General Information Applies to All NAGE/SEIU Local 5000 Trial Court of Massachusetts Health & Welfare Fund Members
WHO IS ELIGIBLE FOR BENEFITS?
TERMINATION OF COVERAGE
COVERAGE WHILE ON INDUSTRIAL ACCIDENT LEAVE
COORDINATION OF BENEFITS
ONE-YEAR LIMITATION FOR SUBMITTING CLAIMS
FAMILY AND MEDICAL LEAVE ACT (FMLA)
COVERAGE WHILE ON ACTIVE MILITARY SERVICE
BOARD OF TRUSTEES' STATEMENT
- Download Enrollment Form
- Download Student Verification Coverage
- Child Care / Elder Care Reimbursement Form
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
In order for the Fund to consider a child an eligible dependent, the child must have the same principal place of abode as you for over half of the year, and must be dependent on you for over half of his or her support. Proof that the child is dependent upon you for over half of his or her support must be furnished to the Fund upon request.
The requirement that you provide over half of the child’s support and that the child has the same principal abode as you for over half of the year, will not apply if: (a) you and the child’s other parent are divorced or legally separated under a decree of divorce or separate maintenance, separated under a written separation agreement, or live apart at all times during the last six (6) months of the calendar year; (b) you and the child’s other parent provide over half of the child’s support; and (c) the child is in the custody of one or both parents for more than half of the calendar year.
In order for the Fund to consider a child under your legal guardianship to be an eligible dependent, in addition to the requirements set forth in section 1 above, if the child is not related to you (in the manner described in Internal Revenue Code section 152(d) (2) (A) through (G)), the child must, for the entire year, share your principal place of abode and be a member of your household.
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.
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.
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.
Effective date. The effective date of this Notice is April 1, 2019.
The NAGE/SEIU Local 5000 Trial Court of Massachusetts Health and Welfare Fund (“The Fund”) takes your privacy seriously. We want to tell you about our privacy practices to protect your personal health information. Protected personal health information is information about you, including demographic information, that may identify your present or past physical or mental health or condition. Use and disclosure of your personal health information is regulated by federal law, the Health Insurance Portability and Accountability Act (“HIPAA”).
YOUR PRIVACY RIGHTS
When it comes to your health information, you have certain rights under HIPAA. This section explains your rights and some of our responsibilities to help you.
You May Ask the Fund to Limit the Information that it Uses or Shares
- You can ask the Fund not to use or share certain health information for treatment, payment, or operations.
- The Fund is not required to agree to your request and may deny your request if it would affect your care.
You May Request Confidential Communications
- You can ask the Fund to contact you in a specific way (for example, home or office phone) or to send mail to a different address.
- The Fund will consider all reasonable requests and must agree to such a request if you would be in danger if the Fund did not.
You May Obtain a Copy of Your Health and Claims Records
- You can ask to see or get a copy of your health and claims records and other health information the Fund has about you. This request must be in writing.
- The Fund will provide a copy or a summary of your health and claims records, usually within 30 days of your request. The Fund will charge a reasonable, cost-based fee.
You May Ask the Fund to Correct its Health and Claims Records
- You can ask the Fund to correct your health and claims records if you think they are incorrect or incomplete. This request must be in writing.
- The Fund may deny your request but will tell you why in writing within 60 days.
You May Obtain a List of Those with Whom the Fund has Shared Information
- You can ask for a list (accounting) of the times the Fund has shared your health information for six years prior to the date you ask, who the Fund shared it with, and why. This request must be in writing.
- The Fund will include all the disclosures except for those about treatment, payment, and health care operations, and certain other disclosures (such as any you asked the Fund to make). The Fund will provide one accounting per year for free but will charge a reasonable, cost-based fee if you ask for another one within 12 months.
You May Obtain a Paper Copy of this Notice upon Request
You can ask for a paper copy of this notice at any time, even if you have agreed to receive the notice electronically. The Fund will provide you with a paper copy promptly.
You May Choose Someone to Act for You
- If you have given someone medical power of attorney or if someone is your legal guardian, that person can exercise your rights and make choices about your health information.
- The Fund will make sure the person has this authority and can act for you before the Fund takes any action.
You May File a Complaint If You Feel Your Rights Are Violated
- You can complain if you feel the Fund has violated your rights by contacting the Fund using the information at the end of this notice.
- You can file a complaint with the U.S. Department of Health and Human Services Office for Civil Rights by sending a letter to 200 Independence Avenue, S.W., Washington, D.C. 20201, calling 1-877-696-6775, or visiting www.hhs.gov/ocr/privacy/hipaa/complaints/.
- The Fund will not retaliate against you for filing a complaint.
For certain health information, you can tell the Fund your choices about what it shares. If you have a clear preference for how the Fund shares your information in the situations described below, tell the Fund what you want it to do, and the Fund will follow your instructions.
In these cases, you have both the right and choice to tell the Fund to:
- Share information with your family, close friends, or others involved in payment for your care.
- Share information in a disaster relief situation.
If you are not able to tell the Fund your preference, for example if you are unconscious, the Fund may go ahead and share your information if the Fund believes it is in your best interest. The Fund may also share your information when needed to lessen a serious and imminent threat to health or safety.
In these cases, the Fund will never share your information unless you give the Fund written permission:
- Marketing purposes.
- Sale of your information.
THE FUND’S USES AND DISCLOSURES
How Does the Fund Typically Use or Share Your Health Information?
The Fund typically uses or shares your health information in the following ways.
Help Manage the Health Care Treatment You Receive
The Fund can use your health information and share it with professionals who are treating you.
Example: A dentist sends the Fund information about your treatment plan so the Fund can arrange additional services and recommend treatment alternatives.
Run the Organization
- The Fund can use and disclose your information to run the organization and contact you when necessary.
- The Fund is not allowed to use genetic information to decide whether it will give you coverage and the price of that coverage.
Example: The Fund uses health information about you to develop better services for you.
Pay For Your Health Services
The Fund can use and disclose your health information as it pays for your dental and vision services.
Example: The Fund shares information about you with your dental plan to coordinate payment for your dental work.
Administer the Fund
The Fund may disclose your health information to the Fund’s Board of Trustees for plan administration.
Example: The Board of Trustees sponsors the Fund’s dental and vision plans, and the Fund provides the Board of Trustees with certain information to set the required contribution amounts.
How Else Can the Fund Use or Share Your Health Information?
The Fund is allowed or required to share your information in other ways – usually in ways that contribute to the public good, such as public health and research. The Fund must meet many conditions in the law before it can share your information for these purposes. For more information see: www.hhs.gov/ocr/privacy/hipaa/understanding/consumers/index.html.
Comply With the Law
The Fund will share information about you if state or federal laws require it, including with the Department of Health and Human Services if it wants to see that the Fund is complying with federal privacy law.
Respond to Lawsuits and Legal Actions
The Fund can share health information about you in response to a court or administrative order, or in response to a subpoena.
Respond to Organ and Tissue Donation Requests and Work with a Medical Examiner or Funeral Director
- The Fund can share health information about you with organ procurement organizations.
- The Fund can share health information with a coroner, medical examiner, or funeral director when an individual dies.
The Fund can use or share your information for health research.
Help with Public Health and Safety Issues
The Fund can share health information about you for certain situations such as:
- Preventing disease.
- Helping with product recalls.
- Reporting adverse reactions to medications.
- Reporting suspected abuse, neglect, or domestic violence.
- Preventing or reducing a serious threat to anyone’s health or safety.
Address Workers’ Compensation, Law Enforcement, and Other Government Requests
The Fund can use or share health information about you:
- For workers’ compensation claims.
- For law enforcement purposes or with a law enforcement official.
- With health oversight agencies for activities authorized by law.
- For special government functions such as military, national security, and presidential protective services.
THE FUND’S RESPONSIBILITIES
- The Fund is required by law to maintain the privacy and security of your protected health information.
- The Fund will let you know promptly if a breach occurs that may have compromised the privacy or security of your information.
- The Fund must follow the responsibilities and privacy practices described in this notice and give you a copy of it.
- The Fund will not use or share your information other than as described herein unless you tell the Fund it can in writing. If you tell the Fund it can, you may change your mind at any time. Let the Fund know in writing if you change your mind.
For more information see: www.hhs.gov/ocr/privacy/hipaa/understanding/consumers/noticepp.html.
CHANGES TO THE TERMS OF THIS NOTICE
The Fund can change the terms of this notice, and the changes will apply to all information the Fund has about you. The new notice will be available upon request, on the Fund’s web site, and a copy will be mailed to you.
IF YOU NEED MORE INFORMATION
If you have any questions, comments or suggestions or if you would like to exercise your rights or feel your privacy rights have been violated, please contact the Fund’s Privacy Officer at:
The NAGE Fund Office
Attn: Johanna McNally, Privacy Officer
159 Burgin Parkway
Quincy, MA 02169
1-800-641-0700 or (617) 773-8947
|PHI use and disclosure by the Plan is regulated by the federal Health Insurance Portability and Accountability Act, known as HIPAA. You may find these rules at 45 Code of Federal Regulations Parts 160 and 164. This notice attempts to summarize the regulations. The regulations will supersede this notice if there is any discrepancy between the information in this notice and the regulations.|
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.
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.
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.
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.