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Service Employees 32BJ North Health Fund
Tri-State Preferred North Summary Plan Description (SPD) >> Table of Contents
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Important Notice
- Eligibility and Participation
- When You Are Eligible
- When You Are No Longer Eligible
- Special Rules for Seasonal Employees
- Dependent Eligibility
- When Your Dependents Are No Longer Eligible
- How to Enroll
- Your Notification Responsibility
- What Benefits Are Provided
- Hospital and Medical Benefits
- Overview of Eligible Expenses
- About the Empire Networks
- When You Go In-Network
- When You Go Out-of-Network
- Coverage When You Are Away from Home
- Benefit Maximums
- Conditions for Hospital and Medical Expense Reimbursement
- Pre-Certification
- Pre-Certification for Medical/Hospital
- Covered Services
- In the Hospital and Outpatient Treatment Centers
- Skilled Nursing Facility
- Hospice Care Facility
- Home Health Care
- Emergency Care
- Care in the Doctor’s Office
- Preventive Medical Care
- Pregnancy and Maternity Care
- Physical, Occupational, Speech or Vision Therapy (including rehabilitation)
- Durable Medical Equipment and Supplies
- Women’s Health and Cancer Rights Act
- Excluded Hospital And Medical Expenses
- Prescription Drug Benefits
- At the Pharmacy
- Through Mail Order
- Eligible Drugs
- Excluded Drugs
- Employee Assistance Program (EAP)
- Behavioral and Substance Abuse Treatment
- Confidentiality
- Pre-Certifying Behavioral or Substance Abuse Treatment
- Eligible Providers
- Conditions for Coverage
- What Is Not Covered
- Dental Benefits
- How the Plan Works
- Participating Dental Providers
- Non-Participating Dentists
- Prior Approval
- What Dental Services Are Covered
- Frequency Limitations
- Schedule of Covered Dental Services
- Alternate Benefit
- What Is Not Covered
- Coordination of Dental Benefits
- Vision Care Benefits
- Eligible Expenses
- Excluded Expenses
- Life Insurance and Accidental Death & Personal Loss Coverage Benefits
- Life Insurance
- Schedule of Life Insurance – Employees
- Age Reduction Rule
- Dependents: Schedule
- Accelerated Death Benefit
- Accidental Death and Personal Loss Coverage
- Schedule of Accidental Death and Personal Loss Coverage – Employees
- Additional Accidental Death Benefit Maximums
- Age Reduction Rule
- Statutory Short-Term Disability Benefits
- Eligibility
- Participant Only
- Procedural Conditions
- Limitations
- When Benefits Begin and End
- Amount of Benefits
- Benefits Exhaustion
- Tax Issues
- Retiree Health Benefits
- Eligibility
- Benefits
- Participants and Dependents Under Age 65
- Participants and Dependents Age 65 and Older
- How The HRA Works
- Annual and Lifetime Maximums
- Administrative Fees
- Termination
- Claims and Appeals Procedures
- Claims for Benefits
- Filing Hospital and Medical Claims
- Filing Dental Claims
- Filing Pharmacy Claims
- Filing EAP Claims
- Filing Vision Claims
- Filing Life Insurance and Accidental Death & Personal
Loss Coverage (AD&PLC) Claims
- Filing Retiree HRA Claims
- Filing Statutory Short-term Disability Claims
- Where to Send Claim Forms
- Approval and Denial of Claims
- Health Service Claims (hospital/medical, pharmacy, EAP, dental and vision)
- Short-term Disability Claims
- Retiree HRA Claims
- Notice of Decision
- Appealing Denied Claims
- Filing an Appeal
- Where to File an Appeal
- Time Frames for Decisions on Appeals
- Expedited Appeals for Urgent Care Claims
- Pre-Service or Concurrent Medical, Hospital,
Pharmacy, Dental or EAP Claim Appeal
- Tri-State Preferred North
Post-Service Medical, Hospital, Pharmacy,
Dental or EAP Claim Appeal
- Voluntary Second Level Appeal of a Medical,
Hospital, Pharmacy, Dental or EAP Claim
- Vision Claim Appeal
- Life and Accidental Death & Personal Loss Coverage
(AD&PLC) Appeal
- Retiree HRA Claim Appeal
- STD Claim Appeal
- Appeal Decision Notice
- Further Action
- Incompetence
- Mailing Address
- Coordination Of Benefits
- Your Disclosures To The Fund
- Subrogation and Reimbursement
- Fraud
- Overpayments
- Continued Group Health Coverage
- During a Family and Medical Leave
- During Military Leave
- Under COBRA
- COBRA Continuation of Coverage
- Other Health Plan Information You Should Know
- Assignment of Plan Benefits
- No Liability for Practice of Medicine
- Privacy of Protected Health Information
- Certificate of Creditable Coverage
- Converting to Individual Coverage
- General Information
- Employer Contributions
- How Benefits May Be Reduced, Delayed or Lost
- Compliance with Federal Law
- Plan Amendment or Termination
- Plan Administration
- Statement of Rights under the Employee Retirement Income Security Act of 1974 as Amended
- Plan Facts
- Funding of Benefits and Type of Administration
- Plan Sponsor and Administrator
- Participating Employers
- Agent for Service of Legal Process
- Glossary
- Footnotes
- Translation Notice
- Contact Information
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