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 seventy-five dollars ($75.00) reimbursement schedule:
a. 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:
| Upgraded Service Example: | Retail Price |
| Designer Frames: | $220.00 |
| Progressives Lenses: | $225.00 |
Total Retail
Price: |
$445.00 |
| 10% Minimum Panelist Discount | ($44.50) |
| Subtotal: | $400.50 |
| Basic Frame Allowance (if upgraded) | $100.00 |
| Subtotal: | $300.50 |
| Welfare Fund Benefit | ($75.00) |
Member's Final Cost: |
$225.50 |
OTHER SERVICE TYPES:
| Type of Service | Minimum 10% Discount | $100 Frame Allowance | $75 Welfare Fund Payment |
| Lens — No Frame | • | • | |
| Lens With Frame | • | • | • |
| Frame No Lens | • | • | • |
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.
b. 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.
c. 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 |
| UV Block | $15 |
| Scratch Resistant Coating | $20 |
| Glare Free Coating | $30 |
| Polycarbonate | $35 |
| Photochromic (Transitions) | $50 |
d. 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 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 $75.00, 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 $75.00, 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 $75.00 from the Fund towards the purchase of contact lenses. The member/ patient is responsible for the balance.