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Service Employees 32BJ North Health Fund
Tri-State Preferred North Summary Plan Description (SPD) >> Eligibility & Participation
When You Are Eligible
Eligibility for benefits from the Plan depends upon the collective
bargaining agreement or other written agreement that covers your work.
Unless specified otherwise in your collective bargaining agreement or other
agreement, eligibility is as follows.
Your employer will be required to begin making contributions to the
Fund on your behalf when you have completed 90 consecutive days of covered employment with the same employer working full-time, unless
specified otherwise in your collective bargaining agreement or other
agreement. For this purpose, covered employment includes certain
leaves of absence for which contributions are due under your collective
bargaining agreement. Days of illness, pregnancy or injury count toward
the 90 day waiting period. Except as otherwise provided (see "Special Rules for Seasonal Employees"), your coverage begins on the 1st
day of the month following the date that your employer is required to
make contributions to the Fund, provided that you have returned your
Enrollment Form to the Fund Office.
Additional eligibility requirements apply to Retiree Health Benefits;
see the "Retiree Health Benefits" section for more information.
Once you are initially eligible for benefits, you remain a participant as
long as you are working in covered employment. You are considered to
be in covered employment:
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during periods of active work
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during paid vacations
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while on jury duty
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while collecting workers’ compensation or short-term disability
benefits from an employer for the period employer contributions are
required, up to 26 weeks from the last date worked.
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during periods of Family and Medical Leave Act (FMLA) leave. (See
the "Continued Group Coverage: During a Family and Medical Leave" section for more information).
When You Are No Longer Eligible
Your eligibility for the Plan ends:
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at the end of the month in which you no longer regularly work in covered employment, subject to COBRA rights (see the "Continued Group Coverage" section), including transfer to a job classification outside the jurisdiction of the collective
bargaining agreement, layoff, leave of absence, or unpaid vacation
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the earlier of when you have completed 26 weeks of workers’
compensation or short-term disability, for a period during which
employer contributions were required, or when you have exhausted
your benefits under workers’ compensation or short-term disability for
a period during which employer contributions were required
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on the date when your employer terminates its participation in the
Plan, or
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on the date the Plan is terminated.
Under a Federal law called the Consolidated Omnibus Budget
Reconciliation Act of 1986 (COBRA), group health plans are required to
offer temporary continuation of health coverage, on an employee-pay-all
basis, in certain situations when coverage would otherwise end. “Health
coverage” includes the Plan’s hospital, medical, EAP, prescription drug,
dental, vision and retiree health coverage. See the "Continued Group Coverage" section for more
information about COBRA.
If you are on active military duty, you have certain rights under the
Uniformed Services Employment and Reemployment Rights Act of 1994
(USERRA) provided you enroll for coverage. See the "Continued Group Coverage: During a Military Leave" section for more
information.
In addition, the Board reserves the right in its sole discretion to
terminate eligibility if your employer becomes seriously delinquent in its
contributions to the Fund as determined by the Board of Trustees based
on the facts and circumstances.
Special Rules for Seasonal Employees
Because of different work schedules and different employer
contribution schedules, the applicable collective bargaining agreement may
provide special rules for the following groups: Yonkers Raceway employees,
country club employees, and flat track employees. If you are a seasonal
employee, consult your collective bargaining agreement or call the Fund
Office for more information regarding your eligibility
Dependent Eligibility
ALERT: 06/10/10 NEW Click
here for important benefit changes>>
As long as you are eligible, your dependents are eligible, provided they
meet the definition of “dependent” under the Plan as described on the
following three pages.
If your collective bargaining agreement or participation agreement
provides for dependent coverage, eligible dependents under the Plan are
described below:
Dependency |
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Requirements |
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Lawful
Spouse |
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The person to whom you are legally married under the laws of the state in
which you live, unless you and your spouse are legally separated pursuant
to either a separation decree or separation agreement. If you are legally
separated, your spouse is not eligible for coverage under the Plan. |
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Domestic
Partner
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You and your same-gender domestic partner:
- have a marriage certificate from a state in the U.S. or province in Canada
where same-gender marriages are valid, or
- have a civil union certificate from a state in the U.S. or province in
Canada where same-gender civil unions are valid, or
- are two individuals 18 years or older of the same gender who:
- have been living together for at least 12 months; and
- are not married to anyone else, and are not related by blood in a
manner that would bar marriage under the law; and
- are financially interdependent, and can show pro of of such; and
- have a close and committed personal relationship and have not been
registered as members of another domestic partnership within the
last 12 months.
In order to establish eligibility for these benefits, you and your domestic
partner will need to provide:
- a marriage certificate from a state in the U.S. or a province in Canada
where same-gender marriages are valid, or
- a civil union certificate from a state in the U.S. or a province in Canada
where same-gender civil unions are valid, or
- if neither marriage or civil union is available, affidavits attesting to your
relationship, plus a domestic-partner registration under state or local law
(if permitted where you live), and proof of financial interdependence.
You are required to provide the highest level of certificate available in the
jurisdiction in which you reside.
Contact the Fund Office for an application or general information.
There may be significant tax consequences for covering your domestic partner. Contact a tax advisor for tax advice.
If you lose coverage due to a Qualifying Event, you and your domestic
partner may elect to continue coverage on a self-pay basis through COBRA.
Domestic partners will not have an independent right to COBRA continuation
coverage unless the Qualifying Event is the participant’s death. |
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Children
(except
disabled
children)
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The child:
- Is not married;
- has the same principal residence as the participant for more than one-half
of the calendar year, or as required under the terms of a QMCSO – see the "Assignment of Plan Benefits" section. However, a child who does not have the same principal
residence as the participant for more than one-half of the year will
nevertheless be eligible for dependent coverage if:
- the child receives one-half of his or her support from parents who are
divorced or legally separated under a decree of divorce or separation;
separated under the terms of a separation agreement; or have lived
apart at all times for the last six months of the year; AND
- one or both of the child’s parents have custody of the child for more
than one-half of the year; and
- Is dependent on the participant for over one-half of his or her support
during the calendar year, or as required by the terms of a QMCSO – see the "Assignment of Plan Benefits" section. However, a child who is not dependent on the participant for
over one-half of his or her support during the calendar year will nevertheless
be eligible for dependent coverage if:
- the child receives one-half of his or her support from parents who are
divorced or legally separated under a decree of divorce or separation;
separated under the terms of a separation agreement; or have lived
apart at all times for the last six months of the year;
AND
- one or both of the child’s parents have custody of the child for more
than one-half of the year;
AND
- has not attained age 19 (or has not attained age 23 and is a full-time
student in an accredited college, university or trade school),
AND
- has one of the following relationships to the participant:
- your biological child
- your adopted* child or a child placed with you in anticipation of
adoption
- your stepchild
- your domestic partner’s child
- eligible foster children (a child placed with you by an authorized
placement agency or by judgment, decree, or other order of any court
of competent jurisdiction)
- your sibling
- your step-sibling
- a descendent of any of the above except for a descendent of your
domestic partner’s child.
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Children
(disabled) |
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The child:
- is totally and permanently disabled
- became disabled while an eligible dependent, and
- meets all of the requirements listed above for a dependent child except age.
You must apply for a disabled child’s dependent coverage extension and
provide proof of the child’s total and permanent disability no later than 60
days after the date the child would have otherwise lost eligibility, and you must
remain covered under the Plan. You will be notified by the Fund if your adult
disabled child is found eligible for continuing coverage. You must enroll your
adult disabled child within 60 days of receiving confirmation of your adult
child’s eligibility. Failure to enroll at this time means your disabled adult child
loses his or her special eligibility. Contact the Fund Office for details. |
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Your dependents remain eligible for as long as you remain eligible,
except for the following:
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Your spouse’s eligibility ends on the date of your legal separation
or divorce. Your domestic partner’s eligibility ends on the date the
requirements for domestic partnership in the "Dependent Eilgibility" section are no longer
satisfied.
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Your child’s eligibility ends on the date your child marries or no longer
satisfies the rules regarding residence or financial dependency that are
described "Dependent Eilgibility", or
- if not a full-time student, on the date the child reaches age 19, or
- if a full-time student,
- on the date of the child’s graduation from school, or, if earlier,
- on the date the child leaves school, or, if earlier,
- on the date the child reaches age 23.
- Your dependent’s eligibility for dependent coverage ends on the date
your dependent commences work in covered employment and
becomes eligible for coverage under the Plan as a participant.
- Eligibility of a spouse, a domestic partner, and dependent children ends
on the date of your death.
A child is not considered a dependent under the Plan if he or she:
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is not a United States citizen and lives outside the United States,
Canada or Mexico, or
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is in the military or similar forces of any country.
*Your adopted dependent child will be covered from the date that child is adopted
or “placed for adoption” with you, whichever is earlier (but not before you become
eligible), if you enroll the child within 30 days after the earlier of placement or
adoption (see “Your Notification Responsibility”). A child is placed
for adoption with you on the date you first become legally obligated to provide
full or partial support of the child whom you plan to adopt. However, if a child is
placed for adoption with you, but the adoption does not become final, that child’s
coverage will end as of the date you no longer have a legal obligation to support
that child. If you adopt a newborn child, the child is covered from birth as long
as you take custody immediately after the child is released from the hospital and
you file an adoption petition with the appropriate state authorities within 30 days
after the infant’s birth. However, adopted newborns will not be covered from
birth if one of the child’s biological parents covers the newborn’s initial hospital
stay, a notice revoking the adoption has been filed or a biological parent revokes
consent to the adoption.
When Your Dependents Are No Longer Eligible
Under a Federal law called the Consolidated Omnibus Budget
Reconciliation Act of 1986 (COBRA), group health plans are required to
offer temporary continuation of health coverage, on an employee-pay-all
basis, in certain situations when coverage would otherwise end. “Health
coverage” includes the Plan’s hospital, medical, EAP, prescription drug,
dental, vision and retiree health coverage. See See the "Continued Group Coverage: During a Military Leave" section for more
information about COBRA.
How to Enroll
Coverage under the Plan is not automatic. In order for your coverage
to begin, you must enroll in the Plan by completing the Service Employees
32BJ North Health Benefit Fund Enrollment Form (Enrollment Form) and
submitting it to the Fund for processing. In most cases, your coverage will
begin on the date you were first eligible, not the date you completed and
returned the Enrollment Form. However, a delay in completing and returning
the Enrollment Form will delay any claims payment(s) to you. You may
contact the Fund Office for information or a copy of the Enrollment Form.
Enroll your dependents as soon as they become eligible. Please see
the "Dependent Eligibility" section to determine when your dependents
are eligible. If at the time you enroll in the Plan, your dependents are eligible
for benefits, you must complete the “Dependent Information” section of
the Enrollment Form. You will be required to submit documents proving
dependent status including a marriage certificate (for your spouse), birth
certificates and, if applicable, proof of full-time student status (for your
children). In most cases, your dependent’s coverage will begin on the date he
or she was first eligible. However, if you do not enroll your dependents that
are eligible when you first complete the Enrollment Form, your dependent’s
coverage will not begin until the date you notify the Fund. No benefits will be
paid until you provide the Fund with your eligible dependent’s information
and supporting documentation. After your coverage under the Plan begins,
if you have a change in family status (e.g., get married, adopt a child) or wish
to change existing dependent coverage for any reason, you must complete the
appropriate form. Special rules apply regarding the effective date of your new
dependent’s coverage. Please see the "Your Notification Responsibility" section below for further details.
Claims for eligible expenses will be paid only after the Fund has
received your completed Enrollment Form, supporting documentation and
proof of hiring from your contributing employer. If your forms are
not completely or accurately filled out, or if the Fund is missing requested
documentation, any benefits payable will be delayed. The Fund may
periodically require proof of continued eligibility for you or a dependent.
Failure to provide such information could result in a loss of coverage.
Your Notification Responsibility
ALERT:
06/10/10 NEW
Click
here for important benefit changes>>
If, after your coverage under the Plan becomes effective, there is any
change in your family status (e.g., marriage, legal separation, divorce,
birth or adoption of a child), it is your responsibility to notify the Fund
immediately of such change and complete the appropriate form. If you
notify the Fund within 30 days of marriage or birth or adoption of a child,
coverage for your new spouse or child will begin as of the date of marriage
or date of birth or adoption. If you do not notify the Fund within 30 days,
coverage for your new spouse or child will begin as of the date you notify
the Fund. No benefits will be paid until you provide the Fund with the
necessary supporting documentation. Also, be sure to notify the Fund
if your child is between age 19 and 23 and graduates or otherwise leaves
school, or if your child marries or no longer satisfies the rules regarding
residence or financial dependency that are described in the "Dependent Eligibilty" section.
Failure to notify the Fund of a change in family status could lead to a
delay or denial in the payment of health benefits or the loss of a right to
elect health continuation under COBRA. In addition, knowingly claiming
benefits for someone who is not eligible is considered fraud and could
subject you to criminal prosecution.
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