Optical Benefits

Guide to Optical Benefits

Members can use the optical benefit once every two years, either by using participating optical centers with a validated certificate which includes a discounted benefit; or through the direct reimbursement program for those members who wish to use their optical service at any non-participating optical provider. They may submit their validated certificate along with original receipts and a copy of the prescription for reimbursement.

Who is covered?

All eligible members and dependents, as defined in the General Information section, are covered for optical benefits.

What is the benefit?

The optical benefit consists of one (1) "optical service" every two (2) years (counted from the date of your last optical service) obtained through a network of participating panelists or direct reimbursement. The listing of participating panelists is also available by calling the Fund’s hotline at 212-539-0539.

An optical service consists of a complete pair of single vision, bifocal or trifocal eyeglasses, or the replacement of a frame, or lens, and at the same time, if necessary, an eye exam*. The optical service cannot be split between two (2) visits or two (2) panelists.

1. A complete pair of eyeglasses includes:
   1. A pair of single vision, bifocal or trifocal lenses, and
   2. A basic frame.
2. A basic frame is defined as any frame with a minimum retail value of one hundred ($100.00) dollars.
3. A basic eye exam, as performed by an optometrist, will encompass a refraction which includes a retinoscopy, a tonometry (glaucoma test), and a physical health evaluation and history. If the patient and optometrist agree that dilation is required, the optometrist is allowed to charge the member an additional $30.00.
4. Prescription sunglasses are a covered benefit.
5. You may elect to purchase contact lenses and receive a credit as per the fee schedule.

*Laws in certain states such as New Jersey, Connecticut and Florida prohibit examinations at certain optical centers or mandate a specific charge for certain specified services. Members are advised to check with centers outside New York State to determine if the eye examination is provided by that center without additional cost. In any event, the Welfare Fund will not reimburse any co-payments for exams.

How are benefits obtained?

1. You must obtain an Optical Benefit Certificate by requesting it from the Fund Office or by calling the Forms Hotline at 212-539-0539. This request must indicate whom the service(s) are for, so that the Fund may verify eligibility prior to issuing the certificate(s).
2. You may obtain the service(s) from a participating panelist, or a non-participating provider whereby you must submit for direct reimbursement.
3. Certificates will not be honored for payment if the patient information is altered in any way.

Please Note: Certificates are not transferable. Photocopied certificates will not be accepted. Certificates cannot be faxed.

How do I use the Participating Panelist Program?

1. Present the validated certificate to any of the Participating Optical Panelists designated on the current list of Welfare Fund Optical Centers. Validated certificates must be presented to the Panelist before the expiration date. If the certificate has not been used within the period, a replacement may be obtained.
2. Panelists are not required to accept a validated certificate after an order is placed.
3. Upon completion of the service at the Participating Optical Panelist, make sure to sign and date Part 6 of the certificate before leaving the store. Payment will be made directly to the Participating Optical Panelist.

What are the advantages of using the Participating Optical Panelist Program?

1. There is no cost to you for one of services listed above.
2. The Fund has negotiated a discount and surcharge program with the panelists who have agreed to give all members and/or their dependents the following discounts in addition to the one hundred dollar ($100.00) reimbursement schedule:

   Upgraded Service Example:

   	Retail Price
   Designer Frames:	$220.00
   Progressives Lenses:	$225.00
   Total Retail Price:	$445.00
   10% Minimum Panelist Discount:	($ 44.50)
   Sub-Total:	$400.50
   Basic Frame Allowance (if upgraded)	($100.00)
   Sub-Total:	$300.50
   Welfare Fund Benefit:	($100.00)
   Member’s Final Cost:	$200.50

   Other Service Types:

   TYPE OF SERVICE	MINIMUM 10% DISCOUNT	$100 FRAME ALLOWANCE	$100 WELFARE FUND PAYMENT
   LENS - NO FRAME	√		√
   LENS WITH FRAME	√	√	√
   FRAME -NO LENSES	√	√	√

   Note: Member’s Final Cost does not take into account the surcharge items in #3 below. These items are not included in the Total Retail Price for calculating the member’s discount.

   1. For any frame or lenses (i.e. progressives) that are upgraded, they will receive a minimum 10% discount. The discount will be applied as follows:
   2. For any item purchased not in connection with their covered service, for example, a second pair of glasses, a minimum 10% discount off the retail price.
   3. If the member/dependent chooses, or the prescription requires, items as listed below, the panelist may charge the member/dependent no more than the following surcharges (per pair):
      
      Tinting $15.00
      UV Block: $15.00
      Scratch Resistant Coating: $20.00
      Glare Free Coating: $30.00
      Polycarbonate: $35.00
      Photochromic (Transitions): $50.00
       
   4. The provider cannot charge more than their usual and customary prices, including sales and special promotions.
3. Because of its contractual relationship with the panelist, the Welfare Fund will offer its assistance in helping you resolve any problems with a participating optical panelist that may arise.

What is the Direct Reimbursement Program?

Under direct reimbursement, which can only be used if you utilize a non-participating provider, you are required to pay for the full cost of the service at the optician and submit to the Fund for payment. Reimbursement is made in accordance with the fee schedule or the actual charge, whichever is less.

How do I get reimbursed?

1. Attach an original, paid, itemized receipt and a copy of the prescription to the validated certificate. Altered or photocopied receipts will not be accepted. Sign and date Part 6 and mail it to the Welfare Fund office for reimbursement.
2. Reimbursement for covered services is made in accordance with the fee schedule in effect at that time, not to exceed the actual charges.
3. Claims must be submitted for payment no later than ninety (90) days from the date of service.

What is not covered under the Direct Reimbursement Program?

1. Services rendered at participating optical panelists.
2. Assignment of payment to a provider.

What is not covered under the Optical Program?

The Optical Plan does not cover non-prescription sunglasses even if recommended by a physician for therapeutic reasons.

Note: The following will not be honored for reimbursement:

1. Expired certificates beyond the eligibility period as stated on the certificate.
2. Non-original certificates. All valid certificates must be original forms.
3. Certificates used by another person in the members' family. The certificate is only valid for the person whose name appears on the form.

Does Special Coordination of Benefits (SCOB) apply to the Optical Plan?

Yes. Members and their spouse/ domestic partner who are also members are entitled to SCOB. This entitles each eligible family member, upon presentation at the same time of two (2) validated certificates, to two (2) covered services, one (1) service under each member's benefit record,whether using a participating provider or the direct reimbursement method. In either event, reimbursement to the provider or the member may not exceed the actual charge for the optical service under SCOB.

If the patient does not want the second service, for example, a second pair of eyeglasses at the same time as the first, he or she can either:

1. use the second certificate toward the out-of-pocket amount of the first service; or
2. use the second service any time within ninety (90) days. After ninety (90) days, you must obtain a new validated certificate.

Reimbursement schedule

1. The provider (or in the case of direct reimbursement, the member) shall receive payment of the usual and customary charge or $100.00, whichever is less, from the Fund for a complete service which includes single vision, bifocal or trifocal lenses, a basic frame and eye exam.
2. The provider (or in the case of direct reimbursement, the member) shall receive payment from the Fund of the usual and customary charge or $100.00, whichever is less, for any partial service rendered. A partial service includes only a frame or lenses.
3. The provider (or in the case of direct reimbursement, the member) shall receive payment from the Fund of $20.00 for an eye exam only.
   Note: If mandated by state law, panelists outside of New York State are allowed to charge the member the difference between the mandated price and our fee schedule.
4. The provider (or in the case of direct reimbursement, the member) shall receive payment of $100.00 from the Fund towards the purchase of contact lenses. The member/patient is responsible for the balance.