Please read each page carefully for changes to various aspects of benefits.
Who are Eligible Members Under this Fund?
Eligible members under this Fund are all employees of the Unified Court System who are in regular, paid, full-time or part-time employment, and who are covered by a collective bargaining agreement between the Ninth Judicial District Court Employees Association (NJDCEA) and the State of New York Unified Court System. An Employee is deemed to be in regular, paid, full-time or part-time employment only during those periods that:
(a) The employee is listed as such on the payroll records of the employer (New York State Unified Court System);
(b) The employer contributes to this Employee Benefit Fund for the employee; or
(c) An employee who previously qualified under (a) and (b) above and the Fund is presently receiving contributions from the employer for the employee
Who are Eligible Dependents Under this Fund?
Eligible dependents under this Fund are spouses and unmarried children up to age 26. Children younger than age 26 who receive more than one-half of their support from the member and are full-time students at an accredited secondary or preparatory school, college, or other educational facility and are not otherwise eligible for other employer-sponsored group coverage, also are covered.
When do Benefits Become Effective for Eligible Members and Dependents?
For benefits that are self-funded and self-administered (no insurance company), the benefits become effective on the 30th day of employment with the NYS Unified Court System. Where the benefit is being provided through an insurance company, the effective day is the first day of the first fiscal quarter after the completion of the 30th day of employment with the NYS Unified Court System. (Note: The first day of the fiscal quarters are: 4/1, 7/1, 10/1, and 1/1 of each fiscal year.)
However, this 30-day initial waiting period for eligibility for benefits will be waived for:
(a) A laid-off employee with at least one (1) year in the System who returns to Covered Employment within two years from the time he/she is laid off, and
(b) An employee who transfers from another New York State Agency (i.e. State Corrections and State Department of Health).
What is the Procedure to File a Claim?
All claims under this Fund must be submitted on appropriate claim forms made available through the Fund Office or from Trustees within 365 days of receiving services. All claims must be accompanied by any information or proof requested by the Trustees that is required to process the claim. In addition, benefits are not payable for accidents occurring on the job or for sickness covered by Workers’ Compensation Laws or for payments reimbursable through No-Fault Insurance.
What is the Appeal Procedure?
Members who have received a notice that their claims have been denied may request a review of the denied claim within 60 day of the receipt of the notice of denial. Anyone who has not received a decision on a claim for benefits within 90 days (or 180 days in special circumstances) may request a review of his/her claim. Members or their authorized representatives may request a review, may have the opportunity to review pertinent documents, and submit issues and comments in writing. Requests for review must be made in writing and should be sent to the Fund Office.
Decision on the review will be made by the insurance company on any question involving the terms of an insurance contract, and by the Board of Trustees on any other question. Copies of all appealed claims decisions are kept on file in the Fund Office.
Our benefit plans contain a non-profit provision coordinating them with other existing plans so that the total benefits available will not exceed 100% of the allowable expense. An “allowable expense” is any necessary, reasonable and customary expense covered, at least in part, by one of the plans.
“Plans” means these types of medical and dental care benefits: (a) coverage provided by a governmental program or provided or required by statute; and (b) group insurance or other coverage for a covered employee or such covered employee’s spouse.
The Fund uses the “Birthday Rule” to determine primary coverage, (i.e. If two people in a household have coverage, the one whose birthdate in the household comes first in the year is primary.)
If you and your spouse are divorced and have dependent children, there are further rules. Benefits will be paid in the following order, unless a court decree specifies otherwise:
Separated or Divorced Parents: Not Remarried
1. The plan of the parent with custody pays first.
2. The plan of the parent without custody pays second.
Separated or Divorced: Remarried
1. The plan of the parent with custody pays first.
2. The plan of the step-parent with custody pays second.
3. The plan of the parent without custody pays last.
Finally, if there is a court decree that establishes financial responsibility for the medical, dental, or other healthcare expenses with respect to the child(ren), the plan that covers the child(ren) as a dependent(s) of the parent with such financial responsibility will pay benefits before any other plan covering the child(ren) as a dependent.
When ours is the secondary plan, and its payment is reduced to consider the primary plan’s benefits, a record is kept of the reduction. This amount will be used to increase our Plan’s payments on the patient’s later claim in the same calendar year to the extent there are allowable expenses that would not otherwise be fully paid by our Plan and the others.
111 Dr. Martin Luther King Boulevard
White Plains, NY 10601