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 |
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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.
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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.â€
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.
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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 residencyâ€
“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
- 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
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|
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. |
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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
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.).
- 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:
- Your hours of employment are reduced, or
- 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 “lossâ€
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.â€
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 beneficiaryâ€. 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:
- You will be personally liable to
reimburse the Plan for the greater of the actual COBRA benefits paid
after the initial qualifying event.
- Extended COBRA benefits will not be available if Notice of a Second Qualifying Event is not timely
received.
- 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 break. Otherwise, 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.
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