Time Limits For Claims Filing

Claims for all Welfare Fund benefits should be filed promptly. The time limitations for claims filing are:

 • Disability Benefits – claims must be filed within sixty days after the exhaustion of accumulated leave;

 • Dental Benefits – claims must be filed within sixty days of the date dental services were completed;

 • All other Benefits – claims must be filed within one year of the occurrence of the expense.

 Procedure For Appeal Review

The following is a description of the appeal review procedure. The rules below do not in any way limit your right to contact the Board of Trustees in writing with regard to any claim you may have.

 In the event that your claim has been denied in whole or in part, and you do not agree with the denial, you may request in writing an appeal review of the Fund’s decision regarding your claim, within sixty (60) days of your receipt of written notification of the denial of your claim.  This request must identify the patient, covered member, if different, the decision to be reviewed, and must also explain the reason you do not agree with the denial of benefits.

 You may designate a representative to act on your behalf in the appeal review procedure.  To designate a representative, you must provide a written statement specifying the name of the representative, the claim number or denial notice number, and the designation must be notarized, signed and dated.  A written designation of a representative is necessary to protect against disclosure of information regarding the claim except to your authorized representative.  Upon receipt of the request for review of the claim, you or your authorized representative have the right to submit issues and comments in writing, and any additional information pertinent to the claim.

 The Fund’s Board of Trustees will provide a written decision within a reasonable period of time from receipt of your request for review.  The written reply will contain the reasons for the decision.

 If your appeal is rejected, you will be given an opportunity to request a conference with a committee of the Board of Trustees at a specified time for further review of your claim.

 All decisions of the Board of Trustees shall be final and binding on the member, his/her representatives or estate.  You must follow the appeal procedure stated above before instituting any judicial proceeding or action.

 Amendment or Termination of Benefits

The benefits provided by the Funds may, from time to time, be changed, modified, augmented or discontinued by the Trustees. The Trustees adopt rules and regulations for the payment of benefits and all provisions are subject to such rules and regulations and to the Trusts which established the Funds and govern their operations.

 Your coverage and your dependent’s coverage will stop on the earliest of the following dates:

 When the Fund is terminated.

 When you are no longer eligible.

 When there is a non-payment of any required direct pay contributions/premiums.

 When the employer ceases to make contributions on your behalf to the Fund.

 Your dependents’ coverage will also terminate when they are no longer your eligible dependents.

 Benefits under this plan have been made available by the Trustees as a privilege and are always subject to modification or termination in the exercise of the prudent discretion of the Trustees. No person acquires a vested right to such benefits. The Trustees may expand, modify or cancel the benefits; change eligibility requirements and otherwise exercise their prudent discretion at any time without legal right or recourse by a member, dependent or any other person.

 Referral For Professional Services

The no-out of pocket expense options under the Welfare Fund’s Dental Plan and Optical Benefit and  are designed to offer covered members convenience and cost savings. As a Fund member, you are free to take advantage of these options; however, the Welfare Fund explicitly disclaims any liability relating to issues of malpractice that might arise through use of any of its benefits. Any member or dependent who uses these programs does so on the express condition that he or she releases the Funds, the Union and all their representatives from any liability for claims or actions arising out of services received or omitted.

 Special Coordination of Benefits

In instances where both spouses or domestic partners are Welfare Fund members, both members can receive the Fund’s Dental, Optical, Hearing Aid Appliance, Abortion and Prosthetic Appliance Benefits from each other’s coverage.  In addition, their eligible children may receive benefits (except Abortion Benefits) from each member’s coverage. This is known as Special Coordination of Benefits (“SCOB”).  Details of how SCOB works are included under the description of each applicable benefit.

 Overpayment/Future Offset

In the event you receive an overpayment, or mistaken payment, by the Welfare Fund, on your behalf or on behalf of your dependent, then you are obligated to refund the overpayment to the Welfare Fund immediately.  In the event you fail to refund the overpayment/mispayment, then the Welfare Fund shall have the right to offset any future benefits due you by the overpayment amount, until the Welfare Fund is fully reimbursed for the overpayment/mispayment to you. Such offset and/or suspension can also be applied to the benefits of a member’s eligible dependents.  An overpayment/misapayment includes, but is not limited to, any payment made on claims submitted by individuals who are no longer eligible dependents (e.g. a divorced  spouse of a member who did not elect to continue coverage under COBRA) as well as payment of an incorrect amount on claim.

 “COBRA” Continuation Coverage

NOTE:  The election of COBRA continuation of the City-provided health plan DOES NOT automatically enroll you in COBRA continuation for coverage under the plan of the SSEU Local 371 Welfare Fund.  You must indicate on the City COBRA form that you wish to enroll in COBRA from your Welfare Fund.  It is your responsibility to follow up on this election directly with the Welfare Fund to insure no interruption in your coverage.

 This is important information about your right to COBRA continuation coverage, which is a temporary extension of coverage under the Plan. This explains COBRA continuation coverage, when it may become available to you and your family, and what you need to do to protect your right to get it. When you become eligible for COBRA, you may also become eligible for other coverage options that may cost less than COBRA continuation coverage.

 The right to COBRA continuation coverage was created by a federal law, the Consolidated Omnibus Budget Reconciliation Act of 1985 (COBRA). COBRA continuation coverage can become available to you and other members of your family when group health coverage would otherwise end.

 You may have other options available to you when you lose group health coverage. For example, you may be eligible to buy an individual plan through the Health Insurance Marketplace. By enrolling in coverage through the Marketplace, you may qualify for lower costs on your monthly premiums and lower out-of-pocket costs. Additionally, you may qualify for a 30-day special enrollment period for another group health plan for which you are eligible (such as a spouse’s plan), even if that plan generally doesn’t accept late enrollees. (This language is required by the Federal Patient Protection Affordable Care Act.  The Fund cannot represent whether or not the “stand-alone” prescription drug, dental, optical, hearing aid, podiatry or prosthetic appliance benefits are available through health insurance exchanges.)

 What is COBRA continuation coverage?

COBRA continuation coverage is a continuation of Plan coverage when it would otherwise end because of a life event. This is also called a “qualifying event.” Specific qualifying events are listed later in this notice. After a qualifying event, COBRA continuation coverage must be offered to each person who is a “qualified beneficiary.” You, your spouse, and your dependent children could become qualified beneficiaries if coverage under the Plan is lost because of the qualifying event.

 COBRA continuation coverage applies to the Welfare Fund’s health-related benefits – i.e. Prescription Drug, Dental, Optical, Hearing Aid, Podiatry, Abortion and Prosthetic Appliance.

 If you’re an employee/member, you’ll become a qualified beneficiary if you lose your coverage under the Plan because of the following qualifying events:

 • Your hours of employment are reduced, or

• Your employment ends for any reason other than your gross misconduct.

 If you’re the spouse of an employee/member, you’ll become a qualified beneficiary if you lose your coverage under the Plan because of the following qualifying events:

• Your spouse dies;

• Your spouse’s hours of employment are reduced;

• Your spouse’s employment ends for any reason other than his or her gross misconduct;

• Your spouse becomes entitled to Medicare benefits (under Part A, Part B, or both); or

• You become divorced or legally separated from your spouse.

 (Note – The law does not require that COBRA continuation coverage be extended to domestic partners. However, the Fund’s Board of Trustees has determined that such COBRA continuation coverage will be offered to domestic partners of Fund members.)

 Your dependent children will become qualified beneficiaries if they lose coverage under the Plan because of the following qualifying events:

• The parent-employee/member dies;

• The parent-employee’s/member’s hours of employment are reduced;

• The parent-employee’s employment ends for any reason other than his or her gross misconduct;

• The parent-employee/member becomes entitled to Medicare benefits (Part A, Part B, or both);

• The parents become divorced or legally separated; or

• The child stops being eligible for coverage under the Plan as a “dependent child.”

 When is COBRA continuation coverage available?

The Plan will offer COBRA continuation coverage to qualified beneficiaries only after the Fund has been notified that a qualifying event has occurred. The employer must notify the Fund Administrator of the following qualifying events:

 • The end of employment or reduction of hours of employment;

• Death of the employee/member; or

• The employee’s/member’s becoming entitled to Medicare benefits (under Part A, Part B, or both).

For all other qualifying events (divorce or legal separation of the employee and spouse or a dependent child’s losing eligibility for coverage as a dependent child), you must notify the Fund Administrator within 60 days after the qualifying event occurs. You must provide this notice to the Fund Administrator; SSEU Local 371 Welfare Fund 1501 Broadway, 4th Floor New York, New York 10036.

How is COBRA continuation coverage provided?

Once the Fund Administrator receives notice that a qualifying event has occurred, COBRA continuation coverage will be offered to each of the qualified beneficiaries. Each qualified beneficiary will have an independent right to elect COBRA continuation coverage. Covered employees/members may elect COBRA continuation coverage on behalf of their spouses, and parents may elect COBRA continuation coverage on behalf of their children.

COBRA continuation coverage is a temporary continuation of coverage that generally lasts for 18 months due to employment termination or reduction of hours of work. Certain qualifying events, or a second qualifying event during the initial period of coverage, may permit a beneficiary to receive a maximum of 36 months of coverage.

There are also ways in which this 18-month period of COBRA continuation coverage can be extended:

Disability extension of 18-month period of COBRA continuation coverage

If you or anyone in your family covered under the Plan is determined by Social Security to be disabled and you notify the Fund Administrator in a timely fashion, you and your entire family may be entitled to get up to an additional 11 months of COBRA continuation coverage, for a maximum of 29 months. The disability would have to have started at some time before the 60th day of COBRA continuation coverage and must last at least until the end of the 18-month period of COBRA continuation coverage.

Second qualifying event extension of 18-month period of continuation coverage

If your family experiences another qualifying event during the 18 months of COBRA continuation coverage, the spouse and dependent children in your family can get up to 18 additional months of COBRA continuation coverage, for a maximum of 36 months, if the Plan is properly notified about the second qualifying event. This extension may be available to the spouse and any dependent children getting COBRA continuation coverage if the employee/member or former employee/member dies; becomes entitled to Medicare benefits (under Part A, Part B, or both); gets divorced or legally separated; or if the dependent child stops being eligible under the Plan as a dependent child. This extension is only available if the second qualifying event would have caused the spouse or dependent child to lose coverage under the Plan had the first qualifying event not occurred.

How much does COBRA Continuation Coverage Cost?

Generally, each qualified beneficiary is required to pay the entire cost of continuation coverage, which may not exceed 102% (150% in the case of an extension of continuation coverage due to disability) of the cost to the Fund for coverage of a similarly situated Fund member or eligible dependent who is not receiving continuation coverage.

Are there other coverage options besides COBRA Continuation Coverage?

Yes. Instead of enrolling in COBRA continuation coverage, there may be other coverage options for you and your family through the Health Insurance Marketplace, Medicaid, or other group health plan coverage options (such as a spouse’s plan) through what is called a “special enrollment period.” Some of these options may cost less than COBRA continuation coverage. You can learn more about many of these options at www.healthcare.gov. (This language is required by the Federal Patient Protection Affordable Care Act.  The Fund cannot represent whether or not the “stand-alone” prescription drug, dental, optical, hearing aid, podiatry or prosthetic appliance benefits are available through health insurance exchanges.)

If you have questions

Questions concerning your Plan or your COBRA continuation coverage rights should be addressed to the contact or contacts identified below. For more information about your rights under COBRA and other laws affecting group health plans, contact the nearest Regional or District Office of the U.S. Department of Labor’s Employee Benefits Security Administration (EBSA) in your area or visit www.dol.gov/ebsa. For more information about the Marketplace, visit www.HealthCare.gov

Keep your Plan informed of address changes

To protect your family’s rights, let the Fund Administrator know about any changes in the addresses of family members. You should also keep a copy, for your records, of any notices you send to the Plan Administrator.

Subrogation/Reimbursement Rights

The Funds have been designed to help you meet certain expenses. They have not been designed for you to collect benefits that exceed your expenses. Therefore, if benefits are also payable from a provider or other third party, the Funds shall be subrogated to all claims, demands, actions and rights of recovery of the individual against any such third party or any insurer, including Workers’ Compensation, to the extent of any and all payments made or to be made hereunder by the Funds.  The Funds have the right to collect payment from the third party or to be repaid from benefits you recover from the third party.  In order to collect payment, the Funds can bring an action in any capacity (i.e. subrogee, assignee, etc.) against the third party if you or your personal representative do not do so. The participant’s right to be made whole is superseded by the Funds’ subrogation rights hereunder.

When you or your personal representative file for benefits under these circumstances, you agree to reimburse the Funds for any benefits you receive to the extent of any and all payments you recover as a result of judgment, settlement or otherwise, whether recovery is full or partial.  You or your personal representative also agree to take whatever action is necessary, including but not limited to executing and delivering in a timely fashion any documents as may be required, and to provide all necessary information, assistance, and paperwork that the Funds require in order to enforce their rights.

Privacy of Protected Health Information Under the Heath Insurance Portability and Accountability Act

A federal law, the Health Insurance Portability and Accountability Act (“HIPAA”), requires the Welfare Fund to protect the confidentiality of your health information.  A complete description of your rights under HIPAA can be found in the Fund’s privacy notice a copy of which is available on the Fund’s website at www.mightyunion.org

The Fund will not use or further disclose information that is protected by HIPAA (“protected health information”), except as necessary for treatment, payment, operations of the Fund’s plan of benefits or as permitted or required by law.  By law, the Fund will not, without authorization, use or disclose protected health information for employment-related actions and decisions.

Under HIPAA, you have certain rights with respect to your protected health information, including certain rights to see and copy the information, receive an accounting of certain disclosures of the information, and under certain circumstances, amend the information.  You also have the right to file a complaint with the Fund or the U.S. Department of Health and Human Services if you believe your rights under HIPAA have been violated.

“Grandfathered” Health Plan Disclosure Notice

The SSEU Local 371 Welfare Fund believes it is a “grandfathered health plan” under the Federal Patient Protection and Affordable Care Act (“ACA”).  A grandfathered health plan can preserve certain basic coverage that was already in effect when the law was enacted.  A grandfathered plan may exclude certain consumer protections of the ACA that apply to other plans, for example, the requirement for the provision of preventive health services without cost sharing.  However, grandfathered health plans must comply with certain other consumer protections in the law, for example, the elimination of lifetime limits on benefits.

Questions regarding which protections apply and which protections do not apply to a grandfathered health plan and what might cause a plan to change status from grandfathered status can be directed to the Fund office.