DC 37 HEALTH & SECURITY PLAN BENEFITS
TABLE OF CONTENTS
PAGE
Introductory Statement ............................................................................................... 3
Establishing eligibility for Health & Security Plan Benefits .......................................... 4
Eligibility Codes............................................................................................................ 5
Establishing eligibility for Full-Time Employees .......................................................... 6
Establishing eligibility for Part-Time Employees ......................................................... 6
Establishing eligibility for SAPIS .................................................................................. 7
Establishing eligibility as a Pensionable Full-Time Retiree ........................................... 7
Establishing eligibility as a Pensionable Part-Time Retiree .......................................... 8
Establishing eligibility as a Pensionable Former Dept. of Edu. Hourly Employee ........ 9
Establishing eligibility as a Non-Pensionable Former Dept. of Edu. Hourly Employee 10
Establishing eligibility for Crossing Guards ................................................................. 11
Establishing eligibility as a Pensionable Former School Crossing Guard ..................... 11
Establishing eligibility as a Non- Pensionable Former School Crossing Guard ............ 12
Establishing eligibility for Former Family Auxiliary Employees ................................ 13
Establishing eligibility After a Break in Service ............................................................ 14
Payroll Management System Holidays for 2011-2013 ...........................................................15
Payroll Management System Cycle for 2011-2013........................................................ 16
Eligibility Enrollment Records Unit ............................................................................. 17
Dependents age 19-26 ................................................................................................... 17
Change of Status ........................................................................................................... 18
Registering of Domestic Partners.................................................................................. 18
Dental Benefit ............................................................................................................... 20
Dental Centers .............................................................................................................. 23
Dental Center Policies ................................................................................... ............... 23
Optical Benefit . ............................................................................................................ 25
Prescription Drug Benefit ........................................................................ .................... 27
Disability Benefit........................................................................................................... 30
Workers Compensation................................................................................................ 31
Substance Abuse .......................................................................................................... 32
Catastrophic Medical Benefit ...................................................................................... 32
def 1/12
Second Surgical Opinion .............................................................................................. 32
Death Benefit ................................................................................................................ 33
Accidental Death & Dismemberment ........................................................................... 33
Extended Death Benefit ................................................................................................ 34
Expanded Death Benefit ............................................................................................... 34
Enhanced Expanded Death Benefit ............................................................................ 35
Survivor Benefits .......................................................................................................... 36
COBRA Benefits .......................................................................................................... 36
Podiatry Benefit ............................................................................................................ 37
Audiology Benefit ........................................................................................................ 38
Personal Services Unit .................................................................................................. 39
Health & Pension Services Unit. ..............................................................................…. 41
Annuity......................................................................................................................... 43
Inquiry Unit.................................................................................................................. 45
legal Services................................................................................................................. 46
INTRODUCTORY STATEMENT
This guide is intended to provide information relating to the benefits and services provided
by the Health & Security Plan. This manual is not intended to supplant the Health & Security
Plan Benefits Booklet which contains a more comprehensive description of Health &
Security Plan’s benefits and services.
3
ESTABLISHING ELIGIBILITY
Eligibility is automatically established within the Health & Security Plan. This is accomplished by
the processing of computerized employee payroll tapes that are produced by the various
departments of the Mayoralty and Non-Mayoralty Agencies.
There are two types of payroll processing systems:
The Payroll Management System known as PMS which is used by all Mayoralty Agencies, Board
of Education Clerical Full-Time employees and Housing Authority. These payroll tapes contain
information for a 28 day payroll cycle.
The Monthly Payroll Tapes are used by Non-Mayoralty Agencies such as CUNY, The Board of
Education, T.A., etc. Each Agency submits its own payroll tapes.
We have included for your information a breakdown of the PMS 28 day pay cycles which extends
from December 2011 through January 2013.
We have also included a breakdown of the Holidays associated with the PMS cycles extending
from December 2011 through January 2013. We receive from the Board of Education a separate
tape covering the Part-Time Clerical employees. With this we are also given a detailed report
which indicates the number of hours an employee worked within the month, and for whom we will
receive a Welfare Fund contribution.
This booklet contains a breakdown of "Eligibility Codes" which will help you understand how the
Plan determines an employee's benefits status. For example, if an employee is reported in an "A
through H" eligibility pay code, then that employee is considered a full time employee, eligible for
full-time benefits. If an employee is reported in a “J through R”(excluding “O”, see page 5)
eligibility pay code, that employee is considered a prevailing rate employee, eligible for full-time
benefits. If an employee is reported in an “I”, “U”, “X” or “Z” pay code, that employee is
considered a part-time employee eligible for part-time benefits (see page 5 for complete list of
codes).
4
ELIGIBILITY CODES
PAY CODE NUMERIC
PAY CODE ALPHA
BENEFITS
0
Full-Time A-H
Full-Time Benefits
1
Part-Time I
Part-Time Benefits
2
Prevailing Rate J-R
Full-Time Benefits
3
Full-Time W (per diem)
Full-Time Benefits
4
Per-Hour X, U and O
Part-Time Benefits
5
Hourly-Bd. of Ed Y
Part-Time Benefits
6
Per-Visit Z
Part-Time Benefits
5
Establishing Eligibility for Full-Time Members
You are a full-time employee if you are a per annum employee - i.e., your salary is figured and
paid on a yearly basis - rather than on an hourly, daily or per session basis. New full-time
employees, working in covered job titles, become eligible for Health and Security Plan benefits on
the first day of employment.
The following benefits are available to you and your dependents as described:









Catastrophic Medical
Second Surgical Consultation
Dental Benefit
Prescription Drug Benefit
Vision Care Benefit, including Supplemental Optical Benefit
Health & Pension Counseling
Personal Service Unit
Survivor Benefit
Municipal Employee Legal Services Benefit
Benefits available only to you (the employee):





Death Benefit
Accidental Death and Dismemberment Benefit
Disability Benefit
Audiology
Podiatry
Establishing Eligibility for Part-Time Members:
New part-time employees working in covered job titles become eligible if:
 They are employed on a part-time per annum, hourly, per diem, per session or seasonal
basis in a title for which there is a full-time equivalent; and they work at least one half the
hours of the full-time employee; or
 They are employed on a part-time per annum, hourly, per diem, per session or seasonal
basis in a title for which no full-time equivalent exists; and, if they are white collar
employees, they work at least 17.5 hours per week. If they are blue collar employees, they
must work at least 20 hours per week.
All part-timers become eligible on the first day of employment if they meet the required credited
service hours. It is important to note that they must work the required number of hours in the
corresponding pay cycle to maintain eligibility for benefits.
6
Keep in mind that the Plan depends on various payroll systems to establish eligibility. In
most cases there is a 4 to 6 week lag in receiving information from the various payroll
systems.
The following benefits are available to you and your dependents as described:








Second Surgical Consultation
Dental Benefit
Prescription Drug Benefit
Vision Care Benefit, including Supplemental Optical Benefit
Health & Pension Counseling
Personal Service Unit
Survivor Benefit
Municipal Employee Legal Services Benefit
Benefits available only to you (the employee):





Death Benefit
Accidental Death and Dismemberment Benefit
Disability Benefit
Audiology
Podiatry
Establishing eligibility for SAPIS
SAPIS employees are eligible for benefits during the summer months if they were active
on the last payroll tape when school closes in June.
Establishing Eligibility as a Pensionable Full-Time Retiree
 You had to retire subsequent to June 30, 1970
 You had to be in a title covered by DC 37 Health & Security Plan or in a title
covered by contractual agreement at the time of retirement
 Have the minimum required years in the Department of Education Retirement
System or a similar Retirement System at the time of separation from the
employer
7
Establishing Eligibility as a Pensionable Part-Time Retiree
To qualify for Health and Security Plan Benefits as a Former Part-Timer, the
member must:
 You had to retire subsequent to July 31, 1992
 Be in a part time title covered by the DC 37 welfare fund or in a title covered by
contractual agreement at the time of retirement
 Had to qualify for Health and Security Plan Benefits for a full year prior to
retirement
 Have the minimum required years in the Department of Education Retirement
System or a similar Retirement system at the time of separation from the employer
 Remain a primary beneficiary of the City-paid health insurance program or
provide a copy of your waiver of employer’s paid health insurance
 You must be receiving a pension
The RETIREE ONLY will be eligible to utilize benefits in the former part-time
package.
If you meet all of the above requirements, the following benefits are available to you,
(the retiree only).










Dental Benefit
Prescription Drug Benefit
Vision Care Benefit including Supplemental Optical Benefit
Health and Pension Counseling
Second Surgical Consultation
Personal Service Unit
Municipal Employees Legal Services Benefit1
Death Benefit
Audiology
Podiatry
(Please note that this benefit package is available to the retiree only, your spouse and
dependents are not eligible for benefits. The spouse and dependent children of an eligible
member can purchase coverage through COBRA for a period of 36 months, measured
from the member’s termination date as an active employee).
8
Establishing Eligibility as a Pensionable Former Dept. of Education
Hourly Employee
To qualify for DC 37 Health and Security Plan Benefits as a Pensionable
Department of Education hourly employee, you must satisfy the following
requirements:
Be eligible to receive a pension as an employee of the Department of Education in one of
the titles listed below:
 Film Inspection Assistant
 School Aide
 School Health Services Aide
 School Lunch Helper
 Senior School Lunch Helper &
 You had to retire subsequent to July 31, 1992
 Be a member of the Department of Education Retirement System
 Have the minimum required years in the Department of Education Retirement
System to qualify for a pension at the time of separation from the Department of
Education
 You must be receiving a pension
 Qualify for Health and Security Plan Benefits for the school year prior to your
retirement
 You had to remain a primary beneficiary of the employer’s paid health insurance
program or provide a copy of your waiver of employer’s paid health insurance.
If you meet all of the above requirements, the following benefits will be available to
you and your eligible dependents:








Dental Benefit
Prescription Drug Benefit
Vision Care Benefit including Supplemental Optical Benefit
Health and Pension Counseling
Second Surgical Consultation
Personal Service Unit
Survivor Benefit
Municipal Employees Legal Services Benefit
9
Benefits available only to you (the retiree):
 Death Benefit
 Audiology
 Podiatry
Establishing Eligibility for Non-Pensionable Former Department of
Education Hourly Employees
In order to qualify for DC 37 Health & Security Plan benefits as a Former NonPensionable employee of the Department of Education Hourly Employee, you must
have been hired prior to 9/1/95 and you must satisfy all of the following
requirements:
 You were a former employee of the Dept. of Education in one of the titles listed
below
A. Family Auxiliary
(Family Worker)
(Family Assistant)
(Family Associate)
(Parent Program Assistant)
B. Film Inspection Assistant
C. School Aide
D. School Health Services Aide
E. School Lunch Helper
F. Senior School Lunch Helper
 You must have worked a total of 10 continuous years in any of the abovementioned titles.
 You have completed at least 10 years in an Hourly School Lunch position and you
were promoted to a monthly/annual school lunch position on or after Oct. 1, 1978.
 If you resigned on or after October 1, 1983, you must have attained the age of 60
prior to your resignation.
 Effective October 1, 1983: if you reach your 60th birthday between the end of the
school term, (June) and the start of the next term (September), and you resign
before the start of the new term, you will be considered on active status during the
summer for the purposes of establishing eligibility.
Early Resignation (Retirement) Due to Disability
If you become disabled between the ages of 55-60 and you are receiving a Service
Compensation award or you have 10 years of continuous service (for other than Former
Hourly Employee of the Dept. of Education and Family Auxiliary) and you meet the
other eligibility requirements, you may apply for resignee benefits and become eligible
for such benefits at age 60. You should have resigned between the ages of 55-60 on or
after January 1, 1984.
10
If you meet all of the above requirements, the following benefits will be available to
you and your eligible dependents:








Dental Benefit
Prescription Drug Benefit
Vision Care Benefit including Supplemental Optical Benefit
Health and Pension Counseling
Second Surgical Consultation
Personal Service Unit
Survivor Benefit
Municipal Employees Legal Services Benefit
Benefits available only to you (the resignee):
 Death Benefit
 Audiology
 Podiatry
Eligibility for School Crossing Guards
School crossing guards must work a minimum of two weeks at 15 hours per week, during
the 28-day pay cycle. In order to receive benefits during the summer months, a School
Crossing Guard must have been eligible prior to school closing for the summer.
Establishing Eligibility for Pensionable Former School Crossing Guards
To qualify for the DC 37 Health and Security Plan Benefits as a Pensionable Former
School Crossing Guard, you must satisfy all of the following requirements:
 You had to retire subsequent to July 31, 1992.
 Be a member of the Department of Education Retirement System.
 Have the minimum required years in the Department of Education Retirement
System (or combined years of service with NYCERS) to qualify for a pension at
the time of separation from the Police Department.
 Qualify for Health and Security Plan Benefits for the school year prior to your
retirement;
 Be receiving a pension.
 You had to remain a primary beneficiary of the Employer’s paid health insurance
program or provided a copy of your waiver of employer’s paid health insurance.
 You had to qualify for Health & Security Plan benefits for the school year prior to
your retirement.
11
If you meet all of the above requirements, the following benefits will be available to
you and your eligible dependents:








Dental Benefit
Prescription Drug Benefit
Vision Care Benefit including Supplemental Optical Benefit
Health and Pension Counseling
Second Surgical Consultation
Personal Service Unit
Survivor Benefit
Municipal Employees Legal Services Benefit
Benefits available only to you (the retiree):
 Death Benefit
 Audiology
 Podiatry
Establishing Eligibility for Non-Pensionable Former School Crossing
Guards
In order to qualify for DC 37 Health & Security Plan benefits as a non-pensionable
Former School Crossing Guard, you must have been hired prior to 9/1/95 and must
satisfy all of the following requirements:
 Have worked a total of 10 continuous years as a School Crossing Guard. (If you
were terminated in 1975 because of dissolution of the School Crossing Guard
Program and were reappointed by June 30, 1979, you will be considered as not
having a break in service).
 Your effective date of resignation is on or after January, 1984, and you were 60 or
older at that time
 You had to be eligible for DC 37 Health & Security Plan benefits prior to
resignation.
 If you reach your 60th birthday in the months between the end of the school term
(June) and the start of the next term (September), you will be considered to be on
active status for the purpose of establishing eligibility.
If you meet all of the above requirements, the following benefits will be available to
you and your eligible dependents:
 Dental Benefit (limited benefit, no orthodontia)
12






Prescription Drug Benefit
Vision Care Benefit including Supplemental Optical Benefit
Health and Pension Counseling
Second Surgical Consultation
Personal Service Unit
Municipal Employees Legal Services
Retiree Benefits for Former Family Auxiliary Employees Who Joined the
Teachers Retirement System
 The member must have a minimum of 10 years in the Teachers Retirement
System;
 The member must be receiving a pension;
 The member must qualify for Health Insurance coverage through the Dept. of
Education (Note: the member must apply for this coverage at the time of
retirement through their personnel office);
 The member must contact the Health & Security Plan office and submit a copy of
the member’s Teachers Retirement System pension stub, and a copy of the
Retiree Health Benefits application. The Health & Security Plan will activate the
member’s eligibility for retiree benefits (subject to receiving contributions from
the Dept. of Education on behalf of the member). It is important to note that an
arrangement was made with the Dept. of Education to furnish the Plan with
quarterly reports which will identify those Family Auxiliaries for whom
contributions will be forthcoming.
If you meet all of the above requirements, the following benefits will be available to
you and your eligible dependents:








Dental Benefit
Prescription Drug Benefit
Vision Care Benefit including Supplemental Optical Benefit
Health and Pension Counseling
Second Surgical Consultation
Personal Service Unit
Survivor Benefit
Municipal Employees Legal Services Benefit
13
Benefits available only to you (the retiree):
 Death Benefit
 Audiology
 Podiatry
Keep in mind that the Plan depends on various payroll systems to establish eligibility. In most
cases there is a 4 to 6 week lag in receiving information from the various payroll systems.
ESTABLISHING ELIGIBILITY AFTER A BREAK IN SERVICE
If, after becoming eligible, the member is laid off or otherwise terminated, and rehired in a covered
job title, eligibility for Health & Security Plan coverage will resume as soon as the member has
worked a full day. Part-timers must work a full day and meet the required credited hours for that
cycle.
14
PAYROLL MANAGEMENT SYSTEM (PMS)
HOLIDAYS ASSOCIATED WITH
PMS CYCLE 2012
CYCLE START DATE__CYCLE END DATE___SCHEDULE RUN DAY
12/24/11
01/20/12
01/21/12
02/17/12
Christmas Day 12/25/2011
NewYear’Day 1/1/12
Martin Luther King’s Birthday
1/16/12
Lincoln’s Birthday 2/12/12
02/18/12
03/16/12
Washington’s Birthday 2/22/12
03/17/12
04/13/12
Good Friday 4/6/12
Passover 4/7/12
Easter 4/8/12
04/14/12
05/11/12
5/12/12
6/08/12
Memorial Day 5/28/12
06/09/12
07/06/12
Independence Day 7/4/12
07/07/12
08/03/12
08/04/12
08/31/12
09/01/12
09/28/12
Labor Day 9/3/12
Rosh Hashanah 9/17/12
Yom Kippur 9/26/12
09/29/12
10/26/12
Columbus Day 10/08/12
10/27/12
11/23/12
11/24/12
12/21/12
Election Day 11/6/12
Veteran’s Day 11/11/12
Thanksgiving Day 11/22/12
Christmas Day 12/25/12
12/22/12
01/18/13
New Year’s Day
15
PAYROLL MANAGEMENT SYSTEM (PMS)
28 DAY PAY CYCLE 2012
CYCLE START DATE
CYCLE END DATE
SCHEDULE RUN DATE
12/24/11
01/20/12
01/30/12
01/21/12
02/17/12
02/27/12
02/18/12
03/16/12
03/26/12
03/17/12
04/13/12
04/23/12
04/14/12
05/11/12
05/21/12
05/12/12
06/08/12
06/18/12
06/09/12
07/06/12
07/16/12
07/07/12
08/03/12
08/13/12
08/04/12
08/31/12
09/09/12
09/01/12
09/28/12
10/08/12
09/29/12
10/26/12
11/05/12
10/27/12
11/23/12
12/03/12
11/24/12
12/21/12
12/31/12
12/22/12
01/18/13
01/28/13
16
ELIGIBILITY ENROLLMENT UNIT
The Eligibility Enrollment Unit receives and processes enrollment forms, change of status cards,
marriage/birth certificates, change of beneficiaries, etc. Benefit claims cannot be processed until a
member has enrolled.
In order to facilitate enrollment, it is necessary that all forms and documents received in this unit
have the member's name and PID or Social Security number on it. A member need only complete
one enrollment form. All changes made after that form is on file, must be done on a change of
status card, or change of beneficiary form.
 All enrollment forms must be completed and signed by the member.
 Change of beneficiary forms must be signed and notarized.
 All change of status requests must have proper documentation attached
(e.g., copy of birth certificate).
(Please refer to the Enrollment Form and Beneficiary Form as shown at the back of this
manual)
Dependents-Age 19-26
Effective July 1, 2011 under the Patient Protection and Affordable Care Act, all eligible
dependents, age 19-26, upon enrollment with DC37 Health & Security Plan will be eligible for the
Plan’s supplemental benefits (prescription drug, dental and optical). These health-related benefits
are available to the dependents up to the end of the month in which he/she reaches the age of 26;
regardless to if:
 he/she lives at home
 is declared a dependent on the member’s tax return
 is in school
 is employed (without benefits), or
 is married or unmarried
(Application forms can be downloaded from the Health & Security Plan’s website or from the Plan
office).
For dependents age19-23 who wish to use the MELS benefit or the PSU benefit, he/she must have
a letter from the Registrar’s office indicating the dependents current full-time status at the time
these benefits are sought. Dependents are not eligible for the MELS and PSU benefit after age 23.
(Please see the Application for dependents age 19 -26 at the back of this manual).
17
Change of Status
All enrollment cards submitted must include a Marriage Certificate (adding spouse), Birth
Certificate if adding a dependent child(ren) under the age of 19, and Application Form if the
dependent is 19-26 years old.
A change of status card must be submitted along with the proper documents, to the Health and
Security Plan whenever any of the following changes occur:
A.
Marriage - Submit a copy of the marriage certificate along with the change of
status
card
B.
Separation/Divorce - Only change of status card is required
C.
Registration of Domestic Partners
Domestic Partners are two people who are both eighteen years or older and neither of
whom are married or related by blood in a manner that would bar his or her marriage in
New York State; who have a close and committed personal and financial relationship and
are living together on a continuous basis; and are residents or employees of, or former
employees of New York City. Domestic Partners can obtain a blank Domestic Partner
Affidavit from the Office of the City Clerk, or they may contact the office by calling (212)
669-8190 for other locations where the form can be obtained. Both partners must sign the
affidavit in the presence of a Notary Public, who will counter sign and notarize the
Affidavit.
The notarized affidavit must be submitted to the City Clerk's office, 1 Centre Street, Room
265. Each partner must present one form of personal identification (i.e., drivers license,
birth certificate, passport, immigration card, etc.) along with the notarized affidavit.
For those who qualify, the Clerk will issue a signed Certificate of Domestic Partnership,
embossed with the City Seal. A copy is made for the City records and the original
certificate will be given to the partners.
To register Domestic Partners with the Health & Security Plan, the following documents
have to be submitted:
1.
2.
Certificate of Domestic Partnership or “civil union” certificate
Change of status card
18
Domestic Partners who are retired and are Non-Residents of N.Y.S., must submit the
following:
1.
2.
Alternative Affidavit
Change of status card
Separation/Termination of Domestic Partners
Once a Domestic Partner severs its partnership, the member cannot re-register with another
partner until after six (6) months have passed.
19
DENTAL BENEFIT
The Dental and Optical Units are responsible for:
a.
b.
Processing dental pre-authorizations and claims.
Issuing optical vouchers and paying optical reimbursement claims.
Dental Pre-Authorizations
Pre-authorization is mandatory for orthodontic treatment, root canal therapy, extensive gum
surgery, crowns, bridges and dentures and TMJ Therapy. If the member sends in a proposed
treatment form (a pre-authorization) accurately completed with all the x-rays attached, he/she will
get a response from the Health & Security Plan within ten working days. The original preauthorization response goes to the dentist and a copy goes to the member. There are no appeals for
proposed treatment (pre-authorization) that have been rejected by the Plan. If the dentist disagrees
with the treatment authorized in the pre-authorization response, the dentist should write to the
Professional Review Unit and send in any additional information justifying why he/she thinks the
procedure should be done.
All pre-authorizations and claims should contain:
a.
b.
c.
d.
e.
f.
Member's PID or Social Security number
Tax I.D. of the dentist
Signatures of dentist and member
Correct CDT codes
Treatment descriptions, tooth #'s and quadrants
Complete patient information
If any of the above information is omitted, the pre-authorization cannot be processed and
will be returned to the member or dentist.
Claims
1.
If treatment does not need pre-authorization, the member should submit the claim form
signed by the member and the dentist with the proper address within 30 days of completion
of treatment. Payment will be issued within 15 working days, if the form is accurately
completed.
20
If the member submitted a pre-authorization, the claim for payment should be returned on the
computer generated pre-authorization form after the dentist inserts the dates of treatment. The
member and the dentist should sign the claim form.
Before the member signs the claim form he/she should be sure that all the procedures signed for
were done. Remember that members will be held responsible for all treatment billed whether
actually provided or not if the Plan is billed. The appropriate restriction will be put in place.
2.
If only a partial payment is requested, the member still has to submit a claim on the same
computer-generated form. A new pre-authorization form will be generated by the
computer, and sent to the member and the dentist, for the rest of the work. The member or
dentist will be paid within 10 working days on this type of claim, provided the form is
accurately completed.
3.
If information is missing from the claim relating to the treatment, or if additional treatment
was done that was not pre-authorized, the claim may be pended. The member and the
dentist will then be informed why the claim was not paid and the dentist will be requested
to provide us with the necessary information so that payment can be made.
4.
When resubmitting a claim, please submit original claim forms with original signatures photocopies of signatures and claims are not acceptable for payment.
It is the member's responsibility to make sure that the dentist completes and signs his/her
portion of the claim and that the form is submitted within 30 days after the completion of
work. Pay close attention to the instructions on the back of the dental claim form. It gives
details regarding pre-authorization rules and frequency limitations regarding dentures,
bridgework, perio-surgery, etc.
(Please refer to the Dental Claim Form shown at the end of this manual).
The Plan Allows:
 $1700 per person per calendar year for covered services based on the Plan’s fee
schedule
 $1840 lifetime orthodontia benefit
Full-time members are eligible for 100% of the Plan’s fee schedule for covered services.
Part-time members are eligible for 75% of the Plan’s fee schedule for covered services; and are
required to pay 25% of the remaining fee schedule.
21
If a non-participating dentist is used, the member is responsible for paying the difference between
the Plan’s allowable fee and the dentist’s charge.
Orthodontics
1. Full-time members: all eligible family members are covered.
2. Part-time members: no one is eligible for orthodontics.
3. Retiree: member/spouse not eligible, dependent children eligible according to the rules of
the Plan.
Appeals




Only the member can appeal a claim for payment.
All appeals must be done in writing
The member, not the dentist must write the appeal.
The member will receive a written response to the appeal in approximately 4-6 weeks.
Inquiries
For information relating to dental pre-authorizations and claims, members should contact the
Inquiry Unit at 212-815-1234.
A maximum if $1,700 will be paid as benefits for each covered person in a calendar year based on
the fee schedule. Benefits are paid after claim forms for completed services are submitted to the
Plan and processed based on Plan rules and guidelines.
22
DENTAL CENTERS
In addition to using any licensed dentist or a dentist from the Plan's list of Participating Panel
Dentists, a member and/or dependent may also obtain treatment at any of the two dental centers.
The same Plan rules regarding: restrictions, limitations and/or annual dollar limit will also apply.
The individual who obtains treatment at the Plan's Centers will be required to comply with the
policies and regulations established by the Center for its patients.
DENTAL CENTER POLICES
The following is a statement of the policies of the Dental Centers. This policy is distributed to
each patient at his or her initial appointment. It is expected that each patient will sign this
statement before dental treatment begins.
JORALEMON DENTAL SERVICES, P.C.
Manhattan Center
115 Chambers Street
New York, NY 10007
(212) 766-4440
Brooklyn Center
186 Joralemon Street
Brooklyn, NY 11201
(718) 852-1400
DC 37 Health & Security Plan Rules and Regulations limit your Dental Benefits to $1,700 per year
based on the Plan's fee schedule. Expenses indicated on your Explanation of Benefits (EOB)
Statement as "Balance Due" are the member's responsibility, whether or not you were informed
prior to treatment. To avoid problems, please discuss your treatment with your Dentist or
Treatment Plan Coordinator.
When your first appointment is scheduled, you will be assigned to a general dentist. Due to the
volume of patients seen at the Center, it is not feasible to have patients select their own dentist. The
dentist will refer the patient to the hygienist. If necessary, specialty care will be provided for active
patients of the Centers.
All visits are by appointment only. Emergency visits are also by appointment and are not treated on
a walk-in basis. If you have an emergency, you must call the Center early in the day. The screening
dentist will advise you how to proceed.
No-Shows - A patient will be considered a "no-show" if he/she fails to appear for a scheduled
appointment, or gives the Center less than 24 hours notice to cancel an appointment. If three (3) or
more no-shows occur, we will ask you to seek dental treatment outside of the Center. If you are a
no-show two (2) or more times for a Specialist appointment, we will also ask you to seek treatment
outside of the Center.
23
Lateness
- Patients are seen by appointment only and time is allocated based upon the
procedure(s) to be completed. If a patient is late for his or her appointment, we may not have
sufficient time to do the scheduled work. In these cases, we reserve the option to reschedule your
appointment. Habitual lateness will be treated as a no-show.
Cancellations - A minimum of 24 hours notice is required for an appointment to be canceled
without penalty. Anything less than 24 hours notice will be considered a no-show.
Maintaining your status
- as an active patient requires your cooperation. The Center
provides comprehensive general dentistry and recommends that patients return each year for a
dental check up. If more than two years lapse, you will not be given an appointment until you
again place your name on the waiting list. Except for orthodontics, we do not co-treat patients who
are in active dental treatment outside of the Center.
We offer these explanations of our policies to assist you. It is not possible for us to address each
individual's specific circumstance. You are encouraged to ask questions for further clarification.
Member/Patient's Signature
Date
My signature indicates that I have been informed of the policies at the Dental Center.
24
OPTICAL BENEFIT
The standard optical benefit is available to the member and his/her eligible dependents once every
two years, measured exactly two years from the last date of service. The benefit consists of an eye
examination, lenses and frames.
There are three ways of using the optical benefit: using the voucher, getting direct reimbursement
or using the DC 37 Vision Center at 115 Chambers Street in Manhattan.
Using a Voucher - If the member wishes to use this method, he/she must complete a Voucher
Request Form and send it to the Plan office, or call the Plan office at 212-815-1234 and request a
Voucher. Upon receipt of the request, a voucher together with a listing of participating opticians
will be forwarded to the member's home. The voucher is valid for 90 days and can be taken to
any of our participating panel providers for a free eye exam, union covered frames and lenses. If
other than the Plan's frames and lenses are selected, the member will be responsible for the
additional expense.
Using Direct Reimbursement - If this method is chosen, the member must complete an
Optical Reimbursement Form and submit it to the Plan office for processing. Payment will be
calculated according to the Plan's optical reimbursement fee schedule (see Full-Time Benefit
Booklet for schedule allowances).
In order to maximize the optical benefit, the member must obtain and file for all three services eye examination, lenses and frames - simultaneously on the same claim form, whether using the
voucher or direct reimbursement method. Remember, the three parts of the benefit cannot be split
between the two available methods - voucher or direct reimbursement. The member should also be
aware that partial usage of the benefit will be considered the same as full usage.
(Please see reimbursement form at the end of this manual).
Using the Vision Center - Appointments must be scheduled in advance at the DC 37 Vision
Center, call (212) 766-4452.
If the member plans on using the Vision Center he/she does not have to request a voucher. The
Center will request one, unless the member has gone to his/her own doctor and has a prescription
for the lenses. In that case, the member must bring the voucher if he/she goes to the Center to
purchase glasses.
Supplemental Optical Benefit - In addition to the standard optical benefit, the member and
his/her eligible dependents can apply for the Supplemental Optical Benefit. This benefit is
provided at the Vision Center only and is available once every 12 months measured from the date
the standard benefit was last used. The benefit includes an eye examination and a change of lenses,
if prescribed by the Vision Center's Optometrist.
25
Reminder
A.
If the member should need glasses for any reason, e.g. an additional pair is desired
or the glasses were lost or destroyed before the eligibility waiting period is satisfied,
frames and lenses can be obtained (member must provide the prescription) at the Center or
at a Participating Provider at a moderate cost without an appointment.
B.
All information submitted to the Plan should indicate member's name and PID number
- even when requesting benefits/services for spouse/children.
C.
A voucher is used for exam, frames and lenses. For cataracts and contact lenses, the
reimbursement method should be used.
D.
If the voucher has been lost, destroyed, or never received, the member should call the
Plan office and request a notary letter. Once the notary letter is completed by the
member and returned to the Plan office, a new voucher will be issued.
E.
If the voucher is outdated, the voucher must be returned to the Plan office
indicating if the voucher is to be voided only, or voided and reissued.
26
PRESCRIPTION DRUG BENEFIT
The Prescription Drug Benefit is available to both active and retired members and their eligible
dependents. A covered prescription drug is a drug approved by the FDA, used for the purpose and
time periods approved by the FDA and can only be obtained with a prescription written by a
doctor or dentist.
The Prescription Drug Benefit can be used in one of three ways: through the use of the prescription
drug card, the direct reimbursement method, or the mail service program. (Prescription Solutions)
The Prescription Drug Benefit is a generic based program. This means that the Plan will only be
responsible for paying the cost of the generic medication except when there is no generic available
and the brand name drug is the only drug available. (Please note that the Food & Drug
Administration requires that generic drugs meet the same standards for purity, strength and safety
as the brand name drug).
If the member chooses to obtain a brand name drug that has a generic equivalent, then he/she will
be responsible for paying the difference in the cost between the brand and the generic drug in
addition to the appropriate co-payment.
Effective January 1, 2010, generic statins have zero co-pay.
Co-payments consist of three tiers:
Generic
Preferred Brand
Non-Preferred Brand
30 day
Retail
90 day
Retail
90 day
$ 5.00
$15.00
$35.00
$ 15.00
$ 45.00
$105.00
$10.00
$30.00
$70.00
Mail Order Program
Mail Order
is designed for members/dependents who have a long-term
illness or condition which requires maintenance medication. Members will save money
when they use the mail order, because they get a 90 day supply of medication for the cost
of two co-payments as opposed to a 90-day supply at a Retail 90Rx pharmacy for three
co-payments. Members should allow 14 days for delivery from the date the original
prescription was mailed in. Members may also order and track their medication on-line
by registering at www.prescriptionsolutions.net.
27
Direct Reimbursement:
If a member does not have their drug card with him/her, or
does not go to a participating pharmacy, then the direct reimbursement method may be
used. They can get a direct reimbursement form by calling the Plan at 212 815-1531 or
download it from the Prescription Solutions website at www.prescriptionsolutions.net.
The form must be completed by the pharmacist and sent to Prescription Solutions for
processing. The member will be reimbursed for the amount listed in the drug schedule in
accordance with the generic based program, minus the appropriate co-pay, regardless of
the actual amount spent for the medication.
Preferred Medications:
Because of the escalating cost of prescription drugs, the
Plan instituted a Preferred Medication List. This list was developed by a select group of
physicians and pharmacists to ensure that all drugs are therapeutically sound. The list
identifies prescriptions that can be used for virtually all illnesses and conditions that will
meet the needs of all types of patients.
Step Therapy:
Step therapy allows the members and their family to receive the
affordable treatment they need and helps the Plan contain the rising cost of the
prescription drug coverage. The drug categories in this program include high blood
pressure, dermatitis and eczema, attention deficit hyperactivity disorder, asthma, and
allergies, depression, rheumatoid arthritis, diabetes, pain and arthritis medications, ulcer
and gastro esophageal reflux disease and cholesterol lowering medications.
The program starts with generic drugs in the “first step”, more costly brand drugs are
usually in the “second step”. Second step medications will have a higher co-payment.
If you are being prescribed a medication for a step therapy condition for the first time and
your doctor did not prescribe a step one drug, your pharmacy will receive a message
indicating our Plan has a step therapy program. Generally the pharmacist will contact the
physician to request a new prescription for a Step One drug. If a physician is unavailable,
the member or patient will be responsible for obtaining the new prescription. If a
member chooses to get the prescription filled as is, he/she will pay the full cost for it, and
the medication will not be covered by the Plan.
Note: if you are on a step two medication and do not fill your prescription for 120 days
or longer, you will not be able to re-start the medication without first trying a step one
drug.
28
Psychotropic, Injectibles, Chemotherapy, Asthma(PICA)
As a result of a benefit bargaining agreement reached between the City of New York and
the Municipal Labor Committee of which DC37 is a member, a program known as PICA
became effective July 1, 2001. This program made these four classes of drugs available
to all members, non-Medicare eligible retirees and their eligible dependents in a City
sponsored health plan.
Effective July 1, 2005, the City sponsored program continued to cover two classes of
medication, Injectibles and Chemotherapy. Psychotropic and Asthma medication
reverted to the Plan’s responsibility and are subject to the Plan’s rules and co-payments.
Annual Limit:
The annual limit for the prescription drug benefit is $100,000 per
cardholder per calendar year.
29
DISABILITY
The weekly disability benefit for full-time per annum employees is 66 2/3% of their weekly salary
but no more than $200 per week (7 day week). The benefit is paid for up to a maximum of 26
weeks but not longer than the member remains totally disabled. The weekly disability benefit for
part-time or hourly employees is 66 2/3% of their weekly salary but no more than $98 per week.
The benefit is paid for up to a maximum of 13 weeks but not longer than the member remains
totally disabled.
Disability payments begin when the member has used up all sick days but not before the end of 8
days of total disability at home. If the member is hospitalized, however, the benefit begins as soon
as he/she has exhausted his/her sick days, 3.5 sick leave grant, donated or dedicated sick time or
any other such sick leave as granted by the employer. In order to assist us in expediting the
processing of the disability claim forms, the following suggestions should be followed:
Be sure that the member completes the claim in its entirety and have his/her physician answer all
relevant questions (i.e. cause of disability, dates of treatment, and or hospitalization, anticipated
return to work date, etc.). Remember, claims must be signed by both member and physician.
Indicate on the claim form the telephone number of the timekeeper, personnel officer, payroll
secretary (depending on the Agency).
*If an accident occurs on the job, the member must file for Workers' Compensation with
his/her employer and also notify the Workers' Compensation Board.
*If the disability was due to a car accident, the member must file for No-Fault Insurance
with his/her own auto insurance carrier. If the member is injured by an uninsured vehicle,
then he/she must file with the motor Vehicle Accident Indemnification Corp. (M.V.A.I.C.
(212) 791-1280).
*In these situations, the member will not receive disability benefits. However, he/she is
eligible for other Health & Security Plan benefits for up to 26 weeks (or 13 weeks if he/she
is a part-time or hourly employee) measured from his/her date of disability. Unless,
subsequent to being disabled, the member remains on active payroll status receiving either
sick leave, vacation pay, Section 3.5 or Section 7.2 leave pay, in which case the eligibility
period for Health and Security Plan Benefits is measured from the last day on active
payroll status. In order to maintain eligibility for these Health and Security Plan benefits
during the period of disability, a disability claim form must be filed with the Plan. The
member must submit copies of Workers’ Compensation payments/No fault payments or
medical each month to extend coverage from month to month until they reach the
maximum time allowable.
30
The Disability Unit of the Health and Security Plan utilizes a list of Reasonable and
Customary convalescent periods associated with each illness. If a member is out on
disability for more than the Reasonable and Customary period of convalescence, the Plan
will require an evaluation be performed by a doctor selected by the Health and Security
Plan at no cost to the member. Failure to keep the evaluation appointment will cause the
denial of any further disability payments, until another evaluation appointment is made and
kept.
The Disability Unit periodically forwards requests for medical statements to the member,
to be completed by the treating physician. Claims processing could be delayed if the
medical statement is not furnished in a timely fashion.
The disability claim form must be filed within 15 days from the onset of the disability,
regardless of the amount of sick time, vacation time or annual time available. If the claim is
filed beyond the 15 days filing limitation, a letter of explanation must be attached to the
claim. Complying with the above mentioned instructions, will permit us to process the
claim within 10 working days. However, other problems may cause processing delays
(information not received from the member’ payroll department etc.).
(Please see the Disability Form at the end of this manual).
Disability Benefits as they Relate to Workers Compensation
According to the rules and regulations governing the administration of the Disability
Benefit, no benefits are payable if a member is receiving or eligible to receive Workers'
Compensation. However, there are instances where a member can turn to the Plan for
assistance when his/her case is being controverted and payments for Workers'
Compensation benefits will be delayed until after a hearing. Therefore, if the following
criteria are satisfied, the Plan will extend Disability Benefits to a member who is in dire
need of financial assistance:
The member applied for Workers' Compensation and received a letter from the Law
Department indicating that the case is being controverted.
 The member has exhausted all accrued sick and annual leave
 The member has made application, if eligible for, but does not qualify for a Section
3.5 or Section 7.2 paid sick leave grant or similar provisions provided by other
Agencies.
Once the above criteria are met and Disability Benefits are released, the Disability Unit will send a
Compensation Lien Form directly to the Compensation Board. The lien becomes part of the
Workers' Compensation Case so that if or when the member is awarded Compensation benefits,
the Workers' Compensation Board will pay the Plan directly.
31
Disability Benefits As They Relate To Substance Abuse
The Plan will pay disability when the member is in an approved treatment program or hospitalized.
They may be seen by a social worker in Personal Service Unit (PSU), or Municipal Employees
Legal Service (MELS). For out-patient care coverage, the individual must be in a rehabilitative
program that is recognized by the Plan and verification of the care must be supplied to the Plan
upon request. This benefit has a maximum coverage of 26 weeks for full-time employees and 13
weeks for part-time employees.
Catastrophic Medical Benefit
This benefit is available only to full-time active members who are enrolled in the GHI-CBP Blue
Cross program.
The GHI-CBP program currently has a $1,500 annual catastrophic limit in the base program for
individuals who choose non-participating providers for in-hospital or related care. Once an
individual has $1,500 in covered out-of-pocket expenses, (excluding deductibles) based on usual
and customary provider fees, GHI pays 100% of the reasonable and customary charges. The inhospital and related services, which are applied to the catastrophic coverage, are: surgery,
anesthesia, maternity care, in-hospital medical care, radiation, chemotherapy, and expenses related
to in-hospital x-ray and laboratory services.
The catastrophic limit is lowered from $1,500 to $1,000 in covered out-of-pocket expenses for fulltime active members enrolled in the GHI-CBP Blue Cross Program.
Second Surgical Consultation Benefit
If a surgeon recommends surgery for a member or his/her covered dependents, the individual can
obtain a Second Surgical Opinion from a highly trained Specialist at no cost to the member.
Simply contact the Health and Security Plan's Second Surgical Consultation Unit at (212) 8151354/1355 and we will schedule an appointment for the member or dependent with a Specialist.
The Specialist will examine the records and the individual and indicate whether he/she agrees that
the operation should be performed. There is no obligation to accept the recommendation of the
Specialist who provides the Second Opinion. The ultimate decision to have the operation will be
made by the member or his/her dependent.
This benefit is available to members regardless of the basic health insurance option elected. The
second opinion must be obtained through the DC37 Health & Security Plan Second Surgical
Consultation Unit or through NYC Healthline.
Contact the Health & Security Plan’s Inquiry Unit at 212-815-1234 if you have any questions
relating to the benefit.
32
DEATH BENEFIT
If an active employee covered by the Plan dies, a Death Benefit of $10,000 for a full-timer or
$6,000 for a part-timer will be paid to his/her beneficiaries.
If a retiree/resignee covered by the Plan dies, a Death Benefit of $2,000 is paid to his/her
beneficiaries.
The Death benefit is not available to Non-Pensionable Former School Crossing Guards.
The Death Benefit is paid to the person or persons selected by the member on his/her Enrollment
Form or Change of Beneficiary Form filed with the Plan office.
The member can change beneficiaries whenever he/she wishes - as long as it is done on the proper
Change of Beneficiary Form. As soon as the new form is received by the Plan office, it becomes
effective and voids any previous designations.
The member may designate primary and contingent beneficiaries. If children are named, and they
are under 18 years of age at the time of the member's death, a custodial letter will be given to the
child's surviving natural parent, if the child lives with that parent. The benefit will then be paid in
installments of $500 per month.
If no natural parent survives, guardianship papers will be requested of the adult individual who has
custody of the infant beneficiary. The benefit will be paid to the guardian and will be subject to the
control of the court until the child/children are 18 years old.
If there are no living beneficiaries or if the member does not name any beneficiaries, the total
benefit will be paid according to the rules and regulations of the Plan.
(Please refer to the Application for Death Benefits at the end of this manual).
Accidental Death And Dismemberment Benefit
If the member dies as a result of an accident*, an additional benefit of $10,000 (full-time) or
$6,000 (part-time) will be paid to the beneficiary(ies) as an Accidental Death Benefit. In order to
be covered for this benefit, the death must occur within 90 days from the date of the accident and
be a result of injuries sustained in that accident.
If the member loses a limb (hand or foot) or the sight of an eye as a result of an accident, he/she
will receive a Dismemberment or Loss of Sight Benefit of $5,000 full-time) or $3,000 (part-time)
for each lost limb or eye - but no more than a total of $10,000 (full-time) or $6,000 (part-time) will
be paid under this benefit.
33
The loss of limb or eye must be the result of an accident; not a disease, act of war, or injuries
received during the commission of a crime, not intentionally self-inflicted, or occurring during the
course of employment and not due to the use of alcohol or drugs.
*There are exceptions based on the rules and regulations of the Plan.
Extended Death Benefit
This benefit is available to an employee/member who is forced to leave employment because
he/she becomes totally disabled and is under age 55. In order to be eligible for this benefit, the
member must meet the following conditions:






the member received the maximum disability benefit provided by the Plan; and
the member is under age 55; and
the member remains disabled; and
the member is uninsurable and unemployable; and
the member is not receiving a pension from a current Employer; and
the member qualified for Social Security Disability benefits.
If the member meets all of the above qualifications, his/her beneficiaries will be entitled to receive
the Death Benefit that was in effect at the time the disability benefits were exhausted.
Coverage for this benefit ends when the member ceases to be disabled, retires, reaches age 55, or
the benefit is discontinued.
Expanded Death Benefit
This benefit is available to a member who is forced to leave employment because he/she becomes
totally disabled and is age 55 or over. In order to be eligible for this benefit the member must meet
the following conditions:






the member received the maximum disability benefit provided by the Plan; and
the member is 55 or older; and
the member remains disabled; and,
the member is uninsurable and unemployable; and
the member is not receiving a pension from a current Employer; and
the member qualifies for Social Security Disability benefits.
If the member meets all of the above qualifications, his/her beneficiaries will be entitled to receive
an Expanded Death Benefit of $1,500.
34
Coverage for this benefit ends three years after the member first met all of the above conditions, or
the benefit is discontinued.
Enhanced Expanded Death Benefit
If an eligible member with 10 years of continuous employment qualifies for an Expanded Death
Benefit and is over 55 and under 62, he/she will be eligible for a $5,000 Death Benefit. All other
components of the benefit remain in place.
35
SURVIVOR'S BENEFIT
Upon the death of a covered member the spouse and eligible dependents can continue to utilize the
Plan benefits available to the covered dependents for a period of twelve months measured from the
member’s date of death at no cost to the eligible dependent.
A surviving spouse and eligible dependents has the option to continue these benefits by purchasing
them for up to an additional two years.
COBRA BENEFIT
The Consolidated Omnibus Budget Reconciliation Act (COBRA) gives workers and their families
who lose their health benefits the right to purchase group health insurance and other health-related
benefits provided by their employer for limited periods of time under certain circumstances such
as: voluntary or involuntary job loss, reduction in the hours worked, transition between jobs, death,
divorce, and other life events.
Under COBRA, the member has the right to purchase continuation coverage with respect to the
Plan’s health-related benefits (e.g. dental, vision, and prescription drug coverage). The maximum
benefit period is between 18-36 months.
In the case of a loss of coverage due to the end of employment or reduction in hours of
employment, coverage will be continued for up to a total of 18 months. In the case of loss of
coverage due to an employee’s death, divorce or legal separation or a dependent child ceasing to be
a dependent under the terms of the Plan, coverage may be continued for up to a total of 36 months.
You will be required to pay 102% of the cost of coverage during this period.
36
PODIATRY BENEFIT
This benefit is provided to the member/retiree only and can be utilized only at the Podiatry Centers.
The benefit includes:
 Podiatry examination including x-rays for diagnostic purposes;
 Routine foot care including the removal of corns, ingrown toenails, calluses and
warts.
 Orthopedic care of structural problems including casting, strapping and the fitting of
orthotics. (The laboratory fees associated with orthotics fabrication and adjustment
are not covered).
 General podiatric medical care including the treatment of infections, dermatitis and
inflammatory disorders. Injections may be administered if needed.
If the member's basic health insurance provides reimbursement for podiatry services, the member
will be required to sign an authorization form allowing Podiatry Options, P.C. to file a claim with
the member’s insurance carrier.
Appointments must be scheduled in advance at the Podiatry Centers located at:
 115 Chambers Street (Manhattan); call: 212-766-4455
 186 Joralemon Street (Brooklyn); call: 718-625-2544
The Podiatrist will determine the frequency of visits; however, no more than six (6) visits may be
scheduled per year.
Podiatry benefits are not available to Non-Pensionable Former School Crossing
Guards.
37
AUDIOLOGY BENEFIT
The Audiology Benefit is provided to the member/retiree only and only at the Health Center
located at 115 Chambers Street, New York, (212) 791-2126. All services are provided by licensed,
certified audiologists.
The Audiology Benefit includes a comprehensive audiologic evaluation that determines the type
and degree of the hearing loss which is outlined as an audiogram. If the evaluation confirms a
hearing deficiency, the member will be given the audiogram and report to be taken to an Ear, Nose
and Throat Specialist for either medical treatment or medical hearing aid clearance.
The member must apply directly to his/her basic health insurance carrier for reimbursement of the
Specialist's fee; it is not covered by the Audiology Benefit.
After seeing the ENT doctor and obtaining medical clearance for hearing aids, the member will be
seen for a hearing aid evaluation. At that time, the Audiologist will review the types of hearing
aids available to fit the member’s hearing loss. If the member chooses basic digital hearing aids,
he/she will receive a right and left hearing aid at no charge. More advanced digital technology is
available at a cost to the member. He/she would pay the Union’s cost less $300. This amount is
payable by check or money order at the dispensing appointment.
The member will return for a hearing aid dispensing. The hearing aids will be programmed and
dispensed to the member with a 45 day trial period. The member is seen during the trial period for
any adjustment necessary to ensure good benefit from the hearing aids.
The Health & Security Plan will provide a maximum of two (2) basic hearing aids (left and right
ear) within a three year period at no cost to the member.
Replacement batteries are not provided, unless otherwise indicated.
Oral rehabilitation is not provided by the Plan.
If the member's basic health insurance provides reimbursement for audiology services, the member
will be required to complete a claim form for the Plan to be reimbursed.
Appointments must be scheduled in advance at the Audiology Center. Call (212) 791-2126 to
make an appointment.
The Audiology Benefit is not available to the Non-pensionable Former School Crossing
Guards.
PERSONAL SERVICES UNIT
38
When You Have A Problem:
Call the Personal Service Unit: 212-815-1260
a.
b.
Phone-In Hours: Monday-Friday - 9:00 A.M. -1:00 P.M.
Walk-In Hours: Monday-Friday - 9:00 A.M.-12:00 Noon
Screening Team is staffed by 4 social workers who are there to respond to requests for assistance.
If they are busy providing services to other Union members, their telephones will be answered by
an answering machine which will advise the caller that all the lines are busy. The member may
have to call a number of times before getting a social worker due to the large volume of calls
coming into the Unit.
What to Expect
Talking to a Social Worker: The member should be prepared to give a brief description of his/her
problem, letting the social worker know who referred him/her to PSU and if the problem is job
related. The social worker will then ask the member a number of questions relating to his/her job,
family and income. This information is for the purpose of planning services for the membership.
All contact with the personal service unit is confidential and no information will be
shared with anyone outside the office unless written permission is given to us to do so.
 The number of Social Workers in Screening varies and Graduate Interns are only
available 3 days per week.
How To Best Utilize The Personal Services Unit
1.
Job Related: If the problem is job related and has resulted in some form of disciplinary
action, a scheduled intake appointment will be arranged for the member to come in to talk
to a social worker who will work with him/her to help solve the problem. There may be a
one to three week wait for such an appointment.
2.
Substance Abuse: If the member has a substance abuse problem, a scheduled chemical
dependency appointment is assigned to the member. At the intake appointment, the Social
Worker does a complete chemical dependency history and will refer the member to the
appropriate level of care.
The Personal Services Unit maintains close relationships with hospitals and community
based programs in order to assure the quality of services provided to our membership.
39
3.
Individual & Family Problems: The social work staff maintains a list of quality,
low cost mental health services within the community. If a member calls with a non-job
related problem, the screening social worker will work with him/her until he/she gets
connected to a community service.
4.
Financial Problems: The Personal Services Unit has limited resources for members
who are experiencing financial problems and we may refer him/her to a food pantry when
indicated, or an agency that provides Budget and Credit Counseling Services.
5.
Housing: The Personal Services Unit does not have the resources to help members
obtain housing in New York City.
6.
Short-Term Counseling: In some instances, the screener may determine that a certain
problem or crisis may be resolved by short-term counseling. An intake appointment is
assigned and the member is seen for six to eight sessions to help resolve the problem.
Outreach Program
Members calling the Screening Unit may be connected to the Outreach Program, a
component of the Personal Service Unit, if they need help for the following types of
situations:
For members out of work on Short-Term Disability
For members planning to retire, newly retired or those expecting difficulty in retirement
For working members who are caring for other family members who are aged and /or ill
Outreach volunteers provide supportive phone counseling to the above members and
retirees. All volunteer groups are supervised by PSU and Social Workers. There are
periodic groups provided by the Outreach Program, such as the Pre-Retirement Seminar
and the Caregiver Support Group.
HEALTH & PENSION SERVICES UNIT
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The Health and Pension Services Unit answers inquiries and resolves problems pertaining
to the various health insurance plans under the City’s Health Benefit Program; the
various pension tiers and Med Team health insurance benefits.
Health Insurance
The Unit assists members in resolving health related matters resulting from the rejection
of claims; problems with balance billing and reimbursement issues with providers;
incorrect payroll deductions; eligibility and enrollment; and interpreting Explanation of
Benefit (EOB) statements.
In addition, the Unit explains the various health insurance benefits and any benefit
modification/adjustments under the City Health Benefits Program; optional rider
coverage (if applicable); coverage upon retirement and the process to retire; and
Medicare.
For assistance with a health insurance-related matter, please call the Unit at:
212-815-1200 or visit us in Room 314.
Pension
The Unit assists members with inquiries and resolves problems relating to three pension
plans – New York City Employees’ Retirement System (NYCERS), Board of Education
Retirement System (BERS), and Teachers Retirement system (TRS).
The Unit provides pension counseling by appointment. Here, the member can receive an
estimate of their pension allowance; an explanation of the different pension options; and
a guide to retiring, which includes information on the necessary documents needed prior
to retirement. They are also given information on the Health & Security Plan benefits that
will be available to them after retirement.
An appointment for pension counseling should be scheduled three to six months before
the planned retirement date.
For assistance with a pension-related or health insurance matter, please call the Unit at:
212-815-1200 or visit us in Room 314.
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DC 37 MED-TEAM (AVAILABLE TO DC 37 MEMBERS ONLY)
DC 37 Med-Team is a City health insurance plan available only to DC 37 members. The
Unit assists members in resolving DC 37 Med-Team health insurance-related problems
resulting from the rejection of claims; problems with balance billing and reimbursement
issues with providers; incorrect payroll deductions; termination of health insurance
coverage; eligibility and enrollment; and interpreting Explanation of Benefit (EOB)
statements.
In addition, the Unit explains the benefits of the DC 37 Med-Team health insurance plan,
benefit changes, Medicare, and how to continue coverage after retiring or when coverage
is terminated temporarily or permanently.
ANNUITY
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The DC 37 Annuity Fund Plan is a defined contribution employees’ pension plan. It is
funded by employer contributions made pursuant to collective bargaining agreements
between DC 37 and agencies and subdivisions of the City of New York and other
governmental entities.
For some of the members this is only a one-time contribution negotiated as part of the
1995-2000 contracts. Some titles have negotiated recurring contributions added to the
Fund. This Fund is not connected to the member’s pensions, retirement or any other
annuity plan.
A percentage based on the amount in the individual’s account balance is deducted each
member’s earnings each year for Administrative Fees.
There will be gains or losses each year based on the investment earnings performance.
(stocks, bonds, etc.)
The member must retire or leave city employment to get a check for the money in the
account. If he/she still works for the City or an affiliated agency and leaves a DC37 title,
he/she can roll it over to another covered city Annuity Fund but cannot withdraw the
monies and close the account.
The Year End Statements are processed and mailed from Amalgamated Bank and
duplicates cannot be issued until notified by the Annuity department.
Rollovers By Non-Spouse Beneficiaries
Effective October 1, 2007, a non-spouse beneficiary of a participant or former participant
who is entitled to receive a distribution from the Annuity Fund Plan may elect to have the
distribution rolled over to an individual retirement account or to an individual retirement
annuity. Prior to this change, a non-spouse beneficiary could not roll over a distribution
from the Annuity Fund Plan.
If the non-spouse beneficiary elects a roll- over of the distribution, the distribution would
be made in a direct transfer from the Annuity Fund Plan to the individual retirement
account or individual retirement annuity. This rollover option is not available if the
distribution is valued at $200 or less.
Rollovers by Participants, Former Participants, Spouses and Former
Spouses
Participants, former participants, spouses and former spouses now have an additional
option regarding rollover of distributions. Effetive December 31, 2007, participants,
former participants, spouses and former spouses may elect to roll over a distribution to a
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Roth IRA. If a roll-over of the distribution is elected, the distribution would be made in
a direct transfer from the Annuity Fund Plan to the Roth IRA. This rollover option is not
available if the distribution is valued at $200 or less.
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INQUIRY UNIT
The Health and Security Plan's Inquiry Unit is the first line of communication between members
and the Plan. Benefits are provided for over 150,000 members and retirees.
The Inquiry Unit receives between 1,500 and 2,000 calls each day from members asking about
benefits, claims, forms and other related information. Unfortunately, the lines are extremely busy
and at times it may be difficult to get through.
The Inquiry Unit is open from Monday to Thursday 8am to 6pm, Friday 8am to 5:30pm. The lines
are busiest on Mondays and Tuesdays. Help us, help you by calling the right number. To request
claim forms only (dental forms, fee schedules, participating providers, optical vouchers, etc.)
please call the Forms Only line at 212-815-1531. If you are calling to check eligibility for benefits,
the status of claims such as dental or disability or other benefit information, please call the Plan's
Inquiry line at 212-815-1234.
The Inquiry and Forms lines, the Health & Pension Unit, Annuity and the Municipal Employees
Legal Services Screening Unit are all part of the Call Management System. Please listen carefully
to the choices when you call the Plan.
The following information is needed when you call the Plan:
1.
2.
3.
4.
PID or Social Security Number
Member /dependent’s name
Type of claim - claim number if available
Approximate date of filing claim or correspondence
Occasionally a question cannot be answered immediately. Many calls require investigation and the
involvement of other units. In these instances, an inquiry may need to be written and sent to the
claims unit for further research and follow up with the member.
In addition to the heavy volume of telephone calls, the Inquiry Unit responds to a steady flow of
correspondence being sent in by both active and retired members.
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LEGAL SERVICES BENEFIT
The Municipal Employees Legal Services (MELS) is a program of personal legal services for
active members, retirees and their eligible dependents.
The program utilizes a staff of lawyers and supporting staff to service its members. Professional
staff advises, counsel and represent members on covered matters. The lawyers are licensed to
practice in New York. They work full-time for MELS, and are not permitted to have an outside
law practice.
Because legal problems are often closely linked to personal and financial concerns, the staff also
includes social workers to help clients with such concerns.
What kind of Legal Matters are Included?
MELS helps with many kinds of problems as listed below:
MELS will advise, represent and prepare legal documents as needed, in the following matters:
 Preparation of wills, health care proxies, living wills, durable powers of attorney
 Debt matters, including bankruptcy-amount in dispute must be over $500
 Disputes with sellers of goods and services if the amount in dispute is over $500 and not within
small claims jurisdiction
 Citizenship
 Correction of inaccurate credit reports
 Billing disputes with utilities (gas, electric, phone)
 Landlord actions that could result in your eviction
 Entitlements from government agencies, like Social Security, food stamps, etc.
 Public school suspensions, primary and secondary
 Divorce, separation and annulment
 Defense in a civil law suit against you if you have no legal representation under insurance
policies-amount of suit must be over $500
 Review by a lawyer of a legal document related to any of the above matters
 Representation is not available for defense of tort claims, such as libel, slander and personal
injury caused by negligence; however, a limited reimbursement is made for fees paid to private
attorneys.
 Support matters are limited to advice only
 Buying or selling a one-family house, co-op or condominium if it is your primary residence
 Buying your two-family house if it is your primary residence
 Disputes over custody, visitation and paternity of children
 Representation where you are the parent in a child abuse, neglect, or foster care case
(representation of foster parents is limited to those having had custody of the child for more
than 24 months)
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 Orders of protection in case of spouse abuse and other domestic violence (representation will
not include cases brought in Criminal Court)
 Adoption
 Name Change
 Guardianship of a minor child
Social Work Services
If you have a personal problem related to a covered legal problem, you can talk it over with a
MELS Social Worker if you wish. Ask your lawyer for a referral when you come in for an
appointment.
Where MELS Services Are Available
The legal services benefit covers only members/retirees living in New York State within 50
miles of the plan office. A lawyer will represent you in five counties of New York city,
Westchester, Nassau, Western Suffolk and Rockland Counties.
The geographic area covered by MELS is limited to the following zip codes:
New York City
Brooklyn-112
Bronx-104
Queens-110, 111, 113, 114
Manhattan-100, 101, 102
Staten Island-103
New York State
Nassau County-110, 115, 116, 117, 118
Suffolk County-117 except 11719, 11764, 11778, 11789, 11792
Westchester County-105, 106, 107, 108
Rockland County-109
How to See a lawyer
To see a lawyer, you will need an appointment. Call (212-815-1111).
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