General Information Applies to All NAGE/SEIU Local 5000
All full-time and regular part-time employees who work at least 18.75 hours of the work week are eligible, in accordance with the terms of the Collective Bargaining Agreements between the National Association of Government Employees (NAGE), or its affiliates, and the Commonwealth of Massachusetts Office of the Trial Court, or another employer who has an employment relationship with NAGE. You are eligible for benefits on your date of hire with your employer. New employees are eligible for benefits after completion of six (6) consecutive months of employment. Presently, the Board of Trustees has voted to waive the six-month waiting period. The Board will revisit the employee eligibility period on an annual basis. Removal of the waiver will not affect existing members. If you are on an unpaid leave of absence, you will be covered for one (1) month after the end of the month during which your leave of absence begins. After the one (1) month period, you will have the option to elect COBRA Continuation Coverage. Upon your return to active employment, your benefits will be reinstated immediately. Your eligible dependents may include your lawful spouse. Your eligible dependents may also include your unmarried natural or adopted children, children legally placed for adoption with you, foster children, stepchildren, or a child under your legal guardianship, from birth to 19 years of age, none of whom are eligible under the NAGE/SEIU Local 5000 Trial Court of Massachusetts Health and Welfare Fund as employees. Your unmarried children who are age 19 or older may also be eligible until they are 25 years of age if dependent upon you for support and maintenance while enrolled in school or college on a full time basis. Student verification must be submitted to the Fund Office each semester. Your unmarried dependent children must also meet the additional dependent eligibility requirements below. Trust Fund coverage for an unmarried child who meets the dependent eligibility requirements, below, who is incapable of self-sustaining employment because of mental retardation or physical handicap and whose incapacity began prior to the limiting age shown above, may continue so long as: (a) your coverage remains in force and (b) such incapacity continues. Proof of such incapacity must be submitted to the Fund Office with-in 31 days of the date the dependent’s coverage would otherwise terminate. Proof of continuing disability may be required from time to time. Additional Dependent Eligibility Requirements
Your dependents’ coverage will become effective as soon as their eligibility information is provided to the Fund Office. You must submit a completed Enrollment Form to the Fund Office before your dependents can obtain benefits. You must provide proof of your dependents’ status, which includes a marriage certificate, birth certificate, full time school registration documents, tax documents, adoption papers or legal foster child documents.
Your coverage and your dependents’ coverage under this Plan will terminate 30 days after the end of the month when you leave the employ of your employer. The Federal COBRA law allows you and your family to receive dental, optical and hearing benefits from the Fund under certain circumstances. Once your coverage has terminated due to: (1) Employee’s termination of employment or a reduction in hours including leave of absence; (2) Employee’s death; (3) Employee’s dependent child reaches age 19 and is not a full-time student, or, if a full time student, has submitted student verification until the age of 25; (4) Employee’s dependent child has married; (5) Employee’s divorce or legal separation; (6) Employee’s entitlement to Medicare; you or your spouse or dependent have the right to continue coverage on a self-pay basis. For the following qualifying events ( divorce or legal separation of the employee and spouse or a dependent child’s losing eligibility for coverage as a dependent child), you must notify the Plan Administrator no later than 60 days after the later of: the date of the qualifying event or the date coverage would be lost under the Plan as a result of the qualifying event. If during the initial 18 month period of COBRA continuation coverage you or anyone in your family, who was covered under the Plan at the time of the employee’s qualifying event of the termination of employment or reduction in hours of employment, is determined by the Social Security Administration (SSA) to be disabled, the disabled individual may be entitled to receive up to an additional 11 months of COBRA continuation coverage for a total maximum of 29 months. You must notify the Plan Administrator of a disability determination by the Social Security Administration (SSA) within 60 days after the later of: the date of the Social Security Administration determination; the date of the qualifying event; or the date on which the qualified beneficiary would lose Plan coverage due to the qualifying event; and before the end of the 18-month period of continuation coverage, if you want to extend your COBRA coverage to a total maximum of 29 months. If the qualified beneficiary is determined to be no longer disabled, you must notify the Plan of the fact within 30 days after SSA’s determination. You must also notify the Plan Administrator within 60 days after a second qualifying event occurs if you want to extend your COBRA continuation coverage. In order to provide these notices, you must complete and submit a notification form to the Plan Administrator. Please contact the Plan Administrator to obtain the notification form and the address where you must submit it. Additional documentation of the qualifying event may also be required (i.e. copy of the divorce decree, court order granting legal separation, birth certificate or other documentation.) The Plan Administrator may reject an incomplete notice from you if the notice does not contain sufficient information to allow the Plan Administrator to identify and determine any of the following: (1) the name of the Plan; (2) the covered employee and qualified beneficiaries; (3) the qualifying event or disability determination; or (4) the date of the qualifying event or disability determination. If you do not notify the Plan of your qualifying event in a timely manner as in accordance with the Plan’s procedures, COBRA coverage will be denied. Please contact the Fund Office at 617-479-5814, 1-800-641-0700 or by writing to 159 Burgin Parkway, Quincy, MA 02169-4213. COVERAGE WHILE ON INDUSTRIAL ACCIDENT LEAVE If you are on Industrial Accident Leave with the Trial Courf of Massachusetts, and your COBRA continuation coverage under the Fund terminates, you may elect to continue Fund coverage on a self-pay basis for the term of your Industrial Accident Leave. Please contact the Fund Office for details. If you or your dependent is entitled to benefits under any other plan which will pay part or all of the expenses incurred for any benefits received or services rendered under this Plan, the amount of benefits payable under this Plan and any other plans will be coordinated so that the aggregate amount paid will not exceed 100% of the expense incurred. However, in no event will the amount of benefits paid under the Plan exceed the amount, which would have been paid if there were no other plan involved. The plan that provides benefits first is known as the primary plan. The primary plan is responsible for providing benefits to the full extent of their coverage. The plan that provides benefits next is the secondary plan. It provides benefits towards any remaining balance of covered services as long as the payment, when added to the primary plan’s payment, is not more than the total amount of the covered benefit expenses. Depending on circumstances, this Plan may be primary plan or the secondary plan. The term “plan” refers to any plan providing benefits or services for hospital, medical or dental care or treatment; that is: (a) group or blanket insurance coverage, (b) group health insurance, and other prepayment coverage provided on a group basis, (c) any coverage under labor-management trusteed plans, union welfare plans, employer organization plans, employee benefit organization plans or any other arrangement of benefits for individuals of a group and (d) any coverage under governmental programs, and any coverage required or provided by any statute. In cases where a more expensive course of treatment may be performed than is necessary or is customarily provided, the Plan will pay for treatment only in accordance with the terms of this Plan. ONE-YEAR LIMITATION FOR SUBMITTING CLAIMS The Plan will not accept claims submitted later than one year after the service occurred. Contact the Fund Office for additional information at 1-800-641-0700. The NAGE/SEIU Local 5000 Trial Court of Massachusetts Health and Welfare Fund (Fund) takes your privacy seriously. We want to tell you about our privacy practices to protect your personal health information. Use and disclosure of your personal health information is regulated by federal law, the Health Insurance Portability and Accountability Act (“HIPAA”). You may find further information regarding privacy rules under HIPAA at 45 Code of Federal Regulations Parts 160 and 164. HIPAA’s regulations supercede any discrepancies with the information provided in this notice. How Do We Use Health Information? The Fund uses your health information to pay Delta Dental Plan of Massachusetts and Davis Vision who provide you with dental and optical care or service, and to conduct normal business known as dental and optical care operations. Examples of how we use your information include:
We comply with all applicable state and federal laws, including any laws that impact our ability to use your health information for payment and operations. Other Services We may also use information to:
Information We Share There are limited times when we are permitted or required to disclose health information without your signed permission. These situations are listed below:
All other uses and disclosures, not previously described, may only be made with your signed authorization. You may revoke your authorization at any time. Our Responsibilities The Fund is required by law to:
Your Rights You have the right to:
Request followed by an asterisk (*) must be in writing. Financial Privacy Policy We do not give your financial information to any person or persons not affiliated with the Fund. It is important to the Fund that you understand what financial information is gathered and how it is used to administer your benefits.
If you would like to exercise your rights, or feel your privacy rights have been violated please contact Johanna McNally, Privacy Officer at the Commonwealth of Massachusetts/NAGE Fund Office at 1-800-641-0700 or (617) 479-5814 or by mail at: The Commonwealth of Massachusetts/NAGE Fund Office, 159 Burgin Parkway, Quincy, MA 02169-4213. All complaints will be investigated and you will not suffer retaliation for filing a complaint. You may also file a complaint regarding health information with the Secretary of Health and Human Services in Washington, D.C. FAMILY AND MEDICAL LEAVE ACT (FMLA) Under the Family and Medical Leave Act (FMLA), you may have the right to take up to 12 weeks of unpaid leave for your serious illness, after the birth or adoption or a child, or to care for your seriously ill spouse, parent or child. FMLA leave requires certain employers to maintain health coverage during the leave period. If you think that this leave may apply to you, please contact your employer. COVERAGE WHILE ON ACTIVE MILITARY SERVICE If you are absent from employment because of service in the United States Armed Forces, under the Uniformed Services Employment and Reemployment Rights Act (USERRA), you may be eligible to continue coverage under this Plan for you or your dependents on a self-pay basis for the period of your military service (to a maximum of 24 months). However, to your benefit, under current Plan provisions, if you are on active military duty, you and your eligible dependents will continue to receive Fund coverage during the term of your active military service, whether or not the Trial Courf of Massachusetts makes contributions to the Fund on your behalf. (Since this is more than what USERRA requires, the Trustees reserve the right to modify this provision.) Provider Selection Plan members may select the benefit options that best serve their needs, and may select the provider who alone is responsible for the delivery of quality care. The Trustees have selected Delta Dental Plan of Massachusetts and Davis Vision to provide contracted panels of dental and vision providers, respectively, throughout the area. Delta Dental Plan of Massachusetts and Davis Vision represent that they have selected these providers based on their demonstrated commitment to providing and maintaining the highest quality of care. Delta Dental Plan of Massachusetts and Davis Vision and the providers in their networks are independent and separate entities, not affiliated with or under the control of the Board of Trustees of the Fund. The Trustees cannot take responsibility for the quality of care or treatment decisions received through Delta Dental Plan of Massachusetts and Davis Vision or their providers, nor will the Trustees interfere in the professional relationship between a member and his or her provider. Plan Amendment, Modification or Termination The Board of Trustees, by a majority vote, may amend, modify, or terminate all or part of each plan, whenever, in their judgment, conditions so warrant, upon reasonable notice. No benefits or rules described on this site are guaranteed (vested) for any employee or eligible dependent. Claim Appeals If your claim is denied or partially denied, you will receive written notification along with the specific reason for the denial. Provided that you have exhausted all appeals available under the dental and vision plans, you may appeal any denial directly to the Board of Trustees of the NAGE/SEIU Local 5000 Trial Court of Massachusetts Health and Welfare Fund, c/o the Commonwealth of Massachusetts/NAGE Fund Office, 159 Burgin Parkway, Quincy, MA 02169-4213 provided you do so within sixty (60) days of the date of the denial notice. Trustees’ Determinations The Fund’s Board of Trustees, or the Fund Administrator acting on its behalf, has the final discretionary authority to determine any questions arising in connection with the administration, interpretation and application of any or all these plans, including any question regarding eligibility for benefits and the right to participate in a plan. Either the Board’s or the Administrator’s determination concerning the administration, application and interpretation of the plans shall be conclusive and binding on all persons subject to the provisions of these plans. Misrepresentations It is illegal for a Fund member to willfully and knowingly misrepresent any fact for the purpose of securing benefits under any of the Fund’s plans. Any member found by the Board of Trustees to have committed such a misrepresentation may immediately become ineligible for benefits, and will be required to reimburse the Fund for any benefits so obtained. The Trust Fund will cooperate with law enforcement agencies investigating and prosecuting criminal complaints, including fraud or larceny. ORAL STATEMENTS CANNOT MODIFY THIS BENEFIT INFORMATION
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