Make your own free website on Tripod.com
Kingston Teachers' Federation
 P.O. Box 4461       Kingston, N.Y. 12402        Phone: (845) 338-5422/Fax: (845)338-0391      Lauri J. Naccarato, President
Welcome
News
Kingston Trust Fund
National Health Administrators Plan
Mid Hudson Teachers Center
Resources for Teachers
Resources for Parents
Community Links
Events
Board and Officers
Contact Us
 
Kingston Trust Fund

Scroll Down For or Navigate Directly To:

Board of Trustees - 2006-2007:

Name Term Expires During
Betty Hendrickson 2010
Gail Diamond 2008
Glenn Gallagher 2009
Bill Tubby 2009
Laura Sexton - Treasurer 2009
Lauri J. Naccarato - Chairperson N/A
Hugh Spoljaric - Executive Director N/A
 

Return to top of page


Schedule of Trust Meetings

All of the meetings below are scheduled for 3:30 pm in the NYSUT Conference Center:

March 2009 Trust Updates

                       See PDF (opens in new window).


July 2008 Dental Upgrade

                       See PDF (opens in new window).


January 1, 2008 Dental Schedule

                       See PDF (opens in new window).


January 2007 Trust Modifications

Click here for the modifications. They will open in a new window.

Return to top of page



June 2006 Trust Modifications

                       Notice of Material Modifications and Amendments

     The Trustees of the Kingston Trust Fund have a fiduciary responsibility to respond proactively, as the medical industry changes, to any impacts on the plan that need to be addressed. Many other plans fail to address changes and continue to raise premiums. Compared to all other plans in the United States, the Trust plan provides a superior benefit package and at no cost to the members. Additional benefits, like stroke screening, are provided at nominal cost.

     Some concerns are beyond local control. Presently, for example, medical ID’s and prescription ID’s, in the industry, do not follow the same criteria and use two separate ID’s (an encrypted medical and a Social Security prescription). The medical card is encrypted to prevent identity theft. Adding another card with your Social Security number (for prescriptions) could prove costly to the member and to the Trust. In the future, to enhance security, a picture ID card would further enhance security.

     Therefore, the following changes have been adopted and agreed to by the Trustees and shall be made effective as July 1, 2006. Please keep a copy of this Amendment and Notice of Material Modification with your plan booklet.

1.       The Rx Out of Pocket (OOP) limit has been increased to $1,500 from $1,000.  This is the first increase in the Rx OOP limit since the plan’s inception.   This limit is significantly less than the OOP limit under Medicare.  The Rx coverage under the NHAI plan continues to Creditable Coverage for purposes of the Medicare part D Program.

2.       The Rx copays have been increased to $10 for generic and $20 for brand for a 30-day refill at your local pharmacy.  For mail order, the generic copay is $15 and the brand copay is $30 for a 90-day refill.  Further, if diabetic supplies and drugs are filled at the retail level, the normal retail copay will apply. 

3.       The Emergency Room copay is now $75 for acute emergency treatment.  The ER copay for non-acute treatment is now $125 and the balance of the expenses shall be paid at 80% subject to the out of pocket limit.   The ER Copay is waived if an individual is admitted within 24 hours.

An emergency or life threatening condition is defined as any accident or illness that requires immediate treatment to relieve the sudden onset of severe pain, fever, swelling, serious bleeding, severe discomfort and to the extent that treatment cannot be delayed until the following day during normal business hours where treatment can be rendered by your own physician or at an Urgent Care Center.

4.       The Physician Office Visit Copay (POV) is increased to $15 from $10 and the Specialist Office Visit Copay (SPOV) is increased to $25 from $20 as of July 1, 2006.  The Chiropractic Copay remains at $20.

5.       Durable Medical Equipment (DME) shall now be paid at 90% with 10% coinsurance in Network or 80% Out of Network with 20% coinsurance up to the Out of Pocket (OOP) limit.  Repairs to DME will be paid at 80% with no deductible.

6.       The monthly COBRA premium as of July 1, 2006 shall be $404 for single medical Coverage and $1,001 for family medical coverage.  The Dental COBRA premium is $23.57 for single and $73 for family.  COBRA Premium will be updated each July l.   This is the first increase in COBRA premiums since 3/1/2004.  The COBRA costs are significantly less than the actual district funding cost. 

7.       The copays for BASIC lab and x-ray will remain at $15.  However, the copays for complex imaging shall be as follows.  Most plans today will not cover the following tests at all.  Most of the tests that fall under item c below are considered “experimental” by major insurers and are not covered at all.  Some of the new tests that are now available may only be offered by one entity, which keeps the costs of such tests quite high.  NHAI plans continue to take a leading stance on preventive and progressive treatment and these modest copays make such treatment available for coverage under the Kingston Trust Fund Plan.

a.       The copay for Complex Imaging and Diagnostic Testing (MRI’s, Cat Scans, Complex CT Scans, Cardio Electro grams and Complex Diagnostic Tests costing $750 or more) shall be $100.

b.       The copay for Ultra Fast Heart Scan, Heart/Chest Scan, or Liver Scan is now $50.

c.       The copay for Chest CT Angiography, Genomic Health Oncotype Diagnostic for Breast Cancer or other State-of-the Art Complex Imaging or Lab Tests with a cost in excess of $2,500 is now $200.

8.       The Precertification requirement for MRI’s and Cat Scans is being reinstated and will now be required along with other diagnostic lab or x-ray test that costs $1,000 or more.

9.       Case Management is monitored on behalf of the Plan by NHAI.  One important element of the Case Management benefits that are unique to NHAI is that NHAI plans have always provided for certain “extended treatment” beyond the basic benefits provided by the plan.  Extended benefits are not available under generally provided by traditional health care plans.  NHAI plans have always provided for extended benefits for therapy, home health care, skilled nursing, etc. under case management when additional benefits were medically necessary.  While extended benefits continue to be available under NHAI’s case management program, there have been some changes.  First, the normal copays and/or coinsurance as specified in the plan now apply to extended treatment and the copays or coinsurance on the extended treatment will not be credited toward your out of pocket (OOP) limit nor subject to the plan OOP limit.  Example:  If physical therapy treatment is required beyond the normal 50 visits, additional treatment approved under case management would be available, subject to the same copay.

Extended benefits for home health care or skilled nursing benefits will be paid at 50% and limited to 50 additional visits or days.  Long term care, custodial care, and nursing home care are not covered benefits under any group health plan.  It is recommended that members consider purchasing Long Term Care to cover this potential need.

Listed on the Trust web site is a detailed explanation of Coordination of Benefits for the plan. Go to the KTF site at www.NYSUT.org and click on Kingston Trust Fund.

     Updated ID Cards will be issued soon. Also, there will be a new Hotline available for providers and members to call for a pre-recorded message that will provide the current copays, deductible and out of pocket limits for your plan.  This will eliminate the necessity to mail out new ID cards whenever there is a change in the basic benefits.  Should you have a specific question about your benefits, contact the Compliance Office at 1-888-679-2400, Ext. 5.

                       DENTAL Modifications and Amendments

     As of July 1, 2006, spouses or domestic partners who are eligible for dental coverage through the Kingston Trust Fund and who are both active and/or retired employees of the Kingston Schools, may designate only one family dental plan for coverage under the Fund.

     The annual dental claim expenditure shall be capped at $2000 per person.        

    Schedule of Benefits: Class 1, #8, add: “except in the case of periodontal prophylaxis where members are eligible for two additional maintenances.”

Foreign Travel Reminder

          IMPORTANT REMINDER FOR FOREIGN TRAVEL

With the summer travel season upon us, members are reminded that if they intend to travel outside the U.S., Mexico or Canada, travel insurance is highly recommended.  Benefits outside the U.S., Mexico and Canada are limited to emergency treatment, which will be paid at 80% after a $250 copay.  Any non-emergency treatment would be subject to prior approval and pre-certification as well as the NPPO deductible as a copay for each incident, as all such treatment is out of network.

     If members or their dependents plan to travel to war zones, you should also be aware that benefits may be denied due to injuries incurred as a result of an act of war, such as a suicide bomber in such countries as Israel, Iraq or other high risk countries.

Foreign Travel (Outside the U.S., Mexico or Canada)

N/A

Paid at 80% after $250 copay (waived if admitted within 24 hours)

Only emergency treatment is covered while traveling, up to a maximum of six (6) weeks outside the U.S. in any one country.  Vacation travel insurance is recommended for extended coverage.  No benefit will be provided after six (6) weeks in any one country or three (3) months of consecutive travel.  Foreign treatment is also subject to NPPO deductible.

Treatment Outside the U.S., Canada, or Mexico:  Treatment is not covered, except for emergency treatment, while traveling “temporarily” for a period not exceeding six (6) weeks in anyone country or three (3) months in total.  Any service provided outside the U.S., Canada, or Mexico will be subject to the normal NPPO Plan deductible as copay for each incident.  The deductible/copay will not be credited to your NPPO deductible or out-of-pocket limit under the Plan.  After the deductible/copay is met, the member will be responsible for the basic NPPO coinsurance up to the NPPO Out-of-Pocket limit for emergency service or for any other non-emergency service as pre-approved by the Plan.   

     Non-emergency treatment of chronic illness requiring hospitalization outside the United States will not be covered unless the treatment is pre-authorized within 24 hours of admission (72 hours if hospitalized over the weekend).  No approved services for medical services rendered outside the U.S. are covered. 

Emergency Treatment in Canada or Mexico will be subject to the same Emergency Room copay as treatment within the U.S. 

     Retirees living permanently outside the U.S. are covered, according to the NPPO Schedule of Benefits, as long as proof of residency is provided and non-residence status is approved by the Plan, in advance.  The approval will be at the sole discretion of the Plan, based on all relevant facts and circumstances, including the country in which the retiree resides.  Coverage in countries considered “high risk” areas will not be approved, subject to the sole discretion of the Plan.  Students on exchange-type programs are not covered.  Parents are advised to secure special travel and medical insurance through their travel or insurance agent, through their school for extended travel, or if they or a dependent intends to live abroad for an extended period.    

War/Service in Armed Forces:  Expenses that result from loss or damage directly or indirectly, due to any act of war (whether war is declared or not), including resistance to armed aggression, will not be covered unless otherwise required by law.


Return to top of page


JANUARY 2006 TRUST MODIFICATIONS

Amendment and

Notice of Material Modification

To the

KINGSTON TRUST

Domestic Partner coverage shall now be available in accordance with the collective bargaining agreement(s) covering members electing coverage under the Kingston Trust.  The following changes have been adopted and agreed to be the Trustees following a special meeting and shall be made effective January 1, 2006 unless otherwise indicated.  Please keep a copy of this Amendment and Notice of Material Modification with your plan booklet.

1.      Basic Domestic Partner Rules as Adopted by the KTF Plan Trustees:   

a.       Domestic Partner coverage shall be provided only to those members covered by a collective bargaining agreement that provides for coverage of Domestic Partners by the District.

b.       Domestic Partner coverage shall apply to unmarried same sex or opposite sex partners who are 18 or older and have maintained a Domestic Partner relationship and financial interdependence for at least one full year, subject to documentation satisfactory to the Plan.

c.        COBRA shall apply for Domestic Partners the same as it would for a legally wed spouse.

d.       Children of Domestic Partners may be covered if the children are a legal dependent of the Domestic Partner or the member and reside with the member and their Domestic Partner.  The cost of any coverage for children who are not a legal dependent of the member (the individual with Primary Coverage) must be imputed to the member and will be considered taxable income.  Members are advised to contact their CPA or tax attorney for advice with respect to the new rules governing dependents under §152(d) of the Code.  See item f below.

e.       An unmarried Domestic Partner is eligible to be covered by a member, even though the Domestic Partner is not a legal dependent of the member. 

f.        The cost of coverage paid for by the District for any Domestic Partner or any dependent of the Domestic Partner who is not a legal dependent of the member will be included as a taxable fringe benefit by the District on the member’s W-2 each year.  A Dependent Tax Affidavit must be filed with the Trust each December attesting to whether or not your Domestic Partner is or is not a legal dependent of the KTF member.  An affidavit is also required for any covered dependent of your Domestic Partner to determine whether or not they are eligible dependents of the member.

g.       The cost of Domestic Partner MEDICAL coverage for both active and retired members will be paid by the District in accordance with the collective bargaining agreement applicable to the member.

h.        The cost of DENTAL coverage for any Domestic Partner of a retiree must be paid by the retired member.  For retirees, the cost of dental coverage will be 2 x the single premium if there are no dependent children.  The family rate will apply if any dependent children are covered.  Dental premiums must be paid in advance at the beginning of each quarter.

i.         The rules to cover a Domestic Partner for the Dental Plan will be the same as the rules for Medical coverage of a Domestic Partner, except for the cost of dental for retirees.

j.         Domestic Partner coverage for retirees shall be the same as for active employees.  Domestic partner coverage for retirees shall be the same as for active employees. A retired member may add a Spouse, Domestic Partner, or Dependant Child after their retirement due to a change in family status. 

k.       Extended COBRA coverage shall be extended to the widowed spouse or Domestic Partner of Retiree.  A widow or widower, including a Domestic Partner, of a retiree shall be permitted to continue coverage for their lifetime (subject to COBRA rules) after the initial COBRA period (36 months) expires.  During the initial COBRA period, the widowed spouse may add a new spouse or dependents but they may only be covered during the initial COBRA period and are not eligible for extended Coverage beyond the initial COBRA period.  Shall continue to be subject to the basic COBRA rules with respect to payment and lapse of coverage.  Extended COBRA coverage for any dependents not covered at the time of the initial COBRA event (death or divorce) is not available after the COBRA period expires (36 months.) The member must request continued coverage under this option and payments to retain coverage will continue to be subject to the COBRA rules.

2.       Coverage for Domestic Partners:  In order for Domestic Partner coverage through NHAI the following criteria must be met: 

a.       Both partners must be eighteen years of age or older and unmarried.  If either or both partners have ever been married, evidence of the termination of the marriage must be provided.

b.       The Domestic Partners must not be related by blood in a manner that would bar marriage under the laws of the State of New York or state of residence.

c.       Each Partner must be the other’s sole Domestic Partner for at least twelve months prior to the date of this affidavit, and intend to remain so indefinitely.  The Partners must affirm that they are in a relationship of mutual support, caring and commitment, and have assumed responsibility for each other’s welfare.

d.       The Domestic Partners must have been living together at the same address, on a continuous basis for at least twelve months prior to the date of this affidavit.

e.       One member must be enrolled and/or eligible to enroll in the KTF/NHAI Plan.

f.        Neither member may have been enrolled or registered as a member of another Domestic Partnership within twelve months.

g.       The enrollee must affirm that they will file a Termination of Domestic Partnership form within 14 days of the date I/My partner no longer meet one or more of the qualifying criteria set forth above.

h.       The enrollee must submit forms for “proof of twelve month residency”  “Affidavit of Financial Interdependence” and “Dependent Tax Affidavit” in addition to an enrollment or Change in Status form, once the Domestic Partner eligibility has been approved by the Trust. 

i.         The member must also provide a copy of their “registry” as a Domestic Partner in your municipality if required.  The following states currently have cities with such registries:  California, Colorado, Connecticut, Florida, Georgia, Hawaii, Illinois, Iowa, Maine, Maryland, Minnesota, Missouri, North Carolina, New York, Oregon, Texas, Washington, and Wisconsin.

j.         Any covered dependent must meet the “relationship test” under §152(d) of the Code in order to be eligible for coverage.  Otherwise, the cost of such coverage is considered taxable in accordance with the rules in Section 1, paragraphs  de and f.

3.       Proof of Financial Interdependence:  Domestic Partners who reside together and are financially interdependent must submit original documents of the following items (at least one of the two items must be from list A) as proof of our financial interdependence:

List A

A.      Joint obligation on a loan (including an affidavit by a creditor for a personal loan

B.       Joint ownership of our residence

C.       Joint renters or home owners insurance policy

D.      Joint responsibility for child care (school documents, guardianship)

E.       Designated as beneficiary under the other’s life insurance policy, retirement benefits account or will or executor of each other’s wills.

F.       An affidavit by a creditor or other person able to testify to partner’s financial interdependence.

G.       Mutually granted durable power of attorney

H.      Designated of one partner as the payee for the others government benefits

I.         Joint ownership or holding of investments

J.        Joint ownership or lease of a motor vehicle

K.      Both listed as tenants on the lease of our shared residence

L.       Mutually granted authority to make health care decisions (healthcare power of attorney)

M.     Share a household budget for the receiving government benefits

List B (must provide proof of at least one of the following:

a.       Joint bank account

b.       Joint credit card or charge

c.       Status as authorized signatory on the partner’s bank account, credit card or charge card

d.      Other proof establishing economic interdependence

  1. Proof of Twelve – Month Residency:  To enroll your Domestic Partner in the KTF/NHAI benefit program you must submit a copy of one item of proof that you and your partner have resided together for at least twelve months.  The proof may be one document with both names or two separate documents that show the residence of each partner.  The following is a list of some items that can be used to demonstrate proof of residency.  You may submit a copy of another document that proves residency began at least twelve months ago.

a.       Driver’s License

b.      Auto registration

c.       Lease agreement

d.      Mortgage agreement

e.       Tax return

f.        Bank statement

g.       Passport

h.       Insurance benefits statement

i.         Paycheck stub

j.        Utility bill

k.      Telephone bill

l.         Joint membership (church, or family association)

The above changes were adopted and approved by the Board of Trustees for the Kingston Trust Fund at the Special Trustee Meeting on November 29, 2005.

Approved: ________________________                 Date:  _____________________

                        Hugh Spoljaric, Chairman

 

Return to top of page



KTF -    SCHEDULE OF DENTAL BENEFITS – as Clarified 1/1/2006

 

Dental Services Covered

Dental Benefits

Dental Benefits will be paid in accordance with the following schedule with No deductible, nor any annual limit on benefits:

Class 1—Preventive Benefits:                                                                      60%

Class 2—Basic Restorative Benefits:                                                           60%

Class 3—Major Restorative Benefits                                                           60%

Class 4—Orthodontics (to age 19)                                                               0%

Class 1

Preventive and Basic Services

Cleaning, prophylaxis and routine oral exam (once every 6 months), bite wings (one x-ray series every 12 months), diagnostic tests, sealants, palliative treatment, space maintainers, and fluoride treatments as follows:  Oral examinations include examinations when the Dentist first examines you to determine if further dental care is required.

1.         We will not pay for more than two routine oral examinations during any twelve-month period, or emergency palliative treatments for the purpose of removing or alleviating pain and sedative fillings.

2.        If additional dental services are provided (other than x-rays) on the same day, we will not make a separate payment for the oral examination.

3.        We will not pay for bitewing x-rays more than twice during any twelve month period.

4.        Occlusal and extra-oral x-rays will not be paid for more than a total of 2 films in any 24-month period.

5.        Panoramic or full mouth x-rays will not pay be paid for more than one panoramic of full mouth x-ray in any 36-month period.

6.        We will only pay for fluoride applications for children age 18 and younger.

7.        We will not pay for more than two fluoride applications in any 12- month period.  Prophylaxis includes polishing and scaling.

8.        We will not pay for more than two prophylaxes during any twelve-month period.

9.         For persons over age 18, the prophylaxis may include periodontics prophylaxis.

10.      Sealants shall be covered to age 18 or as medically necessary.

Class 2

Dental and X-Rays

Diagnostic tests, emergency treatment, recementation, anesthesia, restorations, fillings, amalgams, composites, pulp caps, oral surgery, periodontal. 

1.       The fillings may consist of silver amalgam and or tooth color restorations using synthetic materials. 

2.      Our payment for the filling includes payment for local anesthesia or direct pulp capping on the same date as the filling. 

3.      We will pay for the extraction of teeth including extractions by surgery.  The oral surgery may consist of treatment of fractures and dislocations and diagnosis and treatment of cysts, abscesses and impaction.

KTF DENTAL PLAN SCHEDULE OF BENEFITS

Class 3

Major Services

Class 3 services will be covered for repairs to bridges, crowns, endodontics, repairs to dentures, periodontics, scaling, root planning, anesthesia and partials. 

Covered services include—

1.       Repairs to full or partial dentures or to bridges, including surgical periodontics examination; gingival curettage; gingivectomy and gingivoplasty; osseous surgery including flap entry and enclosure; mucogingivoplastic surgery; and management of acute infections and oral lesions. 

2.       Periodontics treatment of the same portion of the mouth is limited to once every 12-month period.

3.       Periodontal surgery if you were covered under this Plan on the date the surgery is actually performed.

4.       Space maintainers for children up to age 14 and any adjustments, which are made within six months of the installation of the space maintainers.  The apicectomy may include flap surgery, apical curettage, local anesthesia, x-rays and post-operative care. 

5.       Inlay services are covered when the teeth cannot be restored by filling, local anesthesia, direct pulp capping on the same date as cementation, indirect pulp capping, lab charges, base, pins, gum preparation and temporary restoration.  Replacement of inlays is limited to once every five years.  

6.       Crowns are covered when the teeth cannot be restored by other means and when the crown is not part of a bridge.  Crowns for the purpose of periodontal splinting is not covered, but services for local anesthesia, direct pulp capping done on the same date as cementation, indirect pulp capping, lab charges, base, pins, gum preparation and temporary restoration is not covered.  Crowns can be replaced once every five years if medically necessary. 

7.       For child crowns (up to age 14), covered services include pulpotomy, including local anesthesia, x-rays, pulp capping, temporary fillings and post-operative care.

8.       Root canal therapy, including anesthesia, x-rays, pulpotomy, temporary fillings and post-operative care is covered.

Extended Benefits (must be completed within 30 days of termination)

Benefits will be extended for a dental procedure that began before the date a person’s coverage terminated and which was completed within 30 days after the termination date, if the covered charge is for any of the following:

1.        A removable appliance or modification of an appliance for which an impression is made.

2.        A fixed bridge, crown, gold or cast restoration when the tooth or teeth are fully prepared.

3.        Root canal therapy when the pulp chamber is opened and explored to the apex, provided you or your dependents do not become covered under any other Group Dental Plan for that dental procedure.

 

EXCLUSIONS

Dental Exclusions

Charges for the following shall not be covered unless specifically listed as a covered service in the above schedule of benefits:

1.        Orthodontia benefits are not provided or covered by this Plan.

2.        Replacement of a lost or stolen appliance.

3.        Implants or any prosthetic device attached to them or precision or semi-precision attachments, unless medically necessary.  

4.        Instruction in oral hygiene or plaque control, completion of any forms or failure to keep any scheduled appointment.

5.       Dental procedures performed solely for cosmetic reasons or to characterize or personalize dentures or bridges.  Examples of Cosmetic Procedures:  Porcelain overlays and teeth whitening are both considered a cosmetic procedures according to the IRS.

6.        Replacement of a bridge or denture that meets or can be made to meet generally accepted dental standards.

7.        Appliance or restorations except full dentures, to change vertical dimension, or restore occlusion or correct Temporomandibular Joint Dysfunction (TMJ).  Diagnostic procedures for each are also excluded.

8.        Dental procedures performed while you or your dependents are not insured for these benefits.  This includes procedures begun before a person’s effective date of dental care insurance although partially performed after that date.

9.        Dental injuries incurred as a result of “biting” or “chewing” will only be covered under the Dental Plan and not considered as an accident benefit under the Group Health Plan. 

10.     Charges for filing a claim.

11.     Dental procedures performed because of an occupational injury or sickness.

12.     Gold foil restoration.

13.     Oral hygiene instruction; bacteriological studies; caries susceptibility tests; pulp vitality tests; diagnostic photographs; or diet planning.

14.     Consulting with another Dentist on the same day your Dentist provides service covered under this Plan.

15.     Athletic mouth guards; sealants; analgesia; implants; Occlusal analysis; replacement of lost or stolen appliances; myofunctional therapy; precision or semi-precision attachments; denture duplication; charges for broken appointments.

16.     General anesthesia, except that benefits are paid for general anesthesia in connection with complex oral surgery, covered under this Plan.

17.     Other procedures not included on the above list of covered services or services which do not have uniform professional endorsement.

18.     Prescription and non-prescription drugs.  Any prescription drugs prescribed by a dental provider are covered the same as any other Rx under the General Health Plan.

19.     Dental services neither considered within the scope of normal, acceptable dental practice nor consistent with the highest ethical dental standards of the dental profession.

20.     No benefits will be provided for Orthodontic services or Orthognathic surgery.

21.     Major restoration services, Prosthodontics, removable or fixed.

22.     Any cosmetic procedure such as tooth whitening. 

 

Return to top of page


JULY 2005 TRUST MODIFICATIONS
     Effective July 1, 2005, as adopted by the Trustees of the Kingston Trust on May 24, 2005, regarding chiropractic services: In a situation where there is a penalty both for failure to pre-certify benefits and for untimely filing of claims, the maximum penalty will be limited to 50%, subject to a maximum benefit of $25,000 if the claim is not filed prior to the end of any plan year (9/30) or within 90 days of the date of service, if later.
     The amendment is actually a benefit for members. The late filing of claims (beyond 90 days) would result in a complete loss of the benefit as per the plan document. Some chiropractic claims involve letters of referral and medical necessity and, as such, delay the timely filing. This amendment limits the penalty.
LEGAL CHANGES: In 2002, a statute was enacted that required that the practice of psychotherapy and counseling be limited to persons who are licensed in the professions of psychology, medicine (including physicians and physician assistants), nursing, licensed master social workers, licensed clinical social workers, and the four new mental health professions of: Licensed mental health counselor, Licensed psychoanalyst,

Licensed marriage and family therapist, and Licensed creative arts therapist. 

The law has been made effective over a series of dates: 

For psychology, medicine, and nursing, the effective date was September 1, 2003;

For the social work professions, the effective date was September 1, 2004; and,

For the four new professions, the effective date was January 1, 2005.  **

**   For the four new professions, January 1, 2006 will be the date on which persons can be prosecuted for the illegal practice of the four new professions.  During 2005, they will have the opportunity to apply for licensure or a limited permit.

Individuals who have practiced psychotherapy or counseling have been able to do so without licensure, as long as they have not used the restricted titles or terms or engaged in the scope of practice of medicine, nursing, and psychology until September 1, 2003 or engaged in the practice of the two social work professions until September 1, 2004.  Since January 1, 2005 unlicensed individuals have been able to continue the practice of counseling and psychotherapy while applying for licensure in the four new professions, and will not be prosecuted for doing this until January 1, 2006. 

     NHAI will be requiring all the new professions to provide proof of licensing prior to be approved to be a provider under any of the NHAI plan, along with proof of Errors and Omissions Insurance (E&O).  Any provider who is not duly licensed in the state in which they provide services will not be covered under this plan.  These new rules have an impact on many behavioral providers who have previously not been required to be licensed.  The new professions must provide documentation that licensure has been applied for after July 1, 2005 in order for any future services to be covered. 

Special Note to Medicare Retirees:  Effective January 1, 2005, benefits for services provided by any of the new behavioral specialties that must  now be licensed who refuses to accept Medicare assignment or to bill Medicare, will be limited to 35% of allowed charges for any member where Medicare is the primary plan. Such provider will be considered a “contract provider” for Medicare and will not be covered by Medicare.

We recommend that anyone going to any counselor verify with their counselor that they are currently licensed to practice their particular specialty and whether or not they accept Medicare.  You may want to consider changing providers if your provider is not appropriately licensed or if they will not accept Medicare. The Behavioral Health Office will be glad to assist you in locating a new provider. (1-888-679-2400, select 3).

     If any additional information or questions are required concerning this communication, please feel free to contact the Compliance Office. (select 5)    


Return to top of page


Health Care and Trust Information

Kingston Trust Fund

307 Wall Street, 3rd Floor

Kingston NY 12401

(845) 338-5422

(845) 338-0391 facsimile

                                                              November 2004

National Health Administrators, Inc

a Mail Order Prescription Usage Required

Any future maintenance prescription medication used by a NHAI member must be obtained via Mail Order after 3 refills.  Refer to #1 on the enclosed insert.

Obtain forms at:

            a www.medcohealth.com

            a Your Main Office

a  The Trust Office

Refer any questions to the NHAI Compliance Office at 1-800-845-1195.

a  Prescription Drug Benefits when NHAI is the  Secondary Insurance Company

A member’s cost with a prescription drug company that pays first has increased to $25 per prescription.  This is an increase from $20 per prescription.  Refer to #2 on the enclosed insert.

a School Semester Abroad

NHAI excludes coverage for children spending a school semester abroad.  Please refer to page 76 of the Plan Booklet. Parents should obtain Travel Insurance with a Travel Agency or school program to cover the child during this time period.

***Members are required to notify the Trust Office of the dates when their child will be out of the country for six weeks or more. 

***Any child age 19 to 25 must also be documented as a full-time student for the entire semester while abroad.  Submit documentation to the Trust Office.  

HMO’s

a MVP Laboratory Provider Change

Effective 10/18/2004, MVP changed their participating laboratory to Quest Diagnostics network of outpatient labs and patient service centers. In Ulster County, their locations are 148 Aaron Court (near Hannaford) and the Grand Union Plaza in Saugerties. Go to www.mvphealthcare.com for more locations.

Kingston Retired Teachers Federation

a Snowbirds – Mailing Addresses

Any retired member relocating to a different address during the winter months should notify the Trust Office of:

a      The date leaving the area

a      The date returning to the area

a      The mailing address to be used during this time

The newsletter, The Torch, can be mailed to the winter address to ensure you receive it promptly.

Call the Trust Office at (845) 338-5422 to leave this information.

Following are Amendments and Material Modifications to the NHAI health plan of the Kingston Trust Fund.

AMENDMENT ONE &

NOTICE OF MATERIAL MODIFICATION

To the

KINGSTON TRUST FUND

The following changes were adopted and agreed to by the Trustees following the special June meeting to be effective JULY 1, 2004 unless otherwise indicated.  In addition to the plan changes, clarification of existing plan provisions are also being noted.  A “clarification” does not represent a plan change; rather it is an explanation of the present plan provisions.  Please keep a copy of this Amendment and Notice of Material Modification with your plan booklet.

1.       Pharmacy Refills limited to a 31-day refill:  Effective July 1, any prescription that you will be refilling more than 3 times must be filled through mail order.  Refills at the pharmacy level will not be permitted for more than 31 days.   DO NOT send restricted prescriptions that only will allow for a 30-day refill at any one time (certain narcotic types of medications, etc.) to mail order.  These prescriptions need to be filled locally. 

Members are encouraged to get two prescriptions from their provider a 30-day prescription with 1 refill for emergencies and a 90-day prescription with 2 to 3 refills for mail order.  You should get your first 30-day refill and then mail in a 90-day refill to Mail Order.  The first refill takes a bit long and you should receive the 90-day refill prior to the expiration of your 30-day Rx.  Should your mail order Rx not arrive prior to the expiration of your 30-day refill contact Rosalie Fiegoli in the Executive Offices (extension 4) or Gloria Gillespie (extension 5) in the Compliance Office for assistance.  Call 1-888-679-2400 and then the extension.  You may also contact these offices for vacation override assistance.

2.       Name Change:  The name of the NHAI Behavioral Network has changed to BEHAVIORAL HEALTH SOLUTIONS, INC. and their new address is P O Box 1237, Laurence Harbor, NJ 08879.  The phone # remains the same, which is 1-888-679-2400 at extension 3. 

3.       Modification of Behavioral Health Out of Network Coverage:  Behavioral Health Solutions (formerly NHAI Behavioral) network is the exclusive provider of behavioral and addictive treatment, there may be occasions due to emergency, continuity of care or other special requirement of the patient that an out of network provider be used.  All out of network services must be preauthorized in advance of treatment or within 24 hours of any emergency admission or lst working day following a weekend admission due to an emergency admit.

The following are the maximum allowable charges.  The member is responsible for the normal copay and/or NPPO coinsurance % (admission and per visit copays) plus any charges in excess of the allowed charges.  The last paragraph of §3.09, paragraph a will be replaced in its entirely by the following paragraph 9.    (Note:  The Out of Network Deductible must always be met prior to payment of any out of network benefits.)

9.       The maximum allowable charge for out of network care shall be limited to the following amounts less the normal NPPO coinsurance and per admission copay unless (1) another rate is approved by the Plan (at its sole discretion) based on extenuating facts and circumstances as well as medical necessity that would merit an exception or (2) a contractual PPO agreement is negotiated.  The patient or member is responsible for all excess charges in excess of the out of the following maximums and no excess charges will be credited towards the plans out of pocket limit.)

F       In patient – all inclusive per diem:    $750

When a member uses an out of network provider, the member is required to pay the provider up front and then submit claims for reimbursement to Behavioral Health Solutions, Inc.  Members are responsible for getting a billing from the provider and a record of their payment must also be noted on the provider’s bill. 

CLARIFICATION OF PLAN RULES:  Due to frequent misunderstanding by the membership on various plan rules, the following clarification of present plan rules is hereby being made.

F       General Coordination of Benefit (COB Rules):  The determination of which plan is primary and which plan is secondary must be determined based on standard COB rules contained in every plan.  These rules and set out by the National Association of Insurance Commissioners (NAIC) and are using the same from plan to plan. Members cannot “choose” which coverage to use.  Members are required to notify the plan if there is a change in family status, which includes legal separate, divorce, change in employment status or you or your spouse, change in insurance coverage of your or your spouse.  When your family or insurance status changes, this “may” affect which plan is primary and which plan is secondary.

n       The coverage of any active employee (or their covered dependents) is ALWAYS primary to any individual’s coverage as a retiree (or dependent of a retiree) or COBRA coverage.

F       Coordination of Benefit Rules for Rx:  In the event another plan is primary and Rx coverage is provided under that plan, the benefits under that plan must be exhausted and used to the maximum extent available prior to Primary Benefits being payable under the Kingston Trust Plan.

Example:  If a member’s spouse is covered under his or her own plan, that member may not selectively choose not to use the NHAI care for Rx coverage.  If a retired member is also covered by their spouse’s plan and their spouse is actively employed, the spouse’s plan is primary and the Primary Plan must first pay both medical and Rx benefits.

F       Procedures for Reimbursement of Out of Pocket Expenses from Secondary Provider:  When NHAI plan is secondary; you must submit your Rx receipt showing your copay amount to the claims office.   Only those copays in excess of $25 will be subject to coordination of benefits.  To the extent that your copay for a single Rx exceed $25 under the Primary Plan, the NHAI Plan as secondary will reimburse you 80% of your excess out of pocket expenses until you reach your out of pocket limit and then 100% thereafter.  When NHAI pays Rx expenses as the secondary payor, they are treated as major medical expenses and are subject to the lower medical plan out of pocket limit (not the separate Rx out of pocket limit).

Examples:

a.      Primary Plan has a $20 copay – no reimbursement will be paid by NHAI Plan.

b.      Primary Plan has a $30 copay – plan will reimburse you 80% of $5 (excess over $25 copay.)

c.       The Primary plan has a maximum Rx benefit of $2,500 a year and NHAI is secondary.   Once you reach the maximum Rx benefit under the Primary Plan, all Rx charges will be reimbursed at 80% until you reach your out of pocket limit.  You will pay 20% of the Rx charges until you reach the medical out of pocket limit of $300, then all Rx will be paid at 100% thereafter.

F       Reimbursement of Out of Pocket Medical Expenses When NHAI is Secondary:  If the provider does not bill the secondary provider (you need to verify this and be sure to give your provider BOTH ID cards and advise the provider of which plan is primary, etc.), members will be required to submit BOTH a copy of the Explanation of Benefits (EOB) from the Primary Plan along with a copy of the bill/claim from the provider to NHAI Claim Office at P O Box 5000, Endicott, NY 13761-5000.  All bills must be timely submitted per the plan rules, i.e. within 90 days of payment by the primary payor and no later than 1 year from date of service.  Late filed claims will not be paid absent extenuating circumstances and subject to approval by the plan.

Accepted by the Trustees of the Kingston Trust Fund, ______________________________

                                                                                               Hugh M. Spoljaric, Chairman

AMENDMENT TWO &

NOTICE OF MATERIAL MODIFICATION

To the

KINGSTON TRUST

The following changes have been adopted and agreed to by the Trustees following a special meeting and shall be made effective January 1, 2005 unless otherwise indicated.  In addition to the plan changes, clarification of existing plan provisions are also being noted.  A “clarification” does not represent a plan change; rather it is an explanation of the present plan provisions.  Please keep a copy of this Amendment and Notice of Material Modification with your plan booklet.

1.       Dependent Coverage rules:  With the financial pressures of sending children to college and getting them started in life, we propose changes in the dependent rules under the 4.01, paragraph 3 of the Plan be modified to permit parents to cover their dependent children, including adopted children and step children who reside with you or, in the case of divorced parents, children for whom you or your spouse have a legal obligation to provide support according to a divorce decree or court order (documentation must be provided) as follows.   Generally, dependent status will be determined in accordance with IRS Publication 17, which permits you to claim the following children as a dependent on your tax return.

a.       Dependent children under the age of 19 may be covered until the calendar year in which they attain age 19.

b.       After the calendar year in which a dependent attains age 19, if the dependent qualifies as a full time student for at least 5 months out of the year (not a fulltime student under ‘student status’), coverage may be continued through the calendar year in which the dependent attains age 23, so long as the dependent remains unmarried and continues to be listed as a legal dependent on parent’s tax return; or

c.       Any dependent who is determined to be totally and permanently disabled by reason of physical or mental disability or impairment and who is incapable of self support prior to attainment of age 19 or who becomes disabled while enrolled as a full time student prior to attainment of age 23, may be covered as a disabled dependent so long as such disability continues.

d.       A dependent who continues to live at home continuously after attaining age 19 and continues to rely on parents for support may continued to be covered to age 23 regardless of whether or not enrolled in school, provided the dependent has gross income of less than the amount permitted by the IRS (per IRS Publication 17- $3,100 for 2004) and continues to be claimed as a dependent on the parent’s tax return.  Coverage ends as of the last day of the month in which the dependent attains age 23 and may be continued thereafter under COBRA.  (Documentation or a statement of support must be provided annually or upon request.)  Coverage ends and may only be continued under COBRA after the earliest of the following events regardless of age at the time of event:

                                                               i.      When the dependent marries;

                                                             ii.      No longer lives at home;

                                                            iii.      Dependent is responsible for more than 50% of his/her own support;

                                                            iv.      Begins working with an expected annual income that will exceed the above dollar limit; or

                                                              v.      Becomes covered under any other insurance plan.

Parents are responsible for updating the Plan on any change in dependent status and when the dependent no longer meets the above rules.  The failure to timely notify the plan within 60 days of any change may adversely affect the availability of COBRA for the dependent or may create a financial liability for benefits paid by the plan when the member was ineligible to be covered.  Once a dependent ceases to meet the above rules, they are eligible to continue coverage for 36 months under COBRA rules.  If a dependent ceases to be a dependent and then later becomes a dependent by reason of returning to school under b above, then that dependent may again be considered an eligible dependent for purposes of this plan. 

2.       Overall Utilization is up, as is the cost of medical care.  The PPO out of pocket will increase from $300(I) / $750(F) to $500 for individual and $1,000 for family.  This only applies to those  benefits that have percentage copays. Implementation will occur AFTER an IRS 125 Plan is ratified with the district.

·         Due to significant additional cost for NPPO providers: 

o        The NPPO Deductible should be $500 single/$1,000 Family

o        The NPPO out of pocket limit after the deductible is met should be increased to $1,500 single and $3,000 family (currently it is $750/$1,250).  Implementation will occur AFTER an IRS 125 Plan is ratified with the district.

3.       Emergency Room utilization is on the rise and too often the ER is used for non-life threatening injuries and illnesses that do not require emergency care. 

The Emergency Room copay will be increased from $50 to $75. In the cases of accidents, the plan will continue to pay 100% under the Accident Benefits.

Note:  Keep in mind that all coinsurance amounts are limited on an aggregate basis to the out of pocket limits under the plan depending on whether PPO or NPPO doctors are used.

4.       Prescriptions costs have been the fastest rising sector in the medical area.  Rx costs continue to increase at over 20% a year on average for the past 5 years (40% in the last two years).  When members avoid Mail Order for maintenance drugs, it adds tremendous cost to the plan.  Additionally, members do not have any formulary programs in effect and the plan covers two key diabetic meds (Glucophage and Metformin at 100%). 

 

Current

         As of 1/1/05

Medicare Coordination

 This plan is primary.

 This plan will continue to be primary to Medicare for Prescriptions

Rx Card – 31 day supply

$5 Copay – Generic

      $15 Copay --Brand

             $10—Copay--Generic  

             $20—Copay --Brand                   

Mail-Order Rx Copay for 93 day supply

$10 Copay --generic

       $25 Copay-- brand

$

           No Change

5.       While managing costs are important, so is a progressive approach with respect to preventive medication.  Some improvements in benefits are also important and necessary. They provide yet another “preventative” benefit, not generally covered at this level by group health plans. 

 

Current

                       As of 1/1/05

Vision

50% up to Maximum benefit of $150 every year.

Routine eye exams will be covered at 80% after $25 copay up to a maximum benefit of $150 annually.  In addition to the routine eye exam, glasses, frames, contacts will be covered at 50% up to a maximum of $150 a year.  The member is responsible for all charges in excess of the plan benefit.

Diagnostic or medical eye exams will be covered at 100% after $25 copay.

Health Club Dues

Reimbursement

No coverage.

The plan will reimburse members up to $100 per year for single membership and $150 for membership of both the member and their spouse.  Reimbursement will be made at the end of the membership year upon submission of proof of payment and membership in a health club for 12 months.  We want to encourage members to exercise regularly, eat right and to maintain a healthy weight and lifestyle.  Lifestyle, more than anything else, will affect your health over the long-term.  Individuals have control over at least 35% of their own heath and can decrease the potential of significant health problems by a “healthy” lifestyle.  Take control of your health TODAY!

 Accepted by the Trustees of the Kingston Trust Fund, ______________________________________

                                                                                                       Hugh M. Spoljaric, Chairman

                      KINGSTON TRUST FUND

      PO Box 4461, Kingston, NY 12402  (845)338-5422, Fax (845)338-0391

                                                  Email: ktf781@aol.com                            

       COBRA POLICY EFFECTIVE JANUARY 1, 2005

What is the plan policy with respect to COBRA coverage when a member fails to timely notify the Plan  of a COBRA event?

Consequences of Failure to Notify the Plan of a COBRA event or Change in Family Status.

Effective January 1, 2005, financial responsibility for the lesser of the actual COBRA cost or the actual benefits paid on behalf of an ineligible dependent or spouse will become the responsibility of the member if the member fails to notify the plan of an event that makes a dependent ineligible for coverage (legal separation, divorce, child attains age 19 or child ceases to be a full time student, etc.). 

  1. If a member fails to notify the plan of a COBRA event within 60 days of the event, the right to COBRA coverage will be forfeited.  The member will be responsible for reimbursing the plan for the greater of the premiums paid on behalf of the ineligible dependent (or spouse) or the actual claims paid on behalf of such ineligible dependent or spouse during the period the dependent received coverage and was not eligible to be covered as a dependent under the plan rules.

EXTENDED COBRA COVERAGE:

Currently, extended COBRA coverage (beyond 36 months) is offered only to the widows or widowers of retired members under 1 below.  Paragraph 2 is standard language and applies after the Extended COBRA benefits begin.

1.       A widowed spouse may continue COBRA coverage for his/her lifetime following the death of a member at COBRA rates.  COBRA rules with respect to payment and lapse of coverage will continue to apply to extended COBRA coverage under this paragraph.

2.       If the spouse remarries, (s)he may not add any additional dependents or a new spouse to this coverage after the initial COBRA period (36 months) expires.  During the initial COBRA period, the spouse may add a new spouse or dependents but they may only be covered during the initial COBRA period and are not eligible for extended Coverage beyond the initial COBRA period.   COBRA rules with respect to payment and lapse of coverage will continue to apply to extended COBRA coverage under this paragraph.  Extended coverage for any dependents not covered at the time of the initial COBRA event (death or divorce) are not eligible for extended COBRA coverage after 36 months. The member must request continued coverage under this option and payments to retain coverage will continue to be subject to the COBRA rules. Following is an explanation of COBRA.

Accepted by the Trustees of the Kingston Trust Fund, ____________________________

                                                                                           Hugh M. Spoljaric, Chairman


                                                       COBRA 

COBRA Administrator: Name:               Kingston Trust

Attn:  NHAI Compliance Office

Gloria Gillespie/April Carter

                                                Address:           416 Creekstone Ridge

                                                                        Woodstock, GA 30188-3740

                                                Phone:              (845) 338-5422

What is continuation coverage?

COBRA continuation coverage is a continuation of Plan coverage when coverage would otherwise end because of a life event known as a “qualifying event.”  Specific qualifying events are listed later in this Notice.  COBRA continuation coverage must be offered to each person who is a “qualified beneficiary.”  A qualified beneficiary is someone who will lose coverage under the Plan because of a qualifying event.  Depending on the type of qualifying event, employees, spouses of employees and dependent children of employees may be qualified beneficiaries if they were covered prior to the COBRA event and depending on the type of event.  Under the Plan, qualified beneficiaries who elect COBRA continuation coverage are required to pay for COBRA continuation coverage.

Qualifying Events

If you are an employee, you will become a qualified beneficiary if you will lose your coverage under the Plan because either of one of the following qualifying events:

  1. Your hours of employment are reduced, or
  1. Your employment ends for any reason other than his/her gross misconduct.

If you are the spouse of an employee, you will become a qualified beneficiary if you will lose your coverage under the Plan because of any of the following qualifying events:

1.       Your spouse dies;

2.       Your spouse’s hours of employment are reduced;

3.       Your spouse’s employment ends for any other reason other than your gross misconduct;

4.       Your spouse becomes enrolled in Medicare (Part A, Part B, or Both) (this only applies to qualified beneficiaries if this results in an actual “loss” of coverage at time of the initial qualifying event); or

5.       You become divorced or legally separated from your spouse.

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

1.       The parent – employee dies;

2.       The parent – employee’s hours of employment are reduced

3.       The parent – employee’s employment ends for any other reason other than his/her gross misconduct;

4.       The parent – employee becomes enrolled in Medicare (Part A, Part B, or Both);

5.       The parent becomes divorced or legally separated; or

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

Sometimes filing a proceeding in bankruptcy under Title 11 of the United States Code can be a qualifying event.  If a proceeding in bankruptcy is filed with respect to this plan or the district, and that bankruptcy results in the loss of coverage of any retired employee covered under the Plan, the retired employee is a qualified beneficiary with respect to the bankruptcy.  The retired employee’s spouse, surviving spouse and dependent children will also be qualified beneficiaries if bankruptcy results in the loss of their coverage under the Plan.

The Plan will offer COBRA continuation coverage to “qualified beneficiaries” only after the Plan Administrator has been notified that a qualifying event has occurred.  When the qualifying event is the end of employment or reduction of hours of employment, death of the employee, commencement of a proceeding in bankruptcy with respect to the employer, or enrollment of the employee in Medicare (Part A, Part B, or both), the employer must notify the Plan Administrator of the qualifying event.

A Qualified Beneficiary under law is defined as being an individual that MUST be covered under a group health plan on the day before the event that causes a loss of coverage (such as a termination of employment, a divorce or death of a covered employee.)  Qualified Beneficiaries have independent rights to make their own COBRA selections including changes during the COBRA coverage period.  (A Non-Qualified Beneficiaries coverage ends when the coverage for the Qualified Beneficiary’s ends.)

How long will continuation coverage last?

In the case of a loss of coverage due to end of employment or reduction in hours of employment, coverage may be continued for up to 18 months.  In the case of lost coverage due to an employee’s death, divorce or legal separation, the employee’s enrollment in Medicare or a dependent child ceasing to be a dependent under the terms of the Plan, coverage may be continued for up to 36 months.  Page one of the attached Election Notice shows the maximum period of continuation coverage available to the listed qualified beneficiaries.

Continuation coverage will be terminated before the end of the maximum period if any required premium is not paid on time, if a qualified beneficiary becomes covered under another group health plan that does not impose any pre-existing condition exclusion for a pre-existing condition to the qualified beneficiary, if a covered employee enrolls in Medicare, or if the employer ceases to provide any group health plan for its employees.  Continuation coverage may also be terminated for any reason the Plan would terminate coverage of a participant or beneficiary not receiving continuation coverage (such as fraud).

How can you extend the length of continuation coverage?

If you elect continuation coverage, an extension of the maximum period of 18 months of coverage may be available if a qualified beneficiary is disabled or a second qualifying event occurs.  You must notify the COBRA Administrator of a disability or a second qualifying event in order to extend the period of continuation coverage.  Failure to provide notice of a disability or a second qualifying event may affect the right to extend the period of continuation coverage.

¨       Disability

If you or anyone in your family covered under the Plan is determined by the Social Security Administration to be disabled at any time during the first 60 days of COBRA continuation coverage and you notify the Plan Administrator in a timely fashion, you and your entire family can receive up to an additional 11 months of COBRA continuation coverage for a total maximum of 29 months.  You must make sure that the Plan Administrator is notified of the Social Security Administration’s determination within 60 days of the date of the determination and before the end of the 18-month period of COBRA continuation coverage.  This notice should be sent to the COBRA Administrator along with appropriate documentation and physician certification of your disability.

¨       Second Qualifying Event

If your family experiences another qualifying event while receiving COBRA continuation coverage, the spouse and dependent children in your family who are “qualified beneficiaries” may get additional months of COBRA continuation coverage up to a maximum of 36 months.  This extension is available to the spouse and dependent children if the former employee dies, enrolls in Medicare (Part A or Part B, or both), or gets divorced or legally separated.  The extension is also available to a dependent child when that child stops being eligible under the Plan as a dependent child.   

In all of these cases, the Qualified Beneficiary must make sure that the Plan Administrator is notified of the Second Qualifying Event within 60 days of the latest of:

1.       The date of the Social Security Administration disability determination;

2.       The date of the qualifying event;

3.       The date on which the qualified beneficiary would lose coverage under the plan; or

4.       The date on which the qualified beneficiary is informed of the obligation to provide the disability notice through the plan’s SPD or initial notice.

Second qualifying events DO NOT apply to a covered spouse or dependent UNLESS they are a “qualified beneficiary”.  In order to be eligible under the Second Qualifying Event Rules you must meet the following three conditions:

1.       The spouse or dependent must be a Qualified Beneficiary in connection with a termination (or reduction is hours) of employment;

2.       The spouse or dependent child must still be a Qualified Beneficiary at the time that the 36-month occurs; and

3.       The 36-month event must be a qualifying event (see special rules for Medicare).

How can you elect continuation coverage?

Once the Plan Administrator receives notice that a qualifying event has occurred, COBRA continuation coverage will be offered to each of the qualified beneficiaries.  For each qualified beneficiary who elects COBRA continuation coverage, COBRA continuation coverage will begin as of the later of (1) the date of the qualifying event or (2) the date that Plan coverage would otherwise end as noted on your COBRA Election Form.  Under this plan coverage generally ends as of the last day of the month during which the COBRA event occurs.

COBRA continuation coverage is a temporary continuation of coverage.  When the qualifying event is due to the loss of coverage due to the death of the employee, enrollment of the employee in Medicare (Part A or Part B, or both), your divorce or legal separation or a dependent child losing eligibility as a dependent child, COBRA continuation coverage lasts for up to 36 months.

When the qualifying event is the end of employment or reduction of the employee’s hours of employment, COBRA continuation coverage lasts for up to 18 months.  There are two ways in which this 18-month period of COBRA continuation coverage can be extended.  A qualifying disability or a second qualifying event as explained above. 

In considering whether to elect continuation coverage, you should take into account that a failure to continue your group health coverage will affect your future rights under Federal law.  First, you can lose the right to avoid having pre-existing condition exclusions applied to you by other group health plans if you have more than a 63-day gap in health coverage and election of continuation coverage may help you not to have such a gap.  Second, you will lose the guaranteed right to purchase individual health insurance policies that do not impose such pre-existing condition exclusions if you do not get continuation coverage for the maximum time available to you.  Finally, you should take into account that you have special enrollment rights under Federal law.  You have the right to request special enrollment in another group health plan for which you are otherwise eligible (such as a plan sponsored by your spouse’s employer) within 30 days after your group health coverage ends because of the qualifying event listed above.  You will also have the same special enrollment right at the end of the continuation coverage if you get continuation coverage for the maximum time available to you.

Responsibility of Member or Qualified Beneficiary to Notify the Plan of Status Changes

You must notify the Plan Administrator for the 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 due to age or no longer qualifying as a full time student.)  The Plan requires you to notify the Plan Administrator within 60 days after the qualifying event occurs.  You must notify the Plan in writing using forms provided by the Plan.  Notice Forms are available from the Trust office and copies are included in your SPD.

Consequences for Failure to Notify Plan of Changes in Status

If you fail to timely notify the Plan in writing using designated change forms provided by the Plan, the following consequences will apply effective January 1, 2005:

  1. You will be personally liable to reimburse the Plan for the greater of the actual COBRA  benefits paid after the initial qualifying event.
  1. Extended COBRA benefits will not be available if Notice of a Second Qualifying Event is not timely received.
  1. If a member fails to notify the plan of a COBRA event within 60 days of the event, the right to COBRA coverage will be forfeited.  The member will be responsible for reimbursing the plan for the greater of the premiums paid on behalf of the ineligible dependent (or spouse) or the actual claims paid on behalf of such ineligible dependent or spouse during the period the dependent received coverage and was not eligible to be covered as a dependent under the plan rules.
How much does continuation coverage cost?

Generally, each qualified beneficiary may be required to pay the entire cost of continuation coverage.  The amount a qualified beneficiary may be required to pay may not exceed 102 % of the cost to the group health plan (including both employer and employee contributions) for coverage of a similarly situated plan participant or beneficiary who is not receiving continuation coverage (or, in the case of an extension of continuation coverage due to a disability, 150%).  The required payment for continuation coverage for the qualified beneficiaries listed and described on the Election Form attached.

COBRA premiums are subject to change every 12 months, as of each January 1, per Section 3.01 of your Plan.

What coverage will be provided?

COBRA coverage is identical to the coverage provided at the time of the event.  Your benefits will continue to be the same as those available to any active employee including the right to add dependents or make changes in coverage during open enrollment or in the case of a special enrollment situation as described in your Summary Plan Description (SPD).  Contact your COBRA administrator if you need forms or a copy of the Plan.

When and how must payment for continuation coverage be made?

¨       First payment for continuation coverage

If you elect continuation coverage, you do not have to send any payment for continuation coverage with the Election Form.  However, you must make your first payment for continuation coverage within 45 days after the date of your election.  (This is the date the election Notice is postmarked, if mailed.)  If you do not make your first payment for continuation coverage within the 45 days, you will lose all continuation coverage rights under the Plan.

Your first payment must cover the cost of continuation coverage from the time your coverage under the Plan would have otherwise terminated up to the time you make the first payment.  You are responsible for making sure that the amount of your first payment is enough to cover this entire period.  You may contact the COBRA Administrator to confirm the correct amount of your first payment.

Your first payment for continuation coverage as well as all future payments must be sent to the COBRA Administrator listed on page 3.

¨       Periodic payments for continuation coverage

After you make your first payment for continuation coverage, you will be required to pay for continuation coverage for each subsequent month of coverage.  Under the Plan, these periodic payments for continuation coverage are due on the first day of each month of coverage. If you make a periodic payment on or before its due date, your coverage under the Plan will continue for that coverage period without any breakOtherwise, your coverage will be reinstated retroactively upon receipt of your premium.  Late payment may interrupt your ability to fill prescriptions or have coverage verified by providers.  The Plan will not send periodic notices of payments due for these coverage periods.  Payment slips will be provided for you to complete and submit with each payment.

¨       Grace periods for periodic payments

Although periodic payments are due on the dates shown above, you will be given a grace period of 30 days to make each periodic payment.  If you pay a periodic payment later than its due date but during its grace period, your coverage under the Plan will be suspended as of the due date and then retroactively reinstated (going back to the due date) when the periodic payment is made.  This means that any claim you submit for benefits while your coverage is suspended may be denied and may have to be resubmitted once your coverage is reinstated.  You will not be able to fill prescriptions while your coverage is suspended.

If you fail to make a periodic payment before the end of the grace period for that payment, you will lose all rights to continuation coverage under the Plan.  A check that does not clear is not considered a valued payment

Can you elect other health coverage besides continuation coverage?

No other alternative coverage is available, except for that available under COBRA, except for the certain extended coverage provided to retirees as follows:

Special KTF Plan Rules For Retiree Coverage and Extension Benefits

Retired employees may continue coverage on themselves and their spouse so long as they are living and remain married under the Plan rules, which may be changed or modified at any time under the collective Bargaining Agreement.  Both the employee and his or her spouse, upon retirement of the member, shall each be eligible for single coverage at the same cost as any other active employee pays for single coverage, unless a buy-out option is elected.  If a retiree has dependents other than his/her spouse, then coverage shall be continued as family coverage.  Any buy-out election made once in retirement status shall be irrevocable.  Buy-out elections shall be subject to any buy-out rules as agreed to on behalf of retirees and approved by the Plan and shall be incorporated by this reference.  

The following special rules apply to retiree coverage and changes in coverage after retirement:

1.   Upon the death of a retiree’s spouse, if the employee remarries, he/ she may add his or her new spouse and any dependents provided that the cost for such dependent coverage is paid in full by the retiree based on the current COBRA rate.

2.   In the event of divorce, the former spouse may only continue coverage under COBRA.  The retiree may add a new spouse or dependents after retirement only if the cost of the coverage for such new spouse and/or dependent is paid in full by the retiree at the current COBRA rate.

3.   Upon the death of the retiree, the retiree’s spouse’s coverage will end at the end of the month 90 days following the month during which death occurs.  Coverage may be continued following the death of a retired employee under COBRA for 36 months (subject to COBRA rules) and thereafter single coverage only may be continued by the spouse for his/her lifetime based on the COBRA rate. 

4.   Adding dependent/spouse at time of retirement - If a retiree only has single coverage in effect at the time of retirement, he may add spouse and/or dependent coverage provided that the cost for such dependent coverage is paid in full by the retiree at the current COBRA rate.

5.   Cost of Coverage under any coverage continued under items one through three, will be 102% of the actual cost.  Premiums for this coverage must be paid directly to the Trust within 30 days of any due date.  Failure to pay the premiums within 30 days of any due date shall result in immediate termination of coverage as of the due date with no reinstatement rights.  The grace period for payment shall be extended (one time only) to 60 days only in the event that the participant is ill or injured and unable to take care of his/her financial affairs as determined at the sole discretion of the Plan.

Keep Your Plan Informed of Address Changes

In order to protect your family’s rights, you should keep the Plan Administrator informed of 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.

This Notice does not fully describe continuation coverage or other rights under the Plan.  More information about continuation coverage and your rights under the Plan is available to your Summary Plan Description or from the Plan Administrator.  You can get a copy of your Summary Plan Description from your COBRA or Plan Administrator.

For more information about your rights under ERISA, including COBRA, the Health Insurance Portability and Accountability Act (HIPAA), and other laws affecting group health plans, contact the U.S. Department of Labor’s Employee Benefits Security Administration (EBSA) in your area or visit the EBSA website at www.dol.gov/ebsa.

 

Return to top of page



Welcome   News   Kingston Trust Fund   National Health Administrators Plan
Mid Hudson Teachers Center   Resources for Teachers   Resources for Parents   Community Links   Events
Board and Officers   Contact Us

Copyright 2000 - Kingston Teachers' Federation
Charlie Lawrence - Webmaster