid for 28 weeks, whichever occurs first.
3. All periods of disability due to the same or related sickness or injury followed by a recovery and a return to work for a period of less than forty (40) successive work days, will be considered one continuous period of disability.
4. A member who has returned to work for at least forty (40) successive work days after a period of disability shall be entitled to begin a new period of disability of not more than 28 weeks.
5. Benefits for all periods of disability due to the same or related sickness or injury shall not exceed one hundred (100) weeks.
6. Maternity benefits have a maximum of six (6) weeks for normal deliveries, and eight (8) weeks for Cesarean sections. This is known as a routine pregnancy. The Fund will issue payment only once; after the six (6) or eight (8) weeks.
7. Complicated pregnancies will have a maximum of up-to 28 weeks, as determined by the Fund’s Medical advisor.
How are Benefits Obtained?
1. You should request a disability claim form from the Fund Office.
2. There are two types of claim forms in connection with this benefit. One is white and marked in the upper right hand corner, “DBL-1- Initial Application.” The other is blue and marked in the upper right hand corner, “DBL-2- Supplemental Application.” Each form is a three-part form with an Affidavit on the bottom.
It is your responsibility to:
a. complete the members portion Section A and
b. make sure that your principal completes Section B and
c. make sure that your physician completes Section C and
d. sign the affidavit on the bottom and
e. ensure that all the necessary documentation has been attached to the claim form and is forwarded to the Fund Office.
Incomplete claims will be returned to you, thus delaying your benefit payments. Photocopies of any of the claim forms are not acceptable.
3. Your first claim (DBL-1- Initial Application) must be filed no later than 30 days following your 28-day unpaid waiting period, or 30 days following the issuance of your Leave, whichever is later. Failure to file within this period may result in the loss of benefits for the period between the 29th day of disability and the date the claim is received by the Fund Office. Physical inability, or delays in obtaining the required documentation necessary to file within this period, may be considered an exception and will be given consideration.
4. Upon receipt of a properly completed and signed claim form, with necessary documentation attached (see below), the Fund will have the claim reviewed by its Medical Advisor, as described in the Disability Defined section above.
5. After having received your initial disability benefit payment from the Fund, and if you are eligible for further disability benefits, the blue “DBL-2-Supplemental Application,” form must be completed. This form will be enclosed with your benefit check. It must be completed in the same manner as the DBL-1, as described above.
A DBL-2 will not be enclosed when:
a. — the maximum benefit has been paid; or
b. — the Medical Advisor has determined that no additional benefits are payable; or
c. — you have returned to work; or
d. — you were paid for a routine pregnancy.
6. You should apply for supplemental benefits no later than 30 days following the last date of the previous UFT Welfare Fund Disability Payment.
In addition to completing your initial claim form (DBL-1), you must attach the documentation specified as follows;
Regular Pedagogical Appointees: A copy of the Board of Education computerized Personnel Transaction Form signed by you and your Principal or Community Superintendent or Board of Education Form OP#218 (Leave of Absence Without Pay for Restoration of Health or Leave of Absence Without Pay for Maternity). A Leave of Absence Without Pay for Child Care is not acceptable if it does not also specify Maternity Leave.
Paraprofessionals: A copy of the form, Application for Leave of Absence for Employees in Educational Paraprofessional Titles, issued by the Board of Education with “Approval” indicated in the appropriate section by the Medical Director for those on authorized sick leave without pay. For Maternity Leaves your application must be approved by your District or Superintendent’s Office, and not the Medical Director.
Regularly Assigned Substitutes: A letter from your Principal stating that you would have been regularly assigned for the term had it not been for your injury or illness. This letter is required only if you are, or continue to be disabled at the beginning of a new term.
It should be noted that:
1. Whenever applicable, proof of the child’s birth must be submitted.
2. All Board of Education Forms specified above are issued by the Board of Education upon application to the Board. These forms are not available from the Fund Office.
Line of Duty Injuries
When a member has a line of duty injury and has filed for medical arbitration, all of the claim procedures and filing deadlines specified above must be followed, or the member may jeopardize any Welfare Fund disability benefits that may become payable in the event that line of duty injury status is denied. A copy of the Medical Arbitration decision must accompany the claim form.
What is not covered under the Disability Plan?
No benefits shall be paid:
1. For any period for which there has not been proper filing.
2. For any period for which pay is received from the Board of Education, except for the Grace Period.
3. For any period during which benefits are paid or payable under any Workers’ Compensation law, occupational disease law, or similar legislation of the State or Federal Government.
4. For any period during which benefits are paid or payable under any unemployment compensation or similar laws.
5. For any period during which the member is not under the care of a legally licensed physician for the condition causing the disability.
6. For any period of disability which does not commence while a member is covered under the UFT Welfare Fund rules of eligibility.
7. For any period of disability due to willfully and the intentionally self-inflicted injury or sickness or to injury sustained in the commission of a crime.
8. For any period during which pension is received from any governmental retirement service.
9. For any period during which benefits are paid or payable under the New York State or other jurisdiction’s No-Fault Insurance Law. This exclusion is not applicable after No-Fault benefits are exhausted. A letter from the No-Fault insurance carrier confirming this must accompany your DBL-1.
10. For any period for which reimbursement may be obtained from any other third party, such as by way of litigation arising out of an accident, or otherwise, unless a written assignment or lien in a form acceptable to the Fund is executed by the claimant to the Fund for the amount claimed.
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OPTICAL PLAN
• PARTICIPATING OPTICAL CENTERS
Members can use the service once every two (2) years by bringing a validated certificate to any of the participating optical centers. The service, if used at a participating optical center, includes a free eye exam.
• DIRECT REIMBURSEMENT PROGRAM
For those members who wish to use their optical service at any non-participating optical provider, they may submit their validated certificate along with original receipts for reimbursement.
OPTICAL PLAN
Who is Covered?
All eligible members and dependents, as defined in the General Information section, are covered for optical benefits.
What is the Benefit?
The optical benefit consists of one (1) “optical service” every two (2) years (counted from your last optical service) obtained through a network of participating panelists or direct reimbursement. An optical service consists of a full comprehensive eye exam* and at the same time, if necessary, a pair of eyeglasses (defined as single vision, bifocal or trifocal lenses) and frame, or the replacement of a frame, lens or pair of lenses.
You may elect to purchase contact lenses and receive a credit as per the fee schedule.
* Laws in certain states such as New Jersey, Connecticut and Florida prohibit examinations at certain optical centers or mandate a specific charge for certain specified services. Members are advised to check with centers outside New York State to determine if the eye examination is provided by that center without additional cost. In any event, the Welfare Fund will not reimburse any copays for exams.
How are Benefits Obtained?
1. You must obtain an Optical Benefit Certificate by requesting it from the Fund Office or by calling the Forms Hotline. Your request must indicate who the service(s) are for, so that the Fund may verify eligibility prior to mailing out the certificate.
2. Upon receiving a validated Optical Benefit Certificate, make sure to sign it on the bottom of Part 1. You may obtain the service(s) from a participating panelist, or a non-participating provider whereby you must submit for direct reimbursement.
3. Certificates will not be honored for payment if the patient information is altered in any way.
Please Note: Certificates are not transferable. Photocopied certificates will not be accepted.
How do I use the Participating Panelist Program?
1. Present the validated Certificate to any of the Participating Optical Panelists designated on the current list of Welfare Fund Optical Centers. Validated Certificates must be presented to the Panelist within 30 days from the date validated. If the Certificate has not been used within the 30-day period, a replacement may be obtained by following the same procedures as above.
2. Panelists are not obliged to accept validated Certificates after an order is placed.
3. Upon completion of the service at the Participating Optical Center, make sure to complete, date and sign Part 6 of the Certificate before leaving the store. Payment will be made directly to the Participating Panelist.
What are the advantages of using the Participating Panelist Program?
1. There is no cost to you for a complete pair of eyeglasses which include:
a. A pair of single vision, bifocal or trifocal lenses. In addition, and when required, high prescription lenses (“heavy Rx” - lenses with dioptoral power above 4 in the sphere or cylinder and all prisms) will be provided at no cost to you; AND
b. A basic frame which is defined as any frame with a minimum retail value of forty dollars ($40.00). There will be available a selection of at least 10 basic frames, in a variety of shapes and colors.
2. Coverage for eye examinations.
3. The Fund has negotiated a discount and surcharge program with the panelists who have agreed to the following:
a. For any upgraded frame, you will receive a forty dollar ($40.00) allowance or the retail price of the basic frame whichever is greater.
b. For any extra lens features purchased in connection with your optical service that are not mentioned in part “d” below, a minimum 15% discount will be given, for example, Polycarbonate Lenses.
c. For any item purchased not in connection with your service, for example, a second pair of glasses, a minimum 10% discount will be given.
d. If you choose, or the prescription requires, oversize, tinting, UV block, or other items as listed below you may be charged no more than the following surcharges (per pair):
Oversize (Greater than 70mm):
Single Vision Lenses: $ 5.00
Bifocal Lenses: $10.00
Scratch Resistant Coating: $15.00
UV Block: $10.00
Tinting: $10.00
Flattop 35mm Lenses: $25.00
Reflection Free Coating: $25.00
Case Hardening (Glass): $ 8.00
In no event shall the Fund be responsible to pay such additional charge.
4. Based on its contractual relationship with the panelist, the Fund will offer its assistance in helping you resolve any problems with a participating panelist that may arise.
What is the Direct Reimbursement Program?
Under direct reimbursement, you are required to pay for the full cost of the service at the optician and submit to the Fund for payment. Reimbursement is made in accordance with the fee schedule or the actual charge, whichever is less. This may arise in the following situations:
— if you utilize a non-participating optical center; or
— if you use a participating panelist without presenting a validated certificate at initial
date of service.
NOTE: NO reimbursement will be made for eye exams in the NY Metropolitan Area or Florida.
How do I get reimbursed?
1. Attach an ORIGINAL PAID ITEMIZED receipt and a copy of the prescription to the Validated Certificate. Altered or photocopied receipts will not be accepted. Sign and date Part 6 and mail it to the Welfare Fund office for reimbursement.
2. Reimbursement for covered services is made in accordance with the fee schedule in effect at the time of service, not to exceed the actual charges.
3. Claims must be submitted for payment no later than 90 days from the date of service.
What is Not Covered Under the Optical Program?
1. Non-prescription sunglasses even if recommended by physician for therapeutic reasons.
What is Not Covered Under the Direct Reimbursement Program?
1. Services rendered at participating panelists.
2. Assignment of payment to a provider.
3. Eye exams in the New York Metropolitan Area or Florida.
Does Special Coordination of Benefits (SCOB) apply to the Optical Plan?
Yes. Members and their spouses or domestic partners who are also members are entitled to SCOB. This entitles each eligible family member, upon presentation at the same time of two (2) validated certificates, to two (2) covered services, one (1) service under each member’s benefit record.
If the patient does not want the second service, for example, a second pair of eyeglasses at the same time as the first, he or she can either:
1. use the second certificate to receive the amount of the first service or $40.00, whichever is less; or
2. use the second service any time, by obtaining a new validated certificate.
NOTE: HIP/HMO subscribers can also arrange for eye examinations at no cost through their plan. This is not in lieu of the service provided by the Fund.
FEE SCHEDULE
A. COMPLETE SERVICE: *
1. Complete service which includes Single Vision lenses, frame and eye exam- $55.00
2. Compete service which includes Single Vision lenses and frame with NO eye exam- $40.00
3. Complete service which includes Bifocal lenses, frame and eye exam- $65.00
4. Complete service which includes Bifocal lenses and frame with NO eye exam- $50.00
5. Complete service which includes Trifocal lenses, frame and eye exam- $75.00
6. Complete service which includes Trifocal lenses and frame with NO eye exam- $60.00
* Contact lenses are reimbursed in accordance with the above schedule.
B. PARTIAL SERVICE:
1. Eye exam only $15.00
2. Single Vision lenses only $20.00
3. Bifocal lenses only $30.00
4. Trifocal lenses only $40.00
5. Frame only $20.00
High Prescription Lenses ( heavy Rx) fee schedule is available upon request to the Fund Office.
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• Upon termination, COBRA (Federal Consolidated Omnibus Budget Reconciliation Act) requires the Welfare Fund to offer members, retirees and their families, the opportunity to purchase certain benefits.
The election of City (Medical/Hospital) Cobra
does not automatically enroll you in
UFT Welfare Fund Cobra.
A separate Welfare Fund Cobra application is required
COBRA
When am I eligible for COBRA?
Covered members are eligible for continuation under COBRA if Welfare Fund coverage was terminated due to a reduction in hours of employment or the termination of employment including retirement. Termination of employment includes unpaid leaves of absence of any kind and cannot be due to gross misconduct.
Spouses/domestic partners of covered members have the right to continue coverage if coverage is lost for any of the following reasons: 1) death of the member; 2) termination of the member’s employment ; 3) loss of coverage due to a reduction in the member’s hours of employment; 4) divorce or legal separation from the member; 5) termination of the domestic partnership with the member.
Dependents of members have the right to continue coverage if coverage is lost for any of the following reasons: 1) death of the member; 2) the termination of a member’s employment; 3) loss of coverage due to the member’s reduction in hours of employment; 4) the dependent ceases to be a “dependent child” under the Fund’s rules of eligibility.
NOTES: 1 — Individuals covered under another employer sponsored group health plan may not be eligible for COBRA.
2 — The Fund offers Medicare eligible enrollees and/or their Medicare-eligible dependents continuation benefits similar to COBRA if a COBRA event should occur.
3 — Termination of employment due to gross misconduct is not a qualifying COBRA event
What are the periods of continued coverage?
Continuation of coverage for members and eligible dependents as a result of termination of employment, reduction of work schedule, or loss/reduction of Fund benefits due to retirement, is available for a maximum of eighteen (18) months.
If the member is totally disabled on the date of termination from employment or reduction of hours, continuation of coverage for the member and eligible dependents may be extended from 18 to 29 months. The monthly premium for the 19th through the 29th months will be 150% of the group rate. To qualify for 29 months of COBRA coverage, Social Security must determine that the member is totally disabled. If Social Security later determines that the individual is no longer totally disabled, COBRA continuation coverage may terminate before the end of the 29 month period.
Continuation of coverage for eligible dependents as a result of death, divorce, legal separation, termination of domestic partnership or loss of dependent child status is available for a maximum of thirty-six (36) months.
Continuation of coverage can never exceed thirty-six (36) months in total, regardless of the number of events which relate to a loss of coverage. Coverage during the continuation period will terminate if the COBRA participant fails to make timely payments. COBRA may terminate if the participant becomes enrolled in another employer sponsored group health plan (unless the new plan contains a pre-existing condition exclusion).
What are my notification responsibilities?
Under the law, the member, retiree or eligible dependent has the responsibility to notify either their payroll secretary or the Board of Education’s Health and Welfare Office (Actives), or City of NY Health Benefits Program (Retirees) and the Welfare Fund within sixty (60) days of an address change, death, divorce, legal separation, termination of domestic partnership or a child losing dependent status.
Members who are totally disabled (as determined by Social Security) on the date of termination of employment or reduction of hours must notify the Welfare Fund of the disability. The notice must be provided within sixty (60) days of Social Security’s determination and before the end of the 18-month continuation period. If Social Security later determines that the individual is no longer disabled, the former member must also notify the Welfare Fund of this change in determination. This notice must be provided within thirty (30) days of Social Security’s final determination.
When a qualifying event (such as a member’s death, termination of employment, or reduction of hours) occurs, you and your eligible dependents will be notified by the Board of Education’s Health and Welfare Office (Actives), or City of NY Health Benefits Program (Retirees) of your option to choose continuation coverage.
How do I elect City (Medical/Hospital) COBRA coverage?
To elect City COBRA continuation of health coverage, the COBRA eligible person must complete a “COBRA-Continuation of Coverage Application” (Form EB7r). This application is available through the payroll secretary, the Board of Education’s Health and Welfare Office (Actives) or City of NY Health Benefits Program Retirees).
This application is mailed directly to your medical insurance carrier.
How do I elect UFT Welfare Fund COBRA coverage?
To elect UFT Welfare Fund COBRA you must either:
• check off the box marked “yes" on the City COBRA application where it asks “Do you wish to purchase benefits from your Welfare Fund?” The Welfare Fund will receive a copy of your application from your health carrier (this may take up to two (2) months)
or
• make a copy of your City application and send it directly to the Welfare Fund Office. This will expedite the process.
If you do not elect City COBRA but you would like to purchase Welfare Fund COBRA, contact the Fund office directly.
Eligible persons choosing to elect COBRA coverage must do so within sixty (60) days of the qualifying event or the date on which they receive notification of their rights, whichever is later.
When are premium payments due?
The initial premium is due within forty-five (45) days of your COBRA election. Thereafter, premiums are due on the first of the month with a thirty (30) day grace period.
When can I change my benefits selected under COBRA?
COBRA participants are entitled to change the selection of COBRA benefits during the City’s Fall open enrollment period as designated for Actives or Retirees.
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SUPPLEMENTAL BENEFITS
• The Welfare Fund provides benefits that supplement specific City basic medical plans
SUPPLEMENTAL BENEFITS
What are Supplemental Benefits?
Supplemental benefits, as described below, are benefits provided by the UFT Welfare Fund that supplement specific City basic health plans.
The Welfare Fund does not provide supplemental benefits for all plans; only for the four (4) following plans:
HIP/HMO
HIP CHOICE PLUS
GHI-CBP/EBCBS (Empire Blue Cross Blue Shield)
GHI TYPE C
Furthermore, the supplemental benefits differ, according to the city plan.
Who Is Covered?
All eligible members and dependents who are enrolled in one of the City basic plans listed above are covered, including members enrolled as dependents under their spouse’s or domestic partner’s City basic plan.
NOTE: No Welfare Fund Supplemental Benefits are available to dependents not enrolled under the same City contract as the member. However, the other Welfare Fund benefits are available.
What are the Benefits and How are they Obtained?
HIP/HMO Enrollees:
1. — Private Duty Nursing: After a 72-hour deductible, eighty percent (80%) of reasonable, usual and customary charges for in-hospital services performed by a registered nurse, from the fourth day through the 60th day of nursing care, are paid by the Welfare Fund.
2. — Anesthesia: The Welfare Fund pays eighty percent (80%) of reasonable, usual and customary charges, when not covered by HIP/HMO.
3. — Prescription Appliances: The Welfare Fund pays eighty percent (80%) of reasonable, usual and customary charges for certain covered appliances,* after a $25 annual deductible per person, subject to a $1,500 maximum per year/$3,000 lifetime.
*Note: The Fund follows guidelines established by HIP and the Fund’s Medical Advisor. Those appliances that meet these standards are covered.
To obtain benefits for private duty nursing, anesthesia or prescription appliances, a completed claim form should be submitted to the UFT Welfare Fund. In addition, when submitting an anesthesia claim form, you must attach a copy of the HIP/HMO rejection letter. Claim forms are available upon written request to the Fund office or by calling the Forms Hotline (212) 539-0539. Any member who is enrolled in the City basic health plan as a dependent under his or her spouse’s or domestic partner’s City plan must attach a photocopy of the HIP/HMO ID Card to the claim form.
HIP CHOICE PLUS Enrollees:
The benefits described immediately above for HIP/HMO enrollees are also available to HIP CHOICE PLUS enrollees. However, HIP CHOICE PLUS is primary and all claims must be sent to them first. After HIP CHOICE PLUS processes your claim for the above services, you should submit to the UFT Welfare Fund the paid bill and proof of payment or rejection from HIP CHOICE PLUS for reimbursement of any remaining out-of-pocket expenses. Payment for any remaining out-of-pocket expenses is subject to the maximum benefit available as described above. In no case will the Welfare Fund pay more than would have been paid to a HIP/HMO subscriber and in no case are you entitled to receive more than 100% of your expenses.
GHI-CBP/EBCBS Enrollees:
1. — Hospitalization Coverage: The UFT Welfare Fund, through a contract with EBCBS, supplements the City basic hospital coverage by increasing the 75 full days to 365 full days.
The services covered and the limitations and exclusions which apply to the City EBCBS Basic Hospital Plan also apply to the UFT Welfare Fund supplemental hospitalization benefits. Hospitalization coverage for children does NOT continue beyond the child’s 19th birthday UNLESS the member is enrolled in the City Optional Rider, in which case the unmarried full-time student’s coverage will be the same as the member’s until the end of the calendar year of the 23rd birthday or graduation, whichever comes first. EBCBS will make payment to the hospital under both the Basic and Supplemental coverages.
GHI Type C Enrollees:
1. — Hospitalization Coverage: The UFT Welfare Fund, through a contract with EBCBS, supplements the City basic hospital coverage by increasing the 75 full days to 365 full days.
The services covered and the limitations and exclusions which apply to the City EBCBS Basic Hospital Plan also apply to the UFT Welfare Fund supplemental hospitalization benefits. Coverage for children does not continue beyond the 19th birthday. EBCBS will make payment to the hospital under both the Basic and Supplemental coverages.
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LIFE INSURANCE PLAN
• The plan provides for a benefit payable on a decremental scale to the beneficiary of the active member.
LIFE INSURANCE PLAN
Who Is Covered?
All eligible Active members are covered for Life Insurance.
What are the Benefits?
The Life Insurance benefit is paid on a decremental scale to take into account the equity that older members have in the NYC Teachers’ Retirement System. The benefits are payable in accordance with the following Schedule of Benefits:
AGE AMOUNT
Under 40 $30,000
40-44 $20,000
45-49 $15,000
50-54 $9,000
55-59 $6,000
60-64 $4,000
65-69 $2,500
70 and older $1,600
How are Benefits Obtained?
The Fund will send a Life Insurance Notification Form to a member of the family or the beneficiary(ies) of the deceased upon the Fund Office being notified of the death of the member. Certified copies of the Birth and Death Certificates must be attached.
The Welfare Fund will then send a Life Insurance Claim Form to the beneficiary(ies) to be completed, notarized, and returned to the Fund. A check in the appropriate amount will then be sent to the beneficiary(ies).
How do I Designate a Beneficiary?
The beneficiary is designated on the official Enrollment Card of the UFT Welfare Fund. It is very important to keep in mind that the designation of beneficiary be kept up to date. Should there be a change in marital status or should the designated beneficiary die, a new beneficiary should be promptly designated by the completion of an official Change of Marital Status-Dependents-Beneficiary Card provided by the UFT Welfare Fund. Should there be a divorce or an annulment subsequent to a beneficiary designation, that designation will be nullified and a new designation will be required. Official Enrollment Cards and Change of Marital Status-Dependents-Beneficiary Cards may be obtained from the Fund Office or from Chapter Leaders. Should the last named beneficiary(ies) predecease the member, or should no beneficiary(ies) be named, the Life Insurance benefit will be paid to the first surviving class of the following classes of successive preference beneficiaries: the deceased member’s (a) widow or widower/domestic partner; (b) surviving children; (c) estate.
Can I convert my Life Insurance to a Personal Life Policy?
Yes. You have the right to convert to a personal life policy, the amount of your life insurance which terminates or reduces because:
1. — you end employment; or
2. — you change job status and so become ineligible; or
3. — your retire; or
4. — the group policy is terminated.
Your personal life policy amount can be equal to or less than the amount that terminated.
The maximum life amount which may be converted is the terminated life amount. That amount will be reduced by any life amount for which you are or become eligible under any group policy issued or reinstated by the same or another insurer within forty-five (45) days after that termination.
How do I apply for a Personal Life Policy?
To apply, you must contact the Fund office for a conversion application package. The package will include two (2) forms:
1. — Life Insurance Conversion Notification of Conversion Privilege and
2. — Application for Conversion of Group Life Insurance To An Individual Life Insurance Policy.
Both forms must be completed and sent, along with the first premium payment, to First UNUM within thirty-one (31) days from the date the life insurance terminated. No evidence of insurability is needed.
What are my Death Benefits during the 31-day conversion period?
If you die during the 31-day conversion period, First UNUM will pay a death benefit which will:
1. — be paid under the group policy and not under the personal life policy; and
2. — equal the maximum life amount which you might have otherwise converted.
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