SUFFOLK COUNTY MUNICIPAL EMPLOYEES BENEFIT FUND BENEFITS DENTAL

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1 SUFFOLK COUNTY MUNICIPAL EMPLOYEES BENEFIT FUND BENEFITS DENTAL Active Level members, Active COBRA or Self-Pay Enhanced Retire Plan members are covered with an maximums, per eligible member or dependent of: $2,750 Annually for General Dentistry $2,000 Annually for Periodontal Treatment $4,000 Lifetime for Implant and Abutments up to $500 each for no more than implants (4) and abutments (4) $1,995 Lifetime for Orthodontics, Adolescent and Adults. With a $1,000 co-pay for in-network providers. Retired Members and their dependents are limited to an Dental maximum annually of: $750 per family, $500 per individual for all dental services. Dental Plan is Administered by a Third-Party Provider A third-party provider is an administrator hired by the Fund to process and pay claims. In 2009, Healthplex, Inc. was hired by the Fund to streamline the Fund s Dental claims, increase our In-Network Provider List and save money. Healthplex, Inc. is not our insurance company. The Benefit Fund remains financially responsible for your covered benefits. Healthplex administers the dental plan adopted by the Fund s Board of Trustees. As our third-party provider, Healthplex reviews all Fund dental claims to insure payments are made according to the guidelines set by the SCME Benefit Fund. Making Claim for an In-Network Dental Provider: Making a claim with an In-Network Dental provider will be handled between the participating dentist and Healthplex. The member or their eligible dependent simply needs to sign the claim form at the dental office. Making a Dental Claim for Out-of Network Dentists: Request a claim form from your worksite (payroll representative), dentist s office or print them directly from our website. All sections must be completed, including your original signature and the current date placed where indicated when you are utilizing the services of a non-participating provider. The dentist s signature and tax identification number must be contained on all claim forms, regardless of their status with the Fund. Predetermination Request If the procedure or series of treatments is a covered procedure, clinically necessary and is expected to be over $1,000, you must have your dentist file for a predetermination BEFORE the work is done. Payment for such treatment, without this determination will be subject to a fine of $250. Please return Predeterminations and Out-of-Network claim forms, signed and dated to: Healthplex, Inc. P.O. Box 9255 Uniondale, NY

2 Please note: Incomplete claim forms will be returned to you for more information, which may cause a delay in your benefit payment. Predetermination Of Dental Benefits Your Benefit Fund dental program has a Pre-determination of Benefits requirement for any plan of treatment and/or service submitted by a provider that is equal to or exceeding $1,000. In addition, all periodontal and orthodontia services must be pre-determined, regardless of who is providing the service. You are responsible for advising your dentist of this requirement. The pre-determination must be accompanied by a properly mounted set of diagnostic quality x-ray films and any other pertinent documentation that may be deemed necessary to adequately make a review for available benefits. The failure to submit for the required pre-authorization will result in a forfeiture of benefits. Predetermination allowances are payable only after the following conditions are applied. 1. The claimant must be eligible for benefits when the described services are incurred. In the case of termination from the Fund, an expense is incurred when the service is performed, except in cases of: 1. Dentures, or fixed bridgework when the final impression is taken; 2. Crown work when preparation of the tooth is begun; 3. Root canal therapy when root canal treatment is completed. 2. So long as there has not been a change in the plan of benefits prior to performance of the service that would thus vary the allowance indicated. 3. So long as the total benefit payments for all treatment of a patient in any benefit period does not exceed plan maximums. 4. The allowances may be reduced by Coordination of Benefits, if applicable, to each patient. The Benefit Fund shall have the right to request that a member or his/her dependent undergo an oral examination to verify treatment recommended in a Predetermination review, or following treatment to determine the extent of services rendered. This requirement applies where clarifying information can only be obtained in this way. Failure to comply will result in forfeiture of benefits. Periodic Review of Treatment The Fund reserves the right to examine dental patients to assure that in all cases proper care, procedures and costs have been assigned. It periodically reviews prescribed courses of treatment in individual cases to determine whether the Alternate Benefit Provision should be authorized and payments limited accordingly Alternate Benefit Provision If an alternate benefit can be provided, giving consideration to professionally acceptable alternate procedures, services, or courses of treatment, the Fund will determine the amount of benefits payable, that would accomplish the desired results. (The attending dentist and the patient may proceed with the original treatment plan regardless of the Fund s benefit determination.) For example, a payment for a crown will not be allowed if an acceptable professional result can be obtained by placing a filling in the tooth. A payment will be made as if a filling was placed in the tooth that received the crown. Upon presentation of documentation satisfactory to the Fund that the tooth can only be restored by a crown, payment will be made for a crown. The Fund retains the right to limit the number of payments to be made for dental services in circumstances that, in the Fund s sole judgment, require such limitation. 2

3 Participating Dental Program The Fund has made arrangements with many local dentists who have agreed to accept the fees listed in this booklet as payment in full. Should you decide to use one of the participating dentists, no charges will be made for any of the eligible dental services listed and payments will be made directly from the Fund to your dentist. There are some exclusions. Please contact the Fund for more information. Frequency limits and general exclusions remain the same no matter which dentist (participating or otherwise) you might choose. Participating dentists may charge you for services not listed in the Schedule of Dental Benefits, but such services should be infrequently encountered, if at all. Please refer to the list of participating dentists for those offices accepting the Fund plan. Dentists who specialize in orthodontia, periodontia, endodontia or oral surgery are listed separately from general dentists. This list will be revised from time to time by the Fund so check with the Fund office to verify the status of the provider you have chosen. Schedule of Benefits Maximum Amount Payable The maximum amount payable for each individual for the listed dental services will be $2,750 in any calendar year, exclusive of orthodontia or periodontia services, which have separate maximums of $2,000 in any calendar year for periodontia, $1,995 in a lifetime for adolescent and adult orthodontia. Retirees have an all-inclusive annual maximum of $750 per family, $500 per individual. General Limitation of Covered Expenses Covered dental expenses will not include, and no payments will be made for, expenses incurred for the performance of any dental service not provided for in this schedule. In special instances, the Fund Trustees may agree to accept certain expenses as covered dental expenses. To submit the expenses to the Fund for consideration, the dental service should be identified in terms of the American Dental Association Uniform Code of Dental Procedures and Nomenclature (codes for covered services listed in following schedule) and by narrative description. If expenses incurred for a dental service not expressly provided for in this Schedule are accepted by the Fund, the covered dental expense for that dental service will be determined while remaining consistent with those listed in this Schedule and will be conclusive and binding. In any event, expenses incurred for instruction for plaque control, oral hygiene instruction, bite registrations, or for dental services, that do not have uniform professional endorsement, will not be accepted by the Benefit Fund as covered dental expenses. A temporary dental service will be considered an integral part of the final dental service rather than a separate service. The Fund will not absorb or be responsible for any fees or charges that are owed by a member that exceed the benefits herein. The Fund reserves the right to request and receive any additional information it deems necessary to properly adjudicate the claim. GENERAL EXCLUSIONS FROM BENEFITS FOR DENTAL SERVICES As a guide to members in their utilization of the Dental Benefit Plan, the following list specifies but does not limit the particular and general exclusions from the plan. 3

4 Payment will not be made for any expenses incurred: 1. For any services, supplies, or treatment not prescribed by a legally qualified dentist or physician; 2. For services rendered prior to the patient becoming eligible for benefits; 3. For any dental or surgical procedure performed solely or substantially for cosmetic reasons; 4. For procedures, restorations, or appliances performed or fabricated solely for cosmetic purposes or to increase vertical dimension, or to restore occlusion; 5. For replacement of an existing crown, inlay, onlay, fixed bridge, or complete or partial removable denture until five years have elapsed from the date the service was originally completed and only if the crown, inlay, onlay, fixed bridge, or complete or partial removable denture being replaced is unsatisfactory and cannot be made satisfactory; 6. For multiple abutting of teeth for prosthetic purposes when the additional teeth are free of decay and functionally sound, or for prosthetic appliances, fixed or removable, placed for the purpose of periodontal splinting; 7. For charges for temporary crowns (unless tooth is fractured, and only on anterior teeth), or for temporary dental services which will be considered an integral part of the overall dental service rather than a separate service; 8. For dental service performed by a dentist in which the Fund experiences an instance of unsatisfactory documentation or recording of services that is deemed detrimental to the Fund or the patient. 9. All periodontal treatment must be reviewed and approved for benefits prior to treatment. The most inclusive periodontal service includes all related services performed on the same date in the same area and payment will be made for the all-inclusive service only. For osseous surgery (ADA code 4260) and gingivectomy (ADA code 4210) performed on the same date, payment will be made for the all-inclusive osseous surgery. 10. For any benefit that is claimed after a period that exceeds one year from the calendar year in which dental services were rendered, 11. For replacement of a lost, stolen or missing appliance or prosthetic device or the fabrication of a spare appliance or device; 12. For dental supplies or services rendered for injuries or conditions compensable under Worker s Compensation, Employer s Liability laws, or no fault automobile insurance laws; dental services provided by a Federal or State or Provincial government agency, i.e., Veteran s Administration Hospital, or provided without cost to the covered individual by any municipality, county, or political subdivision or community agency, except to the extent that such payments are insufficient to pay for the applicable eligible dental benefits contained in this plan; 13. For dental supplies or services furnished by or for the United States Government or any local governmental agency or where reimbursement is made elsewhere; 14. For services where a charge is not incurred or payment is not required; 15. For dental services or supplies not listed or not consistent with the Schedule of Dental Benefits unless the Fund reviews the services and accepts the expenses as Covered Dental Expenses. The Covered Dental Expense for such services will be determined by the Fund and will be consistent with those listed in the Schedule; 16. For treatment of disturbances of the temporomandibular joint, or myofacial pain; 17. For treatment that does not meet currently accepted standards of dental procedures, or treatments that are experimental in nature; 18. For orthodontic services provided when no severe malocclusion and/or functional problem exist; 19. For analgesics (such as nitrous oxide) or other euphoric or prescription drugs; local anesthesia, or drugs that desensitize teeth; 20. For any charges for broken appointments or completion of claim forms; 21. For any charges for hospitalization, including hospital visits, laboratory tests and/or laboratory examinations; all other services and treatments not specifically listed as included in the Benefit Fund s dental plan. 4

5 NOTE: Further information is available upon request. If you have any questions regarding the coverage, benefits or exclusions, please contact the Fund Office at (631) Hearing Co-Pay Reimbursement Who is eligible? Member and eligible dependents as defined by the Fund. What is the Benefit? Up to $400 will be paid by the Fund once every thirty-six months towards the out-of-pocket-cost of a hearing aid, including charges for its fitting, upon the recommendation of a physician or otologist. Claiming Obtain a Hearing Aid voucher from the Fund office. Your health insurance carrier currently covers this benefit. Submit your expenses to that entity first and the Fund second. When submitting to the Fund you must enclose a copy of the payment made or not made by your primary health carrier in order for us to consider your claim. A bill for the hearing aid must also be attached. The claim will be subject to verification. Limitations The Fund does not pay for any repairs to hearing aids, any non-durable equipment such as replacement batteries, nor any appliances or expenses not recommended or approved by a physician or otologist. Benefits payable under Workers Compensation, Medicaid, or any other Government plan are not covered. Prescription Co-Pay Reimbursement Who is eligible Member, and eligible dependents as defined by the Fund. What is the Benefit Once annually the Fund reimburses to a member the out-of-pocket costs that have been paid within the calendar year for drugs prescribed by a medical doctor, osteopath or dentist. Prescriptions must be dispensed by a licensed pharmacist. Please contact the Fund for the yearly maximum amount or the allowable copayment amount. All rules and regulations governing Suffolk County s primary prescription plan apply to your Fund coverage. Covered expenses Prescriptions that require compounding; Prescriptions for legend drugs (drugs that cannot be dispensed by a pharmacist without a prescription); All other drugs covered by the plan in accordance with the terms and conditions set forth by the plan. Exclusions 1. OTC (over the counter) drugs, vitamins, diet supplements, etc., which even if prescribed by a physician can be legally purchased without a prescription. 2. Drugs covered by this plan must be prescribed by a licensed medical doctor, osteopathic physician or dentist 3. All drugs must be dispensed by a registered pharmacy. 5

6 4. Drugs which are administered to in-patients of any hospital are not eligible. 5. Single prescriptions that exceed a 3-month supply (this does apply to refills obtained at a later date). 6. Growth stimulating drugs, food supplements, cosmetic drugs, or any other drug prescribed for conditions other than injury, illness or disease are not covered by the plan. 7. Expenses not submitted prior to December 31st of the current year for the previous year will not be eligible for reimbursement. Example: Claims for 2013 may be claimed only up to 12/31/2014 Note: The Fund will not pay prescription costs incurred by members in excess of the co-payment maximum. If you use a pharmacy that does not participate with your primary prescription carrier, you will be required to pay the full cost of the prescription to the pharmacy. To receive your benefit, submit a completed reimbursement form to your medical plan. The Fund will only pay the co-payment amount that the plan would have paid if you used a participating pharmacy. Limitations Duplicate claims cannot be honored. Prescriptions for allergies dispensed at a laboratory will be allowed only if the prescriptions would normally be filled at a licensed pharmacy. Claims for prescription drug co-payments can only be filed ONCE annually per family. Submit only after you have accumulated the annual maximum for co-payment costs. If you do not meet the maximum total prior to the end of the year, submit your claim for whatever the amount is below that figure after the last day of that calendar year. Any claim paid by the Fund will NOT be reconsidered at a later date, even if you discover that you failed to include several co-pays on your original claim. Make sure that you have acquired all of the necessary pharmacy print-outs and primary prescription statements before making claim to the Fund. It is your responsibility to ensure that your original claim contains all of your families co-payments. Claiming Obtain a Prescription Drug claim form from your payroll representative or the Fund. Complete instructions for filing are included on the back of the claim form. Proof of payment must be attached. Pharmacy Printout Filings Complete the claim form for all persons covered under the insured s benefit. Prescriptions for the member, spouse, and covered children must be on the same form. Identify each family member and list all printouts for that person, including the total of each one. Do this for each individual you are submitting for. Please complete all required areas of information. Remember to sign and date the bottom of the form. Individual Receipts We do not accept individual receipts. ABOUT THE LEGAL SERVICES Legal The Plan and Coverage Responding to the needs of members for flexibility and free choice of attorney, this legal plan is provided by the Fund. The Trustees have adopted a plan that partially covers fees for services through Benefit allowances. This allowance feature enables our members to choose an attorney according to individual needs and as the type of case warrants. 6

7 Charges are the responsibility of the members. Reimbursement in accordance with the Fund s established fee schedule may be requested at the completion of the covered legal matter. You should explore, with your chosen attorney, the estimate of costs involved for any problem for which you seek help, acquiring a working concept of what services are covered. If you need assistance with locating an attorney, we normally suggest contacting the Suffolk County Bar Association. With a plan of such flexibility, a restriction must be imposed that if a court awards full or partial payment for a member s legal fees, the Fund s payment of allowances shall be reduced by the amount awarded. Specifically, the total court award and Fund allowance cannot exceed the amount charged by the attorney. Costs of documents, filing, court fees, etc., are not covered by this plan. Second-opinion fees are also excluded from coverage. No Fund Member is compelled to use this plan of benefits. NOTE: Further information is available upon request. It you have any questions regarding the coverage, benefits or exclusions, please contact the Fund Office at (631) LEGAL SERVICES PLAN PROVISIONS Enrolling In order to be eligible for benefits you must have completed a Benefit Fund enrollment card and filed it with the Fund Office. When filed at the Fund Office this card confirms whether you are a covered member or an eligible non-member dependent. With this data, the attorney-client relationship will remain exclusively between you and your chosen counselor and yet enable the Fund to properly process your benefit. No employee or Trustee of the Fund can interfere with this relationship. Claiming First, check each listing under the covered benefit you are in need of to determine whether or not you are eligible for it. Once you have determined the benefit category and that you possibly qualify for the coverage call or write the Benefit Office at 30 Orville Drive, Suite D, Bohemia, NY 11716, telephone number (631) and request a legal voucher. Give as much information as you can to the Fund s claims examiner so that he or she can make sure that the proper legal voucher is issued. Payment Payment is not made by the Fund until the legal matter is completed. Members terminating service prior to completion of a matter are NOT eligible for an allowance on that matter. After legal services are completed, you not your attorney should return this form to the Fund, along with a bill detailing the fees charged. Your allowance for services will be sent to you directly once you claim has been approved. It should be noted that from time to time the Trustees may, in their discretion add to, amend, change, delete or modify existing Benefit Fund rules and regulations and benefit allowances. Should a question arise as to benefit coverage, such question shall be resolved upon review of the Legal Service s Trust Indentures, plan of benefits and minutes of Trustees meetings. If additional information is desired call the Fund office where more detailed information is available. Eligibility Each benefit type identifies exactly who is covered under the following rules: 7

8 Covered Members Covered members include; all employees of Suffolk County covered by the collective bargaining agreement between the County of Suffolk and The Association of Municipal Employees for whom contributions are payable to the Suffolk County Municipal Employees Benefit Fund (herein the Benefit Fund ); any other employees of the County of Suffolk, including, but not limited to the faculty and administrative staff of the Suffolk County Community College, that may be deemed eligible by the Board of Trustees, for whom contributions are made payable to the Benefit Fund; the judges and court administrative personnel of the County of Suffolk for whom contributions are made payable to the Benefit Fund; employees of towns, villages and subdivisions of municipalities located in the County of Suffolk that maybe deemed eligible by the Board of Trustees, for whom contributions are made payable to the Benefit Fund; employees of other entities, such as the Vanderbilt Museum, that may be deemed eligible by the Board of Trustees, for whom contributions are made payable to the Benefit Fund; employees of The Association of Municipal Employees for whom contributions are payable to the Benefit Fund by the Union and employees of the Benefit Fund for whom contributions are payable to the Benefit Fund. Dependents Spouses and dependents of covered members are covered for certain benefits as specifically hereinafter described in this booklet. Dependents, as defined by the Fund, are your spouse, unmarried dependent children who have not reached their 19th birthday and unmarried dependent children who are full time students at a college or university who have not reached their 25th birthday; an unmarried child, regardless of age, who is incapable of self-sustaining employment by reason of mental retardation or physical handicap who became so prior to the age of nineteen and resides with and wholly depends upon the covered member for support. Dependent children include legally adopted children, stepchildren and foster children who reside with and wholly depend on the covered member for support. Status In general, subject to the requirements pertaining to the definition of a covered member, employees are eligible for benefits only so long as they are in an active payroll status. Eligibility for benefits terminates as of the effective date your employment is terminated. Therefore, if you are a covered member at the time that you retain an attorney but are no longer on active payroll status at the time that a legal matter is completed, you are not covered under this plan and the costs are your sole responsibility. Active payroll status here means the period for which contributions are paid, or should have been paid, for the employee by the employer to the, Benefit Fund. Members who go on a leave of absence from active employment due to extended illness, job related injury that results in Workers Compensation status, or maternity will remain eligible for benefits for one year commencing with the date of such leave, All employees covered by the Legal Services and in an active payroll status will be eligible for benefits after completion of two full months of employment following the month in which they were hired. For example, an employee hired on February 15 shall be eligible for benefits on May 1; an employee hired on June 2 shall be eligible for benefits on September 1. The Fund reserves the right to request any documents necessary to establish eligibility of a member or dependent. Extension of Dependent Eligibility in Case of Member s Death For a period of 90 days after the death of a member, all legal service benefits for a spouse and dependents as defined by the Fund, will continue to the extent that they were entitled to receive such benefit on the 8

9 date of the decedent s death. In addition, during this extension period, the consultation benefit is available to the surviving spouse, or if there is none the eldest surviving dependent. Appeal Process Within 180 days after receipt of notice that your claim has been denied, in whole or in part, you, or your duly authorized representative, may file a written request for a review of your claim by the full Board of Trustees. Such request must set forth the basis for the appeal, and all pertinent data to substantiate your position. In connection with the appeal, you, or your representative, will be given an opportunity to inspect copies of pertinent documents and to review the information upon which the denial was based. The Board of Trustees in their discretion may hold a full hearing of the issues presented by you. The Board will act upon a request for a review within a reasonable period of time after receipt thereof. You will be notified in writing of the action taken by the Board of Trustees. Such notice shall include the specific reasons for the decision and specific references to the Plan provisions on which the decision was based. All such decisions will be final, conclusive and binding. All appeals must be in writing and addressed to: The Board of Trustees, Suffolk County Municipal Employees Legal Services Fund, 30 Orville Drive, Suite D, Bohemia, NY Who is eligible Member. Tax Preparation Reimbursement What is the Benefit The Fund will pay $30 for the professional preparation of IRS form 1040A or up to $70 for the professional preparation of IRS form 1040 for either the member or for a joint return of the member and spouse. Members may use any accountant of their choice. The Fund s panel of Certified Public accountants have agreed to accept $30 as payment in full for the preparation of form 1040A, including preparation of the related New York State tax return and $75 for the preparation of form 1040, including preparation of the related New York State return. The member is responsible for paying $5 of the 1040 preparation charge plus any other charges for any additional forms. Limitations Members are entitled to reimbursement for one tax return preparation each calendar year. Electronic filing fees are not covered. Claiming Obtain a tax return voucher from the Fund office. If you utilize a participating CPA as your tax preparer, submit the voucher directly to them. Otherwise, send the original completed voucher with a paid bill to the Fund office. The bill must be on the preparer s professional letterhead. Calling or business cards are not acceptable. A copy of page 1 and 2 of your federal return must be filed with the Fund. Photocopies (including faxes) of vouchers are are not accepted by the Fund. Financial information contained on the tax return is not required. The Fund encourages removal of such information prior to filing your claim. Who is Eligible Active Members Only and Active College Aides. Bereavement Benefit 9

10 What is the benefit A death benefit in the amount of $l0,000 payable to the beneficiary or beneficiaries named in writing by the member and filed with the member s payroll representative. If no beneficiary is named, or if a named beneficiary is not living at the time of the member s death, payment will be made to the member s estate. Please note that the Benefit is reduced by half when the deceased is over 70 years of age. Limitations Covered members are those as defined by the Fund in an active payroll status only, with the exception of those members on a leave of absence of up to one year due to extended illness, maternity, or a job-related injury resulting in Worker s Compensation status or Suffolk County Community College Aides. Retired members or members on COBRA are not eligible for this benefit. Claiming A copy of the original death certificate, with cause of death and the issuing municipality s seal must be submitted to the Fund office along with the member s social security number. In those cases where no beneficiary has been named or the named beneficiary predeceased the member, copies of Letters of Administration or Letters Testamentary from the Surrogate Court must also be submitted. Designating a Beneficiary Designation of Beneficiary Forms are filed and kept with your departmental payroll representative. If you wish to update information, complete another form at that time. This information will supersede the original form. Who is eligible Active member or spouse. Survivor s Benefit What is the benefit The Fund will pay $1000 upon the death of either the member or the member s spouse. Claiming Submit a certified copy of the death certificate to the Fund office along with the member s social security number and designation of beneficiary form. Limitations Covered members are those as defined by the Fund and include members on a leave of absence of up to one year due to extended illness, maternity or a job-related injury resulting in Worker s Compensation status. Retired members, their spouses, and those on COBRA are not eligible for this benefit The member will be the beneficiary upon the death of his or her spouse. The member s spouse will be the beneficiary upon the death of a member unless a signed form naming another beneficiary is on file with the employee s payroll office. Payment will be made to the designated beneficiary of single members. 10

11 Plan Rules REQUIREMENTS FOR COVERAGE AND EXTENSIONS Enrolling All employees must file an enrollment card with the Fund office and keep it updated in order to avail themselves of the benefits provided by the Fund. Obtain a card from your payroll representative. It is essential for the orderly processing of claim forms. After filling out and filing the card, you are required to promptly notify the Fund, in writing, of any of the following: 1. Change of Name 2. Change of Address and/or Telephone Numbers 3. Change of Marital Status 4. Any Addition of Dependents 5. Any Loss of Dependents Due to Marriage, Death, or Their Change of Residence The Fund reserves the right to request any documents necessary to establish eligibility of a member or dependent. Waiting Period 1. As an employee, you must be in an active payroll status with an employer who has funded the required contribution. This establishes the period of employment for which contributions are paid or should have been paid to the Benefit Fund by the employer. 2. Eligibility for benefits commences on the first of the month after completion of at least two full months, but not more than three months, of such status. In other words, if you start work on the first of the month, you will be able to participate in benefits in exactly two months. However, if you start on the second day of the month (or later) the remainder of that month must be added to the two full-month minimum. Example: Hired January l, benefits start March l. Hired January 2, benefits start April l. Benefit Payment Requirements Once the waiting period is over, and provided the eligible employee has filed a Fund enrollment card, benefit coverage starts. Before starting payment of benefits to you, the Fund may request confirmation from you or your employer of pertinent payroll, address, and dependent data. Payment of benefits can be put in jeopardy if the employee fails to notify the Fund of changes in marital status, dependent status, or domicile; or neglects to confirm college attendance status of a dependent child of their household. College attendance must be confirmed directly to the Fund each semester. Benefits are payable to those eligible members or their dependents only to the extent of the terms of each benefit as defined in this booklet. Ending of Coverage Coverage and eligibility ends upon the effective date of termination of employment for the employee; this includes all spouse and dependent participation except as provided for under Status, Sections 3 and 4. Participation in benefits end for dependents with a change in their status, such as in cases where they cease to be dependents of the employee or otherwise cease to be a dependent as defined by the Fund. Extension of benefits for a terminated member or dependents under various circumstances may be available under COBRA. Eligibility For Future Retiree Benefits Effective January 1, l998 members who leave or retire from employment with a participating employer and have 20 or more years of service, but have not reached the age of 55, are not eligible for Retiree Benefits until such time as they reach the age of 55 providing the employee has made continuous self payments for coverage to the Benefit Fund during the period of time since leaving employment until age 55. The length of time a future retiree may continue benefits under COBRA has been extended to 11

12 accommodate any additional months needed for retirees eligibility. COBRA notifications are mailed directly to the member s home by the Fund as soon as the employer has advised the Fund of termination of employment. The member has 60 days from receipt of the COBRA notification to choose to continue benefits. Payments must be made continuously, without delinquency, in order to receive retiree benefits at a future date. Failure to select the self-payment of premium option under COBRA will result in a loss of retiree benefits. Appeals The benefits provided by this Fund may be changed by the Board of Trustees at anytime, in their sole and absolute discretion. The Board of Trustees adopts rules and regulations for the payment of benefits. All provisions of the Benefit Reference Guide (BRG) are subject to such rules and regulations and to the Trust Agreement, which established and governs the Fund operations. All benefit and eligibility rules are uniformly applied by the Fund office and Third-Party Administrators. The actions of the Fund or its Administrators are subject to review by the Board of Trustees. A member or beneficiary may request an APPEAL of any action by submitting a written request to the Board of Trustees within 180 days of the last determination: Suffolk County Municipal Employees Benefit Fund Attn: Board of Trustees, for Appeal 30 Orville Drive, Suite D Bohemia, New York The Trustees shall act on the appeal within a reasonable period of time and render their decision in writing, which shall be final and conclusive and binding on all persons. Cobra Direct Payment Plan (COBRA) The plan is required under COBRA to provide continuation of certain benefits for members and dependents that have had their eligibility for benefits terminated. Under this provision you and/or your covered dependent(s) have the opportunity to continue certain coverage, which would otherwise end as the result of any of the following qualifying events : Your termination of employment (except for gross misconduct) A reduction of your hours so that you or your dependent(s) no longer meet the eligibility requirements for coverage In the event of your death In the event of your divorce or legal separation Your child no longer qualifies as a dependent Under the qualifying events cited in 4 and 5, it is the dependent s obligation to notify the Fund within 60- days of the qualifying event that they wish to exercise their COBRA option. If you and/or your covered dependent(s) elect to continue certain coverage, it would be identical to the coverage provided by the Fund, with the exception of legal, which includes the tax benefit, life insurance and surviving spouse benefits, and would be extended as follows: A. Up to l8 months in the event of your termination of employment or a reduction in your hours. B. Up to 36 months for your dependent(s) in the event of your death, divorce, or your child no longer qualifies as a dependent. 12

13 You may receive additional information on direct payments by calling or writing the Fund. Note: No Fund member is compelled to use any of the Fund s plans. Coordination With Other Dental, Optical And Benefit Plans These plans have been designed to help you meet the cost of dental, optical and other needs. Since it is not intended that you receive greater benefits than the actual expenses incurred, the amount of benefits payable under this plan will take into account any coverage you, your spouse, or dependents have under other group plans. That means, the benefits under this plan will be coordinated with the benefits of other group plans that your family may have. A spouse or child will not be covered for any benefits from this Benefit Fund if, for any reason, they choose not to, or neglect to enroll in, their employer s group coverage plan, provided the coverage was available at no cost to them. It is important for you to remember the next few points. 1. This Benefit Fund assumes first responsibility within the limits of our plans for all the member s covered benefits. 2. If your spouse is covered by a group coverage plan, that plan has first responsibility for your spouse s benefit claims. This means that the spouse s plan must pay all the spouse s expenses incurred up to the limit of the schedule in that plan. 3. If the plan covering your spouse does not provide coverage to pay all of the expenses incurred and all of the primary plan s requirements have been met, the Fund will provide the difference of such expenses within the limits of its coverage. You cannot collect from the Fund and under your spouse s plan in excess of fees charged. 4. For dependent children of parents not separated or divorced, the plan of the parent whose month and day of birth falls earlier in the calendar year pays first, and the plan of the parent whose date of birth falls later in the calendar year will pay second. The word birthday refers only to month and day, not the year in which the parent was born. 5. If two or more plans cover a person as a dependent child of separated or divorced parents, the benefits are determined in the following order: a. First, the plan of the parent with custody of the child; b. Then, the plan of the spouse of the parent with the custody of the child; and c. Finally, the plan of the parent not having custody of the child. d. If the specific terms of a court decree state that one of the parents is responsible for the health care expenses of the child, and the entity obligated to pay or provide the benefits of the plan of that parent has actual knowledge of those terms, the benefits of that plan are determined first. The plan of the other parent shall be the secondary plan. This paragraph does not apply with respect to any claim determination period or plan year during which any benefits are actually paid or provided before the entity is aware such a decree exists. 6. Where husband and wife are both members of the Benefit Fund, the same coordination of benefits apply. If you have any doubt about coverage for you, your spouse, and your dependent children, please get in touch with the Fund office. Claiming Your Benefits Review Your Enrollment Review the contents of this information thoroughly. Locate which benefit applies to your needs and provides the best coverage for you. After you are certain that the benefit is due you, check to see that all 13

14 anticipated claims fall within the allowable claim-time limit; that is, within one year of the calendar year in which the services are rendered. Follow directions for submitting claims. Claim Forms Follow all instructions contained on claim forms for completion. All forms or correspondence received by the Fund must contain the following information: Name of member Address, telephone numbers Social Security Number of member Original signature and date ( if a non-participating provider is used) An incomplete form will be returned causing a delay in your benefit payment. If you utilize the services of a non-participating provider, you are required to place your original signature and the current date on all claim forms. The Fund cannot accept photocopied signatures or signature strips. Payment The processes for payment of benefits vary. Payments shall be made either to the member directly or to the establishment that has provided the particular service. Specifics are provided according to each benefit. Payment will not be made for any benefit that is claimed after a period that exceeds one year from the calendar year in which services were rendered. Dental services performed in 2015, for example, must be claimed no later than December 31, The Benefit Fund periodically audits payments made. If, for any reason, the Fund discovers a discrepancy that results in a request for a refund, any failure to comply may place your future benefits in jeopardy. It should be noted that from time to time the Trustees may, at their discretion, add to, amend, change, delete or modify existing Benefit Fund rules and regulations and benefit allowances. Should a question arise as to benefit coverage, such questions shall be resolved upon review of the Benefit Fund s Trust indentures, plan of benefits and minutes of Trustee meetings. If additional information is desired, call the Fund office where more detailed information is available. Eligibility Covered Members Covered members include all employees of Suffolk County covered by the collective bargaining agreement between the County of Suffolk and The Association of Municipal Employees for whom contributions are payable to the Suffolk County Municipal Employees Benefit Fund (herein the Benefit Fund ); any other employees of the County of Suffolk, including, but not limited to the faculty and administrative staff of the Suffolk County Community College, that may be deemed eligible by the Board of Trustees, for whom contributions are made payable to the Benefit Fund; the judges and court administrative personnel of the County of Suffolk for whom contributions are made payable to the Benefit Fund; employees of other entities, such as the Vanderbilt Museum, that may be deemed eligible by the Board of Trustees, for whom contributions are made payable to the Benefit Fund; employees of The Association of Municipal Employees for whom contributions are payable to the Benefit Fund. Dependents Spouses and dependents of covered members are covered for certain benefits as specifically described. Dependents, as defined by the Fund, are your spouse, unmarried dependent children who have not 14

15 reached their l9th birthday and unmarried dependent children who are full-time students at a college or university who have not reached their 25th birthday; an unmarried child, regardless of age, who is incapable of self-sustaining employment by reason of mental retardation or physical handicap who became so prior to the age of nineteen and resides with and wholly depends upon the covered member for support. Dependent children include legally adopted children, step-children and foster children who depend on, and reside with, the covered member for support. STATUS 1. In general, subject to the requirements pertaining to the definition of a covered member, employees are eligible for benefits only so long as they are in an active payroll status. Eligibility for benefits terminates as of the effective date your employment is terminated. 2. Active payroll status here means the period for which contributions are paid, or should have been paid, for the employees by the employer to the Benefit Fund. 3. Members who go on a leave of absence from active employment due to extended illness, job related injury that results in Workers Compensation status, or maternity will remain eligible for benefits for one year commencing with the date of such leave. 4. All employees covered by the Benefit Fund and in an active payroll status will be eligible for benefits after completion of two full calendar months of employment. For example, an employee hired on February l shall eligible for benefits on April l; an employee hired on June 2nd shall be eligible for benefits on September 1st. The Fund reserves the right to request any documents necessary to establish eligibility of a member or dependent. 5. If a covered member dies, his or his dependent s benefits will be continued for an additional 90 days. 6. Retirement benefits are available to members aged 55 or older, unless disabled, who meet other eligibility requirements. 15