Fitzharris/GVS Member Benefits Booklet
PORT JEFFERSON STATION TEACHERS
ASSOCIATION BENEFIT TRUST
Revised – February 2011
TABLE OF CONTENTS
Where to Find Claim Forms 1
When Should you Submit a Claim? 1
How to File Your Claim Forms 1
SYNOPSIS OF BENEFITS – Dental 2
How Do You Enroll? 3
When Does Your Coverage Begins? 3
When Does a Dependent’s Coverage Begin? 3
If Your Do Not Enroll Promptl? 3
WHO IS ELIGIBLE AND WHEN COVERAGE BEGINS 4-5
DENTAL CARE BENEFITS 9-13
WHAT EXPENSES ARE NOT COVERED? 14-15
GENERAL INFORMATION 16
Non-Duplication of Benefits 16-19
Family Continuance Benefit 19-20
When Coverage Ends 20
Claim Filing Procedures 24
Family and Medical Leave ACT 25-26
HIPAA Privacy Notice 27-30
PORT JEFFERSON STATION T.A.B.T.
WHERE TO FIND CLAIM FORMS:
Claim forms are found in the building offices or the Fitzharris & Co. Inc. website at www.fitzharrisinsurance.com.
WHEN SHOULD YOU SUBMIT A CLAIM?
When you have a claim, you should promptly submit the completed claim form and any bills or receipts. We have the right to reject claims submitted more than 180 days after the service. A late claim might be accepted if it is not reasonably possible to submit the claim during the 180 days.
Please note: Benefit checks are VOID after 90 days. Please cash promptly.
HOW TO FILE YOUR CLAIM FORMS:
– Electronic Claim Filing – Electronic Claims can be submitted by your provider. Fitzharris’ Payer Number is 11244 for dental claims.
– The top portion of the Claim Form entitled “Employee’s Section” on the dental form must be fully completed.
– If the Claim is for yourself, your coverage is the primary plan. If the claim is for your spouse and he/she has other coverage, be sure to attach the payment voucher or declination from his/her plan. If the claim is for your dependent children and your birthday (month and day) is earlier in the calendar year than your spouse’s, you should file first. If your spouse’s birthday is earlier, you must file with your spouse’s plan first, and attach copies of their payment voucher to the claim you are filing through our plan.
– Either have the dentist complete his portion of the form or attach itemized bills to the completed form.
– Completed forms should be mailed to the Claims Administrator, Fitzharris Administrator Inc., at the address which appears on the claim form.
SYNOPSIS OF BENEFITS
PLAN EFFECTIVE DATE: September 1, 2002
EMPLOYEES ELIGIBLE: As defined on Page 4
DEPENDENTS ELIGIBLE: All dependents as defined
PLAN CONTRIBUTIONS: As determined by the Contract
DENTAL BENEFITS FOR YOU AND YOUR DEPENDENTS:
Maximum Dental Benefit Per Policy Year (7/1 – 6/30) ……………………….$2,000.00
Orthodontia Maximum ………………………………………………………….$1,500.00
Temporomandibular Joint Disorder (TMJ)………………………………………$1,500.00
Lifetime maximums are not subject to policy year maximums
Dental Deductible: The Individual Dental Deductible per policy year will be $25.00 for each person, up to $75.00 per family.
Note: The deductible does not apply to Diagnostic and Preventive Services.
Dental Co-insurance Rate: 100% for Diagnostic and Preventive Services
80% Basic Services
50% Major Services
50% Orthodontic Services
IMPORTANT: Read the document carefully. See “Definition” and “What Expenses are
Not Covered” for other conditions that may affect coverage.
HOW DO YOU ENROLL?
You enroll for coverage by completing a Request for Coverage form which is available from the union office. If you wish to cover any eligible dependent, you must elect coverage for all of your eligible dependents. If you do not have any eligible dependents when you enroll, you may apply for dependent coverage when you acquire an eligible dependents.
If both you and your spouse are members of the group, both of you may elect dependent coverage.
WHEN DOES YOUR COVERAGE BEGIN?
Your coverage begins on the later of September 1, 1992 or the first day of the month after you begin work.
Employees must be actively at work at the employer’s regular place of business; and physically able to perform all such duties.
Work or duties performed at home or while confined in a hospital or other medical institution may not be used to meet this requirement.
WHEN DOES A DEPENDENT’S COVERAGE BEGIN?
If you have enrolled for dependent coverage, coverage for your eligible dependents begins on the date your coverage begins. Dependents you later acquire will become covered on the day they become eligible dependents.
IF YOU DO NOT ENROLL PROMPTLY?
You should enroll promptly. If you are required to contribute for coverage and if you or your eligible dependents do not enroll within the first 31 days after you become eligible, coverage will be limited during the first 24 months. See Late Entrants
WHO IS ELIGIBLE AND WHEN COVERAGE BEGINS
WHO IS ELIGIBLE FOR COVERAGE?
All active members of the Port Jefferson Station Teachers Association Benefit Trust.
Your following dependents, if any, are also eligible for coverage:
- Legally married spouse. Legally separated spouse or divorced spouses are not covered.
- Each of your unmarried children: who are under 19 years of age; or who are full-time college students under 25 years of age and are dependent upon you for support; or stepchildren, adopted children, or foster children who are dependent upon you for support.
- Coverage for a full-time student will end on the earlier of (a) the attainment of the limited age (25 years), or (b) the end of the third month following the day he/she graduates or leaves school.
Exceptions – The dependent age limit does not apply to handicapped dependent children. You may be required to show proof of handicapped status once a year.
Mentally or Physically Handicapped Children
If a Covered Dependent child:
(a) reaches the age at which he would otherwise cease to be a Covered Dependent; but
(b) is then mentally or physically incapable of earning his own living; and
(c) is primarily dependent upon you for support; and if
(d) you submit satisfactory proof of the child’s incapacity within 31 days of the date the child reaches such age,
then coverage may continue for such child for as long as he remains incapacitated, subject to payment of required contributions and all other terms of the plan.
When you retire, coverage may continue on a self-paid basis. Coverage must be continuous. If you allow the coverage to terminate due to non-payment of premium, coverage cannot be reinstated.
The following applies only to Dental Benefits if provided on a Contributory Basis:
LIMITATION FOR LATE ENTRANTS – DENTAL
If you or any of your Dependents enroll later than 31 days after the date on which you or such Dependent becomes eligible, then they will be subject to the following restrictions:
(1) Under Diagnostic & Preventive Services, only routine oral examinations and x-rays will be covered for the first six months; and
(2) Periodontal treatment, Major Services and Orthodontia Services will not be covered for the first 24 months.
Except as noted below, an expense is deemed to be incurred on the date a service is rendered or a supply is furnished.
– Expense for an appliance or modification of an appliance is deemed to be incurred on the date the master impression is made.
– Expense for a crown, a bridge, or an inlay or onlay restoration is deemed to be incurred on the date the tooth is prepared.
– Expense for root canal therapy is deemed to be incurred on the date the pulp chamber is opened.
The charge usually made by an individual Dentist for a given service.
The charge usually made by Dentists for a given service within the locality where the service is rendered.
A charge which is both Usual and Customary for the service rendered
Necessary Service or Supply
A service or supply which is generally considered by Dentists to be an appropriate dental service or supply for a given dental condition.
For purposes of this plan, the Plan Administrator reserves the right to determine:
(1) Usual Charges; and
(2) Customary Charges;
(3) Reasonable Charges; and
(4) Necessary Services or Supplies
A Reasonable Charge incurred by a Covered Person for a Necessary Service or Supply which appears on a list of Covered Expenses.
Pre-Determination of Benefits
A Dentist’s report to the Claims Administrator which:
– is on a claim form; and
– lists the dental services he proposes to render to a Covered Person; and
– shows his charge for each service; and
– is accompanied by pre-treatment, x-rays or other diagnostic data which the Claim Administrator may require.
A licensed Dentist who is practicing within the scope of his license.
A person who:
– is licensed to practice dental hygiene; and
– works under the direct control and supervision of a Dentist.
The total amount of benefits which will be available to a Covered Person during a Policy Year.
Lifetime Maximum Benefit
The total amount of benefits which will be available to a Covered Person during his lifetime.
A 12-month period beginning July 1 and ending June 30
If: (1) there is a less costly alternative to any service or supply which is:
(3) such alternative is within accepted standards of dental practice;
then only the Reasonable Charge for such alternative shall be considered to be Covered Expense.
Refers to you or any of your eligible dependents covered under the plan.
DENTAL CARE BENEFITS
WHAT IS THE DEDUCTIBLE?
The policy year deductible is $25.00 per covered person up to $75.00 per family.
Covered dental expenses incurred by a covered person which was applied toward the deductible during the months of April, May, and June will carry over to the next policy year.
WHAT DO WE PAY?
We will pay 100% of Diagnostic and Preventive Expenses. After you pay the deductible we will pay 80% of Basic Expenses, 50% of major expenses and 50% or Orthodontic expenses, including TMJ. These expenses are subject to reasonable and customary allowances as determined by the Plan Administrator.
Is There a Maximum Benefit?
The maximum we will pay for all Covered Expenses, excluding orthodontia, during a policy year is $2,000.00. Also, the maximum we will pay for orthodontic treatment is $1,500.00 per lifetime. Additionally, the maximum we will pay to TMJ treatment is $1,500.00 per lifetime.
Should Benefits Be Determined Before Treatment Starts?
One of the advantages of this dental plan is that it enables you to see the amount payable by the plan prior to having your dentist begin any extensive treatment. This procedure is known as a Predetermination of Benefits. Through this process, you can prevent any misunderstanding as to what is covered by the dental plan. Benefits should be predetermined before you begin treatment if the charges for the treatment will be more than $300.00.
A dental claim form should be completed and submitted to the Claims Administrator. The Claims Administrator will advise you and your dentist of the approved covered dental procedures.
DENTAL CARE BENEFITS (continued)
What If More Than One Method Of Treatment Is Available?
When more than one method of treatment is available, we will pay for Covered Expenses for the least expensive method of treatment, regardless of which method is actually used. Examples of this are: restoring teeth with a crown when the tooth could be restored with a filling; fixed bridgework when a partial denture would provide a similar result.
What Are Covered Expenses?
Covered Expenses are USUAL OR CUSTOMARY CHARGES by a dentist for necessary dental services furnished to a covered person under the plan. There are four types of Covered Expenses: Preventive Expenses, Basic Dental Expenses, Major Dental Expenses and Orthodontic Expenses. Not all expenses are covered. See – WHAT EXPENSES ARE NOT COVERED?
What Are Preventive Expenses?
Preventive Expenses are the following:
ORAL EXAMINATIONS – not more than twice in a policy period.
PROPHYLAXIS – including the scaling and polishing of teeth (limited to 2 a policy period).
TOPICAL APPLICATION OF FLUORIDE limited to two treatments per policy year for children under age 15.
BITEWING X-RAYS (not more than twice a year).
FULL-MOUTH SERIES OF X-RAYS, including bitewings (limited to once every 3 years).
PANORAMIC SURVEY (considered full mouth series) limited to once every 3 years.
SPACE MAINTAINERS – Charges for space maintainers for missing primary teeth.
SEALANTS – One application of sealant material for each permanent molar tooth for dependent children under age 16 (limited to once in 36 months).
DENTAL CARE BENEFITS (continued)
What Are Basic Expenses?
Basic Dental Expenses are for the following services:
ORAL SURGERY – Charges for surgery performed on the gums, alveolar processes and teeth. This includes removal of impacted or erupted teeth and preparation of the gums for dentures.
EXTRACTIONS – Charges for extractions, including those in connection with orthodontic treatment (includes local anesthetic and post-operative care).
ANESTHESIA – Charges for general anesthesia administered in connection with covered surgical procedures. The anesthetic agent must produce a state of unconsciousness with absence of pain over the entire body.
PERIODONTICS – Periodontal charting and mounted original full mouth x-rays are required for all periodontal procedures. If more than one surgical service is performed per quadrant, only the most inclusive surgical service performed will be considered a covered dental service. Flap entry and closure is considered part of the dental service for osseous surgery and osseous graft. Periodontal procedures include: periodontal scaling/root planning (limited to 4 quad per year), gingivectomy or gingivoplasty, osseous surgery.
ENDODONTICS – Charges for root canal therapy, includes necessary x-rays.
FILLINGS – Charges for amalgam and composite fillings, other than gold fillings. Composite restorations are covered charges and limited to the first ten teeth in each arch.
TEMPOROMANDIBULAR JOINT DISORDER – Routine office visits for adjustment to the appliance (limited to six visits in a six consecutive month period beginning after the seating or placement of the appliance).
Transacutaneous electro-neural stimulation and trigger point injection of local anesthetic in to muscle fascia (limited to four treatments in a six-month period for each).
Mandibular orthopedic repositioning appliance (limited to one appliance in any five year period).
DENTAL CARE BENEFITS (continued)
What Are Major Expenses?
Major Dental Expenses are for the following services:
RESTORATIONS – Restorative Cast Restorations, crowns, crowns over implants, inlays and onlays are covered only when necessitated by decay or traumatic injury and the tooth cannot be restored with a routine filling material.
BRIDGES AND DENTURES – Charges for initial installation of dentures or fixed bridgework to replace at least one natural tooth extracted while the family member is covered under the plan’s dental care program.
REPLACEMENT WORK – Charges for replacement of existing crowns, inlays, onlays, dentures or fixed bridgework if the existing was installed at least five years prior to its replacement and cannot be made serviceable. The replacement must not be needed because of the loss or theft of the crown, inlay, onlay, dentures or fixed bridgework.
Also, charges for replacement of existing dentures or fixed bridgework, or for the addition of teeth to existing dentures or fixed bridgework , if needed to replace at least one natural tooth extracted while the family member is covered under the Plan’s Dental Care Program.
REPAIR WORK – Charges for repair and recementing of crowns, inlays and fixed bridgework.
DENTAL CARE BENEFITS (continued)
WHAT ARE ORTHODONTIC EXPENSES?
The following is a list of covered orthodontic expenses covered by this plan.
DESCRIPTION OF SERVICES
PREVENTIVE TREATMENT PROCEDURES
MINOR TREATMENT FOR TOOTH GUIDANCE
Removable appliance therapy
Fixed or cemented appliance therapy
INTERCEPTIVE ORTHODONTIC TREATMENT
Removable appliance therapy
Fixed appliance therapy
TREATMENT OF THE TRANSITIONAL DENTITION
Class I Malocclusion
Class II Malocclusion
Class III Malocclusion
TREATMENT OF THE PERMANENT DENTITION
Class I Malocclusion
Class II Malocclusion
Class III Malocclusion
HOW ARE ORTHODONTIC BENEFITS PAID?
Payments will be made for 50% of the covered orthodontic charges described above which are incurred while eligible, up to the maximum lifetime benefit of $1,500.00.
Orthodontic benefits are calculated as follows:
Maximum allowable $3,000.00 at 50%. The insertion allowance is considered to be no more than 25% of the total fee. The remainder will be calculated over the estimated number of months of treatment.
WHAT EXPENSES ARE NOT COVERED?
The following charges are not covered or are covered only to the extent states.
- OCCUPATIONAL INJURY – Charges due to an on-the-job injury are not covered. However, this exclusion will not apply if the law does not permit a family member’s employer (or the family member) to obtain coverage for the family member under a Workers’ Compensation Act or similar act. Nor will it apply if the law permits but does not require a family member who is a partner or an individual proprietor to have coverage under a Workers’ Compensation Act or similar act and that person does not have such coverage.
- OCCUPATIONAL SICKNESS – Charges due to any sickness which would entitle the family member to benefits under a Workers’ Compensation Act or similar act are not covered.
- GOVERNMENT SERVICES – Charges for dental services furnished by or paid for by any government or government agency are not covered. Charges for dental services are not covered if the family member would not have been required to pay for the services in the absence of insurance for dental care. However, this exclusion will not apply where prohibited by law.
- COSMETIC DENTISTRY – Charges in connection with dental services primarily for the purpose of improving appearance are not covered. For example, the following are not covered
Alteration or extraction and replacement of sound teeth
Porcelain or other veneer crowns or pontics to replace molar teeth
Composite or plastic fillings placed in molar teeth
WHAT EXPENSES ARE NOT COVERED? (continued)
- Replacement of existing dentures or fixed bridgework, or addition of teeth to existing dentures or fixed bridgework, unless:
(I) the replacement or addition is needed to replace at least one natural tooth extracted while the family member is covered under the Dental Plan; or
(II) the existing denture or fixed bridgework was installed at least five years prior to the replacement and cannot be made serviceable. However, this exclusion will not apply to any such replacement which is required because of accidental bodily injury which a covered person sustains while covered under this plan.
- Replacement of lost or stolen crowns, dentures or fixed bridgework.
- Appliances, restorations, or procedures for:
a. altering vertical dimension; or
b. restoring or maintaining occlusion; or
c. splinting; or
d. replacement of tooth surface lost by abrasion or attrition; or
e. treatment of dysfunction of the temporomandibular joint (TMJ), unless specifically included in your booklet.
- MISCELLANEOUS SERVICES – Charges for oral hygiene instruction, plaque control, dietary instructions.
- SERVICES BY RELATIVES – Charges for dental care furnished by any person related by blood or marriage, except for covering for lab costs and materials.
- Charges for Implantology.
- Any service or supply which is not customarily performed, not reasonably necessary for dental care or treatment or is experimental nature.
- Any service or supply which is not furnished by a dentist, except:
a. A service performed by a Dental Hygienist working under supervision of a dentist; and
b. X-rays ordered by a dentist.
TREATMENT STARTED BEFORE COVERAGE BEGINS
Charges for the following are not covered:
Dentures, if the impression for the denture was taken before the family member because covered under the Dental Care Plan; crowns, bridges or gold restorations if preparation of the teeth was begun before the family member became covered under the Dental Care Plan; root canal therapy if begun before the family member became covered under the Dental Plan.
Orthodontic charges which were charged prior to the employee’s effective date of coverage.
This orthodontic maximum will be reduced by all orthodontic services rendered prior to the effective date of coverage.
ACTIVE WORK/ACTIVELY AT WORK
This means the performance of all the duties that pertain to your work at the place where it is normally done, or where it is required to be done by your Employer.
For purposes of Dental Benefits, the term “doctor” means a dentist or physician. The term:
(a) “dentist” means a Doctor of Dental Surgery or a Doctor of Medical Dentistry;
(b) “physician” means a legally qualified physician.
The terms “charges”, “fees”, or “expenses”, will not include any amount:
(a) for a service or supply not generally accepted in health care practice as needed in the diagnosis or treatment of the patient, even if ordered by a doctor;
(b) for repeated tests which are not needed, even if ordered by a doctor;
(c) more than what is reasonable and customary in the locale where incurred.
These amounts will be determined by the Plan Administrator.
NON-DUPLICATION OF BENEFITS
If a covered person is entitled to benefits for dental care under this Plan and at least one other plan, the amount of benefits provided by this Plan for that care, if this Plan is the Secondary Plan, may be reduced to the extent that the total benefits paid or provided by all plans during a Claim Determination Period are not more than the total of the Allowable Expenses that the person incurs in that period. The amount by which the Secondary Plan’s benefits have been reduced shall be used by the Secondary Plan to pay the stated percentage of Allowable Expenses, not otherwise paid, which were incurred during the Claim Determination Period by the person for whom the claim is made. As each claim is submitted, the Secondary Plan determines its obligations to pay for the stated percentage of Allowable Expenses based on all claims which were submitted up to that point in time during the Claim Determination Period.
This will be done as set forth in Order of Payment.
This term means any necessary, reasonable and customary item, expense or part of the cost of which is covered by (a) this Plan, or (b) one of the other plans, except Medicare or a “no-fault” motor vehicle plan.
When a Plan provides benefits in the form of services, the reasonable cash value of each service will be considered as both an Allowable Expense and a benefit paid.
Claim Determination Period
The time during any one Plan Year when a person is covered and incurs charges for one or more items of expense covered under: (i) this Plan; and (ii) at least one other plan.
NON-DUPLICATION OF BENEFITS – (continued)
As each Claim is submitted, each Plan is to determine its liability and pay or provide benefits based upon Allowable Expenses incurred to that point in the Claim Determination Period. But that determination is subject to adjustment as later Allowable Expenses are incurred in the same Claim Determination Period.
Refers to Fitzharris & Co. Inc.
This term means any plan that provides medical or dental care coverage written on an expense incurred basis with which coordination is allowed.
“Plan” may include:
(a) any group insurance or any other method of coverage for persons in a group.
(b) an uninsured arrangement of group coverage.
(c) group coverage through HMO’s and other prepayment, group practice and individual practice plans.
(d) any governmental plan but not including a state plan under Medicaid.
(e) any plan required by law but shall not include a law or plan when, by law, its benefits are excess to those of any private insurance plan or other non-governmental plan.
(f) the medical benefits coverage in group and individual mandatory automobile “no-fault” and traditional mandatory automobile “fault” type contracts.
“Plan” shall not include:
(a) blanket school accident coverage; or
(b) hospital indemnity coverage.
The part of the Group Policy which, provides benefits for dental care.
This Plan, or any other Plan, which determines its medical or dental care benefits for an insured person without taking into account any other Plan. A Plan is Primary if either:
(i) the Plan does not have a Non-Duplication of Benefits provision like This Plan; or
(ii) the Plan, in accord with Order of Payment, would determine its benefits first.
Any plan which is not a Primary Plan.
TITLE XVIII of the Federal Social Security Act, as it now is or as it may be changed. A person who is eligible for Medicare will be deemed to have all the coverages for which he or she is so eligible.
NON-DUPLICATION OF BENEFITS – (continued)
No-Fault Motor Vehicle Plan
A motor vehicle plan which is required by law and provides medical or dental care payments which are made, in whole or in part, without regard to fault.
A person subject to such law who has not complied with the law will be deemed to have received the benefits required by the law.
Order of Payment
When a person is covered under two or more plans, the rules that follow will decide the order in which the plans will pay benefits:
1. A plan which does not have a provision like this Non-Duplication of Benefits will pay before this Plan.
2. A plan which covers a person other than as a dependent will pay before a plan which covers a person as a dependent.
3. A plan which covers a person as a dependent of a person whose date of birth occurs earlier in a calendar year will pay before a plan which covers the person as a dependent of a person whose date of birth occurs later in a calendar year; provided that:
(a) if said dates of birth are the same, the plan which has covered a person for the longest time will pay first.
(b) if the other plan does not have the rule described above but instead has a rule based upon the gender of the parent, and if, as a result, the Plans do not agree on the order of benefits, the rule in the other plan will determine the order of benefit.
In Item 3, date or birth means day and month of birth. It does not mean year of birth.
However, if the person is a dependent child of divorced or separated parents, the order will be as follows:
(i) first, the Plan of the parent with custody of the child;
(ii) then, the Plan of the spouse of the parent with custody of the child;
(iii) finally, the Plan of the parent not having custody of the child.
However, if there is a court decree which sets forth a financial duty for the health care expenses of the child, and the entity obligated to pay or provide the benefits of the Plan of that parent has actual knowledge of those terms, the benefits of the Plan are determined first. This paragraph does not apply with respect to any Claim Determination Period or plan year during which any benefits are actually paid or provided before the entity has the actual knowledge.
NON-DUPLICATION OF BENEFITS – (continued)
4. The benefits of a plan which covers a person as an employee who is neither laid off nor retired (or as that person’s dependent) are determined before those of a plan which covers that person as a laid-off or retired employee (or as that person’s dependent).
5. If these four rules do not decide which plan will pay its benefits first, the plan which has covered the person for the longest time will pay first. The length of time a person has been covered under a Plan by the following:
(a) Two plans shall be treated as one if the claimant was eligible under the second within 24 hours after the first ended.
(b) The claimant’s length of time covered under a Plan is measured from the claimant’s first date of coverage under that Plan. If that date is not readily available, then it is measured from the date the claimant first became a member of the group.
To administer claims, the Plan Administer, without the consent of any person, will have the right:
(a) to give or to get any data needed to determine benefits under this provision; and each person claiming benefits under a Plan must give the Plan Administrator any data needed to pay the claim.
(b) to pay an organization for the payment made under this Plan which should have been paid by the Plan Administrator. Amounts so paid will be deemed benefits paid under this Plan; and to the extent so paid there will be no more liability under this Plan.
(c) to recover any excess if the amount paid is more than it should have paid under this provision from one or more of:
(i) the persons it has paid or for whom it has paid;
(ii) insurance companies; or
(iii) other organizations.
A Secondary Plan which provides benefits in the form of services may recover the reasonable cash value of providing the services from the Primary Plan, to the extent that benefits for the services are covered by the Primary Plan and have not already been paid or provided by the Primary Plan. Nothing in this provision shall be interpreted to require a Plan to reimburse a covered person in cash for the value of services provided by a Plan which provides benefits in the form of services.
FAMILY CONTINUANCE BENEFIT
In the event of your death while covered, Dental Benefits will be continued for dependents who are covered at that time. The benefits continued are the same as those inforce at the time of your death and are provided without contributions.
The coverage on all dependents will be continued for two years from the date of your death or until the date your surviving spouse remarries, whichever occurs first.
FAMILY CONTINUANCE BENEFIT – (continued)
Retired employees under age 65 are eligible for this Family Continuance Benefit.
The coverage on any one dependent will end on the date the individual ceases to qualify as an eligible dependent for any reason except lack of your primary support.
Any extension of benefits after coverage ends will also apply to dependents when the coverage provided by the Family Continuance Benefit ends.
WHEN COVERAGE ENDS
Your coverage ends when any of the following events occurs:
(a) the last day of the month in which you leave your employ.
(b) you are no longer eligible.
(c) you cease to make the necessary contributions.
(d) the Group Plan ceases.
A dependent’s coverage ends when any of the following events occurs:
(a) your coverage ends.
(b) that dependent is no longer an eligible dependent.
SURVIVOR BENEFIT COVERAGE
In the event of your death, your eligible surviving spouse and/or eligible dependent children’s dental coverage will continue for six months from the date of your death with no cost to your survivors. However, coverage will cease immediately upon the following:
– your spouse remarries; or
– your spouse becomes insured for dental benefits from his/her employer; or
– the eligibility requirements are no longer met; or
– the date the policy terminates
NOTE: If you cease active work, ask if arrangements may be made to continue coverage. Contact the Plan Administrator, Fitzharris & Co. Inc.
VISION – General Vision Services
Plan Year 7/1 to 6/30
IN-NETWORK Benefits once per plan year
A. Comprehensive Eye Exam No charge
B. Selection of Various Frames No Charge
Up to retail of $200 Gold Program
C. Selection of Lenses No Charge
a. Single Vision
b. Conventional Bifocal
c. Conventional Trifocal
d. GVS Standard Progressive
D. Contacts No Charge
a. Standard contacts
b. disposable (12 month supply/Cooper-$200 credit all others)
Loss Protection Program is included in the program – This program allows for replacement of benefits package for a co-pay of $25, no questions asked.
Lasik Surgery Benefit
Coverage through GVS entitles members and their dependents that are eligible at time of services for benefits of Lasik Surgery. The available Lasik Benefit contributes $500 per eye towards any LASIK corrective surgery. General Vision utilizes Long Island Surgical for LASIK procedures; however, the member is not required to utilize Long Island Surgical. Discounts have been negotiated with Long Island Surgical in addition to the payments made by GVS to the provider.
OUT OF NETWORK FEE SCHEDULE – 1/1/2011
Lens, Frame & Exam
Single Vision: $90.00
GVS Progressive: $140.00
Contact Lenses: $140.00
Single Vision: NC
GVS Progressive: $175.00
High Index Transition III
Single Vision: $144.00
GVS Progressive: $212.00
Single Vision: $60.00
All frame upgrades from the GVS collection receive $200 credit. All other frames receive $150 credit towards any amount purchased.
Call: 1-800-vision if you have any questions
On April 7, 1986, the Consolidated Omnibus Reconciliation Act (COBRA) of 1985 was signed into law. The provisions of the federal law are outlined below.
OPTIONAL CONTINUANCE OF DENTAL COVERAGE
The effective date of the federal legislation is the commencement of the plan year after the later of:
1. January 1, 1987 – or
2. Expiration date of the last Collective Bargaining Agreement (of all covered classes) if in existence on April 7, 1986.
If you would like further clarification concerning the effective date for your dental plan, contact your Plan Administrator, Fitzharris & Co. Inc. directly.
Special Continuance of Employee and Dependent Coverage
If your coverage ends, you may elect to continue for a maximum period of eighteen months the dental coverage under the Group Plan for you and your dependents, if the coverage ends due to:
(b) a reduction in the scheduled work hours per week;
(c) voluntary termination of employment with your Employer; or discharge from your Employer’s employ (other than for gross misconduct).
(d) your attaining age 65.
Fitzharris & Co. Inc. will notify you of your right to continue coverage within 45 days of the occurrence of an above event.
Special Continuance of Dependent Coverage
If your dependent’s coverage ends, they may elect to continue for a maximum period of thirty-six months the health coverage under the Group Plan as follows:
(a) Your dependent spouse may elect to continue coverage on his or her own behalf and on the behalf of any dependent children whose coverage would otherwise end, if the coverage ends due to:
(i) your death, or
(ii) your divorce or legal separation.
(b) Your dependent child whose coverage would otherwise end, may elect to continue coverage on their own behalf, provided that the coverage ends due to the death of the employee when there is no surviving parent, or the child’s marriage or attainment of the age limit.
You or your dependent must notify your Employer of the occurrence of the events shown in (a) (ii) or (b) above. The notice should be given to your Employer as soon as reasonably possible after the date the event occurred.
OPTIONAL CONTINUANCE OF DENTAL COVERAGE- (continued)
Within 45 days of receipt of notice that an event ending a dependent’s coverage has occurred, Fitzharris & Co. Inc. shall send notice to your dependent of the right to continue the coverage.
To continue coverage, you or your dependent must apply in writing to Fitzharris & Co. Inc. within 60 days of the later of (1) the date the coverage ends; and (2) the date you or your dependent receive notice of the right to continue the coverage.
You or your dependent must pay the required amount if any, for the continued coverage. Fitzharris & Co. Inc. will inform you of the monthly amount to be paid. You or your dependent must also pay such amount for any period of continued coverage which began prior to the election of such continuance. This amount must be paid within 45 days after the date the continued coverage is elected.
The continued coverage will begin on the day after the date that coverage would have ended. It will end when the first of the following events occurs:
(a) the Group Plan Terminates;
(b) the end of the period allowed for continued coverage;
(c) the end of the period for which contributions were paid;
(d) the date you or your dependent become covered under a group plan;
(e) the date you or your dependent become eligible for Medicare;
(f) the date your former spouse remarries and thereby becomes covered under a group plan.
CLAIM FILING PROCEDURES
Benefits reimbursed under your dental plan for covered services may be made payable to you or the provider who performed the service.
Proof of Claim
Written proof of claim must be given to the Plan Administrator within 90 days after the date of loss for which claim is made. Late proof will be accepted only if it is furnished as soon as reasonably possible. Itemized bills and fully completed claim forms are required as part of proof of claim.
The Plan Administrator, at its own expense, has the right to have a doctor examine any person when it deems it reasonably necessary while there is a claim pending under the plan.
No one may sue for payment of claim less than sixty days after due proof of claim is furnished or more than 2 years after the date proof of claim is required by the plan.
FAMILY AND MEDICAL LEAVE ACT (FMLA)
as Federally Mandated
This rider is effective on the later of (a) the effective date of the policy; or (b) the date required by Federal law.
Family and Medical Leave
If you become eligible for a family or medical leave of absence in accordance with the Family and Medical Leave Act of 1993 (FMLA) (including any amendments to such Act) your coverage may be continued on the same basis as if you were an actively-at-work employee for up to 12 weeks during the 12 month period, as defined by your employer, for any of the following reasons:
(a) to care for your child after the birth or placement of a child with you for adoption or foster care; as long as such leave is completed within 12 months after the birth or placement of the child;
(b) to care for your spouse, child, foster child, adopted child, stepchild, or parent who has a serious health condition; or
(c) for your own serious health condition.
In the event you and your spouse are both Covered as employees of the school, the continued coverage allowed under item (a) and (b) may not exceed a combined total of 12 weeks.
(a) If, on the day your Coverage is to begin, you are already on an FMLA leave of absence you will be considered actively at work. Coverage for you and any eligible dependents will begin in accordance with the terms of the policy. However, if your leave of absence is due to your own or any eligible dependent’s serious health condition, benefits for that condition will not be payable to the extent benefits are payable under any prior group plan.
(b) You are eligible to continue coverage under FMLA if:
(1) you have worked for your employer for at least one year;
(2) you have worked at least 1,250 hours over the previous 12 months;
(3) your employer employs at least 50 employees within 75 miles from your worksite;
(4) you continue to pay any required premium for yourself and any eligible dependents in a manner determined by your employer.
(c) In the event you choose not to pay any required premium during your leave, your coverage will not be continued during the leave. You will be able to reinstate your coverage on the day you return to work, subject to any changes that may have occurred in the policy during the time you were not covered. You and any covered dependents will not be subject to any evidence of good health requirement provided under the policy. Any partially-satisfied waiting periods, including any limitations for a preexisting condition, which are interrupted during the period of time premium was not paid will continue to be applied once coverage is reinstated.
FAMILY AND MEDICAL LEAVE ACT (FMLA)
(d) You and your dependents are subject to all conditions and limitations of the policy during your leave, except that anything in conflict with the provisions of the FMLA will be construed in accordance with the FMLA.
(e) If requested by us, you or your employer must submit proof acceptable to Claims Administrator that your leave is in accordance with FMLA.
(f) This FMLA condition is concurrent with any other continuation option except for COBRA, if applicable. You may be eligible to elect any COBRA continuation available under the policy following the day your FMLA continuation ends:
(g) FMLA continuation ends on the earliest of:
(1) the day your return to work;
(2) the day you notify your employer that you are not returning to work;
(3) the day your coverage would otherwise end under the policy;
(4) the day your coverage has been continued for 12 weeks.
Contact the Teachers Association for additional information regarding FMLA.
NOTICE OF HEALTH INFORMATION PRIVACY PRACTICES
TO: Participants in health plans sponsored by Fitzharris & Company Inc.
FROM: Plan Administrator
The health plan options sponsored by Fitzharris & Company (referred to this Notice as the “Health Plan” may use or disclose medical information about participants (employee and their covered dependents) as required for purposes of administering the Health Plans, such as for reviewing and paying claims, utilization review. Regardless of who handles medical information for the Health Plans, the Health Plans have established policies that are designed to prevent the misuse or unnecessary disclosure of protected health information.
Please note that the rest of this Notice uses the capitalized word, “Plan” to refer to each Health Plan sponsored by the Port Jefferson Station Teachers Association Benefit Trust including any trustees who are responsible for handling health information maintained by the Health Plans as well as any service providers who handle health information under contract with the Health Plans. Health Plan means, for purposes of this notice, medical, dental, vision, and other coverages that meet the definition of Health Plan container in HIPAA.
As required by Federal Law, this Notice is being provided to you to describe the Plan’s health information privacy procedures and policies. It also provides details regarding certain rights you may have under Federal Law regarding medical information about you that is maintained by the Plan.
You should review this Notice carefully and keep it with other records relating to your health coverage. The Plan is required by law to abide by the terms of this Notice while it is in effect. This Notice is effective beginning April 14, 2003 and will remain in effect until it is revised.
If the Plan’s health information privacy policies and procedures are changed so that any part of this Notice is no longer accurate, the Plan will provide a new updated Privacy Notice. The Plan reserves the right to apply any changes in its health information policies retroactively to all health information maintained by the Plan, including information that the Plan received or created before those policies were revised.
Protected Health Information
This Notice applies to health information held by the Plan that includes identifying information about you (or your dependents). Such information, regardless of the form in which it is kept, is referred to in this Notice as Protected Health Information or “PHI”. For example, any health information that includes details such as your name, street address, a date of birth or social security number is PHI. However, information that does not include such obvious identifying details is also Protected Health Information if that information, under the circumstances, could reasonably be expected to allow the person who is reviewing that information to identify you as the subject of the information. Information that the Plan possesses that is not Protected Health Information is not covered by this Notice and such information may be used for any purpose that is consistent with applicable law and with the Plan’s policies and requirements.
How the Plan Uses or Discloses Protected Health Information
Protected Health information may be used or disclosed by the Plan as necessary for the operation of the Plan. Specifically, PHI may be used or disclosed for the following Plan purposes.
- Treatment: If a provider who is treating your requests, any part or all of your health care records that the Plan possesses, the Plan generally will provide the requested information.
- Payment: If the plan needs PHI to review a claim or to make a payment to a provider or for similar payment-related purposes, the Plan may use that information (or will request that information, if it does not already possess it) and will review the information for payment purposes.
- Other Health Care Operations: The Plan may also use PHI as needed for various purposes that are related to the operation of the plan. These purposes include utilization review programs, quality assurance review, contacting providers or participants regarding treatment alternatives, insurance or reinsurance contract renewals and other functions that are appropriate for purposes of administering the Plan.
NOTICE OF HEALTH INFORMATION PRIVACY PRACTICES
- Use or Disclosure Required by Law: To the extent that the Plan is legally required to provide Protected Health Information to a government agency or anyone else, it will do so. In such cases, the Plan will make reasonable efforts avoid disclosing more information that is required by applicable law.
- Disclosure for Public Health Activities: The Plan may disclose PHI to a public health authority that is authorized to collect such information (or to a foreign government agency, at the direction of a public health authority) for purposes of preventing or controlling injury, disease or disability.
The Plan may also disclose PHI to a public health authority or other government agency that is responsible for receiving reports of child abuse or neglect.
In addition, certain information may be provided to pharmaceutical companies or other businesses that are regulated by the Food and Drug Administration (FDS), as appropriate for purposes relating to the quality, safety and effectiveness of FDA-regulated products.
Also, to the extent permitted by applicable law, the Plan may disclose PHI, as part of a public health investigation or intervention, to an individual who may have been exposed to a communicable disease or may otherwise be at risk of contracting or spreading a disease or condition.
- Disclosures about victims of abuse, neglect or domestic violence: (The following does not apply to disclosures regarding child abuse or neglect, which may be made only as provided under Disclosure for public health activities).
If required by law, the Plan may disclose PHI relating to a victim of abuse, neglect or domestic violence, to an appropriate government agency. Disclosure will be limited to the relevant required information. The Plan will inform the individual if any PHI is disclosed as provided in this paragraph or the next one.
If disclosure is not required by law, the Plan may disclose relevant PHI relating to a victim of abuse, neglect or domestic violence to an authorized government agency, to the extent permitted by applicable law, if the Plan determines that the disclosure is necessary to prevent serious harm to the individual or to other potential victims. Also, to the extent permitted by law, the Plan may release PHI relating to an individual to a law enforcement official, if the individual is incapacitated and unable to agree to the disclosure of PHI and the law enforcement official indicates that the information is necessary for an immediate enforcement activity and is not intended to be used against the individual.
- Health Oversight Activities: The Plan may disclose Protected Health Information to a health oversight agency (this includes Federal, State or local agencies that are responsible for overseeing the health care system or a particular government program for which health information is needed) for oversight activities authorized by law. This type of disclosure applies to oversight relating to the health care system and various government programs as well as civil rights laws. This disclosure would not apply to any action by the government in investigating a participant in the Plan, unless the investigation relates to the receipt of health benefits by that individual.
- Disclosure for Judicial and Administrating Proceedings: The Plan may disclose Protected Health Information in the course of any judicial or administrative proceeding in response to an order from a court or an administrative tribunal. Also, if certain restrictive conditions are met, the Plan may disclose PHI in response to a subpoena, discovery request or other lawful process. In either case, the Plan will not disclose PHI that has not been expressly requested or authorized by the order or other process.
- Disclosures for Law Enforcement Purposes: The Plan may disclose Protected Health Information for a law enforcement purpose to a law enforcement official if certain detailed restrictive conditions are met.
- Disclosures to Medical Examiners, Coroners and Funeral Directors Following Death: The Plan may disclose Protected Health Information to a coroner or medical examiner for the purpose of identifying a deceased person, determining a cause of death, or other duties as authorized by law.
NOTICE OF HEALTH INFORMATION PRIVACY PRACTICES
- Disclosures for Organ, Eye or Tissue Donation Purposes: The Plan may disclose Protected Health Information to organ procurement organization or other entities engaged in the procurement, banking or transplantation of cadaveric organs, eyes or tissue for the purpose of facilitating organ, eye or tissue donation and transplantation.
- Disclosures to avert a serious threat to health or safety: The Plan may, consistent with applicable law and standards of ethical conduct, use or disclose Protected Health Information, (1) if it believes the use or disclosure is necessary to prevent or lessen a serious and imminent threat to the health or safety of a person or the public; and the disclosure is made to a person or persons reasonably able to prevent or lessen the threat, including the target of the threat; or (2) if it believes the disclosure is necessary for law enforcement authorities to identity or apprehend an individual because of a statement by an individual admitting participation in a violent crime that the Plan reasonably believes may have caused serious physical harm to the victim or where it appears that the individual has escaped from a correctional institution or from lawful custody.
- Disclosures for Specialized Government Functions: If certain conditions are met, the Plan may use and disclose the Protected Health Information of individuals who are Armed Forces personnel for activities deemed necessary by appropriate military command authorities to assure the proper execution of the military mission.
The Plan may also or disclose PHI to authorize federal officials for the conduct of lawful intelligence, counter-intelligence, and other national security activities or for the provision of protective services to the President or other persons as authorized by Federal law relating to those protective services.
- Disclosures for Workers’ Compensation Purposes: The Plan may disclose Protected Health Information as authorized by and to the extent necessary to comply with laws relating to workers’ compensation or other similar programs.
Uses and Disclosures Not Mentioned Above: Authorization Require
The Plan will not use or disclose Protected Health Information for any purpose that is not mentioned above, except as specifically authorized by you. If the Plan needs to use or disclose PHI for a reason not listed above, it will request your permission for that specific use and will not use PHI for that purpose except according to the specific terms of your authorization. You may complete an Authorization Form if you want the Plan to use or disclose health information to you, or to someone else at your request, for any reason.
Any authorization you provide will be limited to specified information, and the intended use or disclosure as well as any person or organization that is permitted to use, disclose or receive the information must be specified in the Authorization Form. Also, an authorization is limited to a specific limited time period and it expires at the end of that period. Finally, you always have the right to revoke a previous authorization by making a written request to the Plan. The Plan will honor your request to revoke an authorization but the revocation will apply to any action that the Plan took in accord with the authorization before you informed the Plan that you were revoking the authorization.
Your Health Information Rights
Under Federal Law, you have the following rights:
- You may request restrictions with regard to certain types of uses and disclosures: This includes the uses and disclosures described above for Treatment, Payment and other health plan operations purposes. If the Plan agrees to a restriction you request, it will abide by the terms of that restriction. However, under the law, the Plan is not required to accept any restriction. If the Plan determines that a requested restriction will interfere with the efficient administration of the Plan, it may decline the request.
NOTICE OF HEALTH INFORMATION PRIVACY PRACTICES
- If PHI is being provided to you, you may request that the information be provided to you in a confidential manner: This right applies only if you inform the Plan in writing that the ordinary disclosure of part or all of the information might endanger you. For example, an individual may not want information about certain types of treatment to be sent to his or her home address because someone else who lives there might have access to it. In such a case, the individual could request that the information be sent to an alternate address. The Plan will honor such requests as long as they are reasonable, but the Plan reserves the right to reject a request that would impose too much of an administrative burden or financial risk on the Plan.
- You may request access to certain medical records possessed by the Plan and you may inspect or copy those records: This right applies to all enrollment, claims processing, medical management and payment records maintained by the Plan and also to any other information possessed by the Plan that is used to make decisions about you or your health coverage.
- You may request that Protected Health Information Maintained by the Plan be amended: If you feel that certain information maintained by the Plan is inaccurate or incomplete, you may request that the information be amended. The Plan may reject your request if it finds that the information is accurate and complete. Also, if the information you are challenging was created by some other person or organization, the Plan ordinarily would not be responsible for amending that information unless you provide sufficient information to the Plan to establish that the originator of the information is not in a position to amend it.
The Plan normally will respond to a request for an amendment within 60 days after it receives your request. In certain cases, the Plan may take up to 30 additional days to respond to your request.
If the Plan denies your request, you will have the opportunity to prepare a statement to be included with the health records to explain why you believe that certain information is incomplete or inaccurate. If you do prepare such a statement, the Plan will provide that statement to any person who uses or receives the information that you challenged. The Plan may also prepare a response to your statement and that response will be placed with your records and provided to anyone who receives your statement. A copy will also be provided to you.
- You have the right to receive details about certain non-routine disclosures of health information made by the Plan: You may request an accounting of all disclosures of health information with certain exceptions. This accounting would not include disclosures that are made for Treatment, Payment and other health plan operation purposes, disclosures made pursuant to an individual authorization from you, disclosures made to you and certain other types of disclosures. Also, your request will not apply to any disclosures made before April 14, 2003 or for any period earlier than 6 years from the date your request is properly submitted to the Plan. You may receive an accounting of disclosures once every 12 months at no charge. The Plan may charge a reasonable fee for any additional requests during a 12-month period.
- You have the right to request and receive a paper copy of the Privacy Notice: If the Plan provides this Notice to you in an electronic form, you may request a paper copy and the Plan will provide one.
Health Information Complaint Procedures
If you believe your health information privacy rights have been violated, you may file a complaint with the Plan. To file a complaint, you should contact Fitzharris’ Privacy Department, P.O. Box 9182, Farmingdale, NY 11735. In addition to your right to file a complaint with the Plan, if you feel your privacy rights have been violated, you may file a complaint with the U.S. Department of Health & Human Services. You will never be retaliated against in any way as a result of any complaint that you file.
FITZHARRIS & COMPANY, INC.
814 Fulton Street (Route 109)
P.O. Box 9182
Farmingdale, NY 11735-9182