Coordination of benefits
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 plan 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, in which case 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 of 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, prescription drugs and hearing aid benefits from each other's coverage. This is known as Special Coordination of Benefits (SCOB). In addition, their eligible children may receive benefits under each member's coverage. Details are included within each specific benefit description.