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General Information (Retiree)
Guide to General Information (Retiree)
- Enrolling and Updating Information
- Coverage Rules
- Coordination of Benefits (COB) Information
- Special Coordination of Benefits (SCOB) Information
- Forms and Claim Submission Information
- General Questions and Answers
- Miscellaneous Information
What are my Welfare Fund benefits?
The UFT Welfare Fund provides:
Continuation of Coverage
Health and Cancer Helpline
Medicare Part D Catastrophic Reimbursement
Optional Rider Reimbursement and
Legal Plan with Elder Law Supplement.
See the applicable chapter(s) in the Red Apple booklet for the benefits listed above
Note: For other benefits provided by the UFT, consult your UFT-RTC Retiree Handbook.
All eligible members are covered by a City basic health plan of their choice. For detailed descriptions of these benefits refer to the NYC Health Benefits Program Summary Program Description booklet. Additionally, members may contact the different plans listed in that booklet for further information.
How do I update information?
All members must notify the Fund Office of a change in address, marital status or dependent status by filing an Update Your Information Form. When enrolling or changing dependents, the member must attach or submit photocopies of necessary documentation to the Update Your Information Form. The Fund reserves the right to request additional documentation verifying the bona fide relationship of any dependent to a member.
Please note that upon divorce or termination of domestic partnership an Update Your Information Form must be completed with applicable documentation attached or submitted to delete a spouse or domestic partner.
May I decline further coverage for an enrolled eligible dependent?
Yes. You may decline further coverage for an enrolled eligible dependent at any time by completing a Declination of Welfare Fund Coverage for Eligible Dependents form. You can also obtain this form from the Fund Office.
If you decline Welfare Fund coverage for any dependent, you will only be permitted to re-enroll that dependent, upon submission of proof to the Fund of that dependent’s loss of other comparable coverage, within 30 days of the loss of such comparable coverage.
When does coverage begin?
Coverage begins on the date that you meet the criteria specified in the Who is Covered? section.
Dependents become eligible on the same date as the member, or on the date they first become eligible dependents.
When does coverage terminate?
Coverage for a member terminates in the following situations:
- when the member returns to “in-service” status
- when the NYC Department of Education ceases to make contributions to the Fund on their behalf
- upon death
Dependent coverage terminates when a member's eligibility ends for any reason other than death, or on the date when the dependent no longer meets the definition of eligible dependent, whichever occurs first. In cases of the member’s death, dependent coverage terminates three (3) months following the month in which the member died.
What do my dependents do if they lose coverage?
- COBRA -The Federal Consolidated Omnibus Budget Reconciliation Act of 1985, (COBRA), requires that the City and UFT Welfare Fund offer eligible dependents of members the opportunity to continue health and certain Welfare Fund benefits at 102% of the group rate. The maximum period of coverage is thirty-six (36) months.
Refer to the COBRA section for further details.
- Dependent Survivor Coverage - In cases of the member's death, dependent coverage terminates three (3) months following the month in which the member died.
- Unmarried Dependent Children 29 years of age or under - New York State Insurance Law allows unmarried children to be covered by the member’s insured health plan, if they so choose, by paying the premium cost of the coverage until the unmarried child reaches his/her 30th birthday. Welfare Fund coverage for unmarried children 29 years of age or under, will coordinate with the coverage afforded said children under New York City health plans.
Coordination of Benefit Rules
Benefits provided by the UFT Welfare Fund are subject to Coordination of Benefits (COB) provisions. COB is applicable when you or your dependents are covered by another group benefit plan. A patient's basic health coverage will always be Primary and the UFT Welfare Fund benefits Secondary.
Benefit claims under COB are payable under a Primary-Secondary formula. The Primary plan determines its benefits first, and pays its normal benefit. The Secondary plan computes its benefit second, and may reduce its benefit payment so that the insured does not receive more than 100% reimbursement of expenses. In no event would the UFT Welfare Fund's liability exceed the benefits payable in the absence of COB.
The order of payment is determined as follows:
- If one plan does not have a COB provision, that plan will be Primary;
- If the patient is our (UFT Welfare Fund) member, the UFT Welfare Fund is the Primary plan. However, if the patient is the spouse/domestic partner of our member, and is covered under another group plan, the other group is Primary and the UFT Welfare Fund is Secondary.
- If the patient is a dependent child under both plans, the plan of the parent whose birthday (month and day) occurs first within the calendar year will be Primary, unless the parents are separated or divorced, then the following rules will apply:
- If a court order establishes that one of the parents is financially responsible for medical, dental or other health care expenses of a child, the contract under which the child is a dependent of that parent shall be Primary;
- If financial responsibility has not been established by a court order and the parent with custody of the child has not remarried, the contract under which the child is the dependent of the parent with custody will be Primary;
- If financial responsibility has not been established by a court order and the parent with custody has remarried and the child is also covered as a dependent of the step-parent, then the order of payment shall be: 1st the contract under which the child is a dependent of the parent with custody; 2nd the contract under which the child is a dependent of the step-parent; 3rd the contract under which the child is covered as a dependent of the parent without custody.
- If none of the above applies, then the plan under which the patient has been enrolled the longest will be Primary. However, the plan covering you as a laid-off or retired member, or as a dependent or such person, shall be Secondary and the plan covering you as an in- service member shall be Primary, as long as the other plan has a COB provision similar to this one.
The Fund will not pay any benefits that are covered by New York State or other jurisdiction's no-fault insurance law.
Special Coordination of Benefits
Members and their spouse/domestic partner who are also UFT Welfare Fund members can receive UFT Welfare Fund dental, optical, hearing aid benefits from each other’s coverage. This is known as Special Coordination of Benefits (SCOB). In addition, their eligible dependents may receive benefits under each member's coverage. Details are included within each specific benefit description.
How to Obtain Form, Current Panel Listings and Information
For forms needing validation, such as optical and hearing aid, members should access the Forms Hotline at 212-539-0539. Current panel listings and some forms are also available online.
Fund representatives are available to members who request assistance with specific health plan related problems. Members should include in any correspondence their full name, address, Welfare Fund alternate ID number or social security number, and telephone number. Members should always include photocopies of appropriate documentation such as the Health Benefits Application or the claim rejection notice from the health plan and a Protected Health Information Authorization Form (PHI) giving the Health Plan permission to discuss your claims.
Note: Health Insurance claim forms are available directly from the carrier and are not supplied through the Fund.
Submission of Claims Rules
Dental Claims (Direct Reimbursement)*
These claims must be submitted to CIGNA within one (1) year from the date of service. The penalty for late submissions will be non-payment of the claim.
Hearing Aid Claims
These claims must be submitted to the UFT Welfare Fund no later than ninety (90) days from the date of service. The penalty for late submissions will be non-payment of the claim.
Optical Claims (Direct Reimbursement)*
These claims must be submitted to the UFT Welfare Fund no later than ninety (90) days from the date of service. The penalty for late submissions will be non-payment of the claim.
Optional Rider Reimbursement Benefit
You must notify the Fund in writing within two (2) years from the date the benefit should have been paid.
Medicare Part D Catastrophic Reimbursement Form
Due to legal requirements this form must be submitted by Feb. 1 of the year following the calendar year requested.
Generally speaking, no exceptions will be granted for the late submissions of claims. However, physical inability to file within the period e.g., because of hospitalization or like circumstances, will be given consideration. Likewise, there will be no penalties for delays which are beyond the member's control, such as by a primary carrier or arbitrator. In these cases, appropriate documentation will be required. The late filing of a claim by a dentist, doctor or other provider will not be considered an exception, since it is the member’s responsibility to file claims.
Claim forms must be fully completed, giving all requested information or the claim cannot be processed. Claims which have been rejected and returned to the member for additional information must be resubmitted within ninety (90) days of the date of rejection, or by the original submission deadline, whichever is later. If claims are ultimately rejected by the Fund Office, you may appeal the rejection. You must do so by writing the Board of Trustees within sixty (60) days of the rejection.
With respect to any claims incurred prior to a member’s death, benefits will be made payable, in the absence of a named beneficiary(ies), to the first surviving class of the following classes of successive preference beneficiaries:
The deceased member’s:
- widow/widower or domestic partner;
- surviving children;
*Direct reimbursement means that a member has not utilized the services of a panel provider. When using the services of a participating provider (panelist), the panelist will submit the claim.
Some General Questions and Answers
What is the Fund?
The Fund was established to provide certain benefits to supplement City Basic Health Plans. It was created as a result of collective bargaining between the United Federation of Teachers and the NYC Department of Education located at 52 Chambers Street, New York, New York 10007. Employer contributions are predicated on the amount stipulated in the current Collective Bargaining Agreements and are provided at the annual rates, prorated monthly, on behalf of each covered member. Members, other than COBRA members, do not make contributions to the Fund.
Who administers the Fund?
The Fund is administered by a Board of Trustees. It consists of five persons designated by the United Federation of Teachers. Current members of the Board of Trustees are listed below and they can be communicated with in writing at the Fund office. The Board of Trustees governs the Welfare Fund in accordance with an Agreement and Declaration of Trust. The Board of Trustees employs an Executive Director and staff who are responsible for the day-to-day operation of the Fund, including the determination of eligibility and the processing of claims.
The Trustees and the Executive Director of the Fund are subject to a body of law designed to protect the beneficiaries of the Fund. Under this body of law, the Fund is mandated to submit our financial records to an annual audit by Certified Public Accountants. The Fund is further mandated to submit copies of these audits annually to the Internal Revenue Service. Copies of these reports are provided to the Comptroller of the City of New York.
Who are the current members of the Board of Trustees?
The current members of the Board of Trustees are:
Michael Mulgrew, Chair
What are my rights of appeal?
Decisions of the Executive Director and the staff are subject to review by the Trustees upon appeal. The Fund Office uniformly applies all rules. The action of the Fund Office is subject only to review by the Board of Trustees. An appeal must be filed with the Fund Office within sixty (60) days of denial of the claim, by submitting notice in writing to the Board of Trustees, United Federation of Teachers Welfare Fund, 52 Broadway, New York, New York 10004. The Trustees shall act on the appeal within a reasonable period of time and render their decision in writing, which shall be final, conclusive and binding on all persons. If the Trustees have denied your appeal, and you still believe you are entitled to the benefit, you have a right to file suit in the New York State Supreme Court.
Do the contributions to the UFT Welfare Fund become part of the general treasury of the union?
No. The United Federation of Teachers and the United Federation of Teachers Welfare Fund are two (2) distinct and separate legal entities. Their resources are not commingled.
What becomes of the contributions that the Department of Education makes to the United Federation Teachers Welfare Fund?
Under the Agreement and Declaration of Trust, contributions to the Welfare Fund are used to provide benefits for covered members and their families and to finance the cost of administration.
Does the UFT Welfare Fund operate under ERISA?
No. The Fund is not subject to the provisions of the Employees Retirement Income Security Act of 1974 (ERISA).
Does the UFT Welfare Fund operate under the supervision of the New York State Insurance Department?
No. The Fund is not within the jurisdiction of the New York State Insurance Department as it is a unilaterally operated trust fund, administered by union trustees only.
Amendment or termination of benefits
The Red Apple booklet and amendments constitute the plan of benefits for members provided by the United Federation of Teachers Welfare Fund and, as such, includes the specific terms and conditions governing the coverage and the benefits provided for members by the Fund. In addition, there are various administrative policies and procedures that are applied on a uniform basis by the Fund, and claimants will be informed whenever such policies and procedures are applied.
The United Federation of Teachers Welfare Fund is maintained for the exclusive benefit of employees and retirees of the New York City Department of Education who are "covered" under agreements with the UFT, and for whom the Department contributes monies to the UFT Welfare Fund. The Fund, as well as the plan terms, was established, pursuant to applicable law and regulation with the intention of being legally enforceable and maintained for an indefinite period of time. However, the Fund reserves its rights, under applicable law, to alter and/or terminate the plan of benefits as it currently exists.
The benefits provided by this Fund may, from time to time, be changed, modified, augmented or discontinued by the Board of Trustees. The Board of Trustees adopts rules and regulations for the payment of benefits and all provisions of the Red Apple booklet are subject to such rules and regulations and to the Trust indenture that established the Fund and governs its operations.
Your coverage and your dependent’s coverage will stop on the earliest of the following dates:
When you are no longer eligible; or
When the NYC Department of Education ceases to make contributions on your behalf to the Fund; or
When the Fund is terminated.
Your dependents' coverage will also terminate on the date when they no longer meet the definition of "eligible dependent."
Member benefits under this plan have been made available by the Trustees as a privilege and not as a right and are always subject to modification or termination in the exercise of the prudent discretion of the Trustees. The Trustees may expand, modify or cancel the benefits for members; change eligibility requirements and otherwise exercise their prudent discretion at any time without legal right or recourse by a member or any other person.
If a covered member or dependent is injured through the acts or omissions of a third party, the Fund shall be entitled -- to the extent it pays out benefits -- to reimbursement from the covered member or dependent from any recovery obtained from the responsible third party. Fund benefits will be provided only on the condition that the covered member or dependent agrees in writing:
To reimburse the Fund, to the extent of benefits paid by it, out of any monies recovered from such third party, whether by judgment, settlement or otherwise; and
To take all reasonable steps to effect recovery from the responsible third party and to do nothing after the injury to prejudice the Fund's right to reimbursement.
In the event you receive an overpayment of Welfare Fund benefits, on your behalf or on behalf of your dependent, you are obligated to refund this overpayment to the Fund immediately. In the event you fail to refund this overpayment, the Fund can offset this overpayment against future benefits until this overpayment is fully recouped, or suspend your benefits until this overpayment is paid in full. Such offset and/or suspension can be applied to the member’s and eligible dependents’ benefits.
Privacy of Protected Health Information under the Health Insurance Portability and Accountability Act (“HIPAA”)
A federal law, the Health Insurance Portability and Accountability Act, (“HIPAA”), requires the Welfare Fund to protect the confidentiality of your private health information. A complete description of your rights under HIPAA can be found in the Fund’s privacy notice, which was distributed to all members of the Fund prior to April 14, 2004 and is distributed to all new members upon enrollment, a copy of which is available from the Fund Administrator. A copy of the Fund’s privacy notice is also available online.
The Fund will not use or further disclose information that is protected by HIPAA (“protected health information”), except as necessary for treatment, payment, operations of the Fund, or as permitted or required by law. By law, the Fund has required all business associates to also observe HIPAA’s privacy rules. In particular, the Fund will not, without authorization, use or disclose protected health information for employment-related actions and decisions.
Under HIPAA, you have certain rights with respect to your protected health information, including certain rights to see and copy the information, receive an accounting of certain disclosures of the information, and under certain circumstances, amend the information. You also have the right to file a complaint with the Fund or with the U.S. Department of Health and Human Services if you believe your rights under HIPAA have been violated.