Please click on one of the questions below:

General questions
4How do I know which Benefits Fund plan I have?
4I lost my ID card. What should I do?
4My husband and I are covered by two different health plans. Which plan is considered primary?
4Under which plan are my children covered?
4Who qualifies as a Benefits Fund covered dependent?
4How do I add a new dependent?
4I'm raising my grandchildren. Are they covered by the Benefits Fund?
4How long is my college student dependent covered?
4How long are benefits covered under COBRA, and when do I have to start paying?
4What's the difference between a copayment and coinsurance?

Medical care questions
4How do I find an in-network provider?
4Do I need a referral to see a specialist?
4How are usual, customary, and reasonable charges determined for out-of-network benefits?
4How long will it take to receive my out-of-network claims reimbursement from Health Net?
4What do I do if my out-of-network reimbursement is sent to my doctor instead of me?
4Who's responsible for getting prior authorization?
4How long do I have to appeal a denied out-of-network claim?

Vision care questions
4How can I find an in-network vision care provider?
4Why don't our vision care benefits cover the entire cost of new pair of glasses?
4My optometrist recommends an eye examination every year, but the Fund covers only one every two years. Why?
4Do my vision benefits cover laser eye surgery?

Dental care questions
4How often can I have my teeth cleaned each year?
4How do I locate an Aetna provider?

Supplemental benefits questions
4How do I qualify and file for short-term disability?
4How does my long-term disability benefit work?
4What is my life insurance benefit?

General questions

Q: How do I know which Benefits Fund plan I have?

A: The fastest way is to check on Pages 5 - 7 of your Summary Plan Description. There you'll find a list of hospitals, plan numbers, and eligibility dates. Your NYSNA contract also includes this information.

If you can't find either of these two items, call the Benefits Fund at (877) RN BENEFITS [762-3633].

Q: I lost my ID card. What should I do?

A: Call the Benefits Fund at (877) RN BENEFITS [762-3633] to get a new one. If you need to see a Health Net provider before the new one arrives, he or she can call the Benefits Fund to verify that you're a participant.

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Q: My husband and I are covered by two different health plans. Which plan is considered primary?

A: The Benefits Fund follows New York State Insurance Department rules for determining primary and secondary carriers. You are primary under the Benefits Fund and secondary under your husband's health plan, if he has one provided by his employer.

Your husband is primary under his health plan and secondary under the Benefits Fund.

Q: Under which plan are my children covered?

A: Your children are primary under the health plan covering the parent whose birthday falls first in the year and secondary under the other parent's plan.

Stepchildren and children of divorced or separated parents are primary under the health plan covering the custodial parent, unless specified otherwise. The plan of the custodial parent's spouse is secondary.

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Q: Who qualifies as a Benefits Fund covered dependent?

A: Dependents include your spouse; unmarried children from birth through age 19; unmarried, full-time students between the ages of 19 and the end of the year they turn 23; unmarried children who are disabled and unable to earn their own living; stepchildren under your custody; dependent children who live with you pending legal adoption by you; your legal wards; your same-sex domestic partner; and dependent children of your same-sex domestic partner.

Q: How do I add a new dependent?

A: You have 30 days from the date of any event that would add a new dependent to your Benefits Fund coverage to notify the Fund. Events include birth, adoption, and marriage.

The Fund requires a copy of your child's birth certificate to add your child; adoption papers to add your adopted child; marriage license to add your spouse; a copy of the ward's birth certificate, proof of residency (student ID, driver's license, tax return, or letter from the ward's school), and certified copy of guardianship appointment for your legal ward; and an affidavit of domestic partnership for your same-sex domestic partner. If the Fund has a signed disability claim stating that you are pregnant or have delivered, a copy of the birth certificate isn't necessary, but you still need to notify the Benefits Fund of the child's name and birth date within 30 days of the delivery.

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Q: I'm raising my grandchildren. Are they covered by the Benefits Fund?

A: Unless you have legally adopted your grandchildren, they cannot be covered under the Benefits Fund's health plans.

There are resources, however, for people in your situation. The Children's Health Insurance Program is a joint effort by federal and state governments to provide physical exams, immunizations, lab tests, outpatient surgery, emergency care, dental care, and vision care for children who don't fall under Medicaid guidelines or are in low- to medium-income families.

For information about CHIP, call (800) 698-4 KIDS or visit Family Health Plus in New York; (800) 701-0710 or visit NJ Family Care in New Jersey; (877) CT-HUSKY or visit Husky in Connecticut; and (800) 986-KIDS or visit the Pennsylvania Insurance Department in Pennsylvania. 

Q: How long is my college student dependent covered?

A: Your college student dependent is covered until the end of the year he turns 23, as long as he is unmarried and a full-time student (taking at least 12 credit hours or four academic courses per semester).

The Benefits Fund must receive a mailed letter from the school registrar by September 1 and January 1 each year stating that your child is enrolled as a full-time student for the coming semester.

Once he ceases to be a full-time student or reaches the end of his 23rd year, he is eligible for COBRA continuation coverage for 36 months.

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Q: How long are benefits covered under COBRA, and when do I have to start paying?

A: COBRA continuation coverage provides 18 months of medical, vision, prescription drug, and dental care benefits for RNs whose coverage ends due to a reduction in hours or termination of employment. An RN's spouse and dependents who lose eligibility can receive COBRA for up to 36 months. Former full-time students also are eligible for 36 months of COBRA continuation coverage. Life insurance and disability insurance are not included. You can choose COBRA for yourself, your spouse, and/or your eligible dependents.

Your initial premium must be received within 45 days of the date you elect COBRA, and be paid on a timely, monthly basis thereafter.

For more information about COBRA, click here.

Q: What's the difference between a copayment and coinsurance?

A: Simply put, a copayment is the amount you pay for in-network services, while coinsurance is what you pay for out-of-network benefits.

A copayment is the maximum amount you owe for in-network services. You should not be charged any additional fees for covered services performed by an in-network provider.

Coinsurance, however, is your required percentage of the usual, customary, and reasonable charges that are not payable by Health Net (medical) or, in the case of Aetna (dental), usual and prevailing charges, for out-of-network services. This percentage typically is 20 percent to 50 percent, with Health Net (or Aetna) paying the remaining 50 percent to 80 percent of the UCR (or UP) after you meet any deductible. Any amount above the UCR or UP is the participant's or dependent's responsibility.

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Medical care questions

Q: How do I find an in-network provider?

A: A list of in-network providers can be found on the Health Net Web site  by selecting "Search Our Doctor Network," or by calling Health Net's Directory By Phone at (800) 686-9847. You also can locate a provider by calling the Benefits Fund at (877) RN BENEFITS [762-3633].

Q: Do I need a referral to see a specialist?

A: No. As a Benefits Fund participant in the Health Net Charter Point of Service Plan, you have unrestricted access to in- and out-of-network specialists.

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Q: How are usual, customary, and reasonable charges determined for out-of-network medical benefits?

A: Health Net, the Fund's medical services provider, determines usual, customary, and reasonable charges for out-of-network medical services based on a fee schedule established by the Health Insurance Association of America within a particular geographical location. Health Net uses that figure, or the amount charged, whichever is less.

Q: How long will it take for me to receive my out-of-network claims reimbursement from Health Net?

A: It generally takes 12 business days from the day Health Net receives the claim until it's processed and a reimbursement is issued. The time frame may vary depending on the complexity and completeness of the claim form. Incomplete forms and a lack of itemized bills slow claims processing.

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Q: What do I do if my out-of-network reimbursement is sent to my doctor instead of to me?

A: You can get your money back by calling your provider and asking for a reimbursement or credit to your account.

Q: Who's responsible for getting prior authorization?

A: When you see an in-network provider, he takes care of contacting Health Net for prior authorization, which should take no longer than 48 hours, excluding weekends.

When you see an out-of-network provider, you need prior authorization for all inpatient hospitalizations and certain out-of-network elective surgical, diagnostic, and therapeutic procedures.

If your provider is out-of-network, ask if he'll obtain prior authorization for you. If he won't make the arrangements, call the toll-free prior authorization phone number at (888) 747-8080. Have your doctor's name and phone number and the procedure code on hand. The call must be made at least seven business days before the procedure and within two days of an emergency admission.

Failure to obtain prior authorization for inpatient hospital stays and elective procedures will reduce your out-of-network benefits for medically necessary procedures by 50 percent or $500, whichever is less.

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Q: How long do I have to appeal a denied out-of-network claim?

A: When an out-of-network claim is denied by Health Net, you are sent a notification letter or an explanation of benefits that explains under which plan provision the claim is denied. If, after reading the explanation, you disagree with the determination, you must file an appeal within six months of the notification. Detailed information on the appeals process is available in Chapter Seven of the NYSNA Benefits Fund Summary Plan Description.

Vision care questions

Q: How can I find an in-network vision care provider?

A: You can find a vision care provider in the Davis Vision network one of three ways:

Call the Benefits Fund at (877) RN BENEFITS [762-3633}, Davis Vision at (800) 999-5431, or logon to www.davisvision.com.

Q: Why don't our vision care benefits cover the entire cost of a new pair of glasses?

A: In order to provide a vision care benefit that is economical for the Benefits Fund and its participants, the Fund's Board of Trustees chose a plan that promotes cost-sharing for in-network benefits through Davis Vision. For a $10 copayment, you and your dependents can have a routine eye exam every two years (every year for children up to age 18) and a complete pair of eyeglasses or contact lenses every two years for a low copay. All ranges of prescriptions are covered.

If you see an out-of-network provider, services are reimbursed up to a $75 maximum allowance every two years. Click here for more information on your routine vision care benefit.

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Q: My optometrist recommends an eye examination every year, but the Fund covers only one every two years. Why?

A: Although the American Optometric Association recommends a preschool eye exam for children age 3 and then every two years until age 60, optometrists and opticians vary in their recommendations. The Benefits Fund covers in-network eye exams every year for children until age 18. In- and out-of-network eye exams are covered every two years for those over age 18.

Q: Do my vision benefits cover laser eye surgery?

A: Laser eye surgery for vision correction is not covered under your Davis Vision or medical benefits plan because it is considered a cosmetic procedure. You, your spouse and your eligible dependents can receive the lesser of: up to a 25 percent discount, or a 5 percent discount on an advertised special on laser vision correction at an in-network Davis Vision provider. To locate a laser vision correction provider in the Davis Vision network, call the Benefits Fund at (877) RN BENEFITS or logon to the Davis Vision Web site.

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Dental care questions

Q: How often can I have my teeth cleaned each year?

A: Twice-a-year cleanings at an Aetna in-network dental care provider are covered in full (you pay nothing). Any additional cleanings are not covered. If you have twice a year cleanings at an out-of-network provider, you'll pay 20 percent of the usual and prevailing allowance after satisfying your deductible, plus any amount over the UP.

Q: How do I locate an Aetna provider?

A: Call the Benefits Fund at (877) RN BENEFITS [762-3633] or search Aetna's online provider directory at www.aetna.com and selecting the Dental PPO option.

Q: How are usual and prevailing charges determined for out-of-network benefits? 

A: Aetna, your dental care provider, determines usual and prevailing charges for out-of-network dental services based on a fee schedule established by the Health Insurance Association of America within a particular geographical location. Aetna uses that figure and internal data to determine usual and prevailing charges.

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Supplemental benefits questions

Q: How do I qualify and file for short-term disability?

A: You're entitled to short-term disability benefits if you become totally disabled due to a nonoccupational accidental injury, illness, or pregnancy while covered by the Benefits Fund. You must be under the care of an appropriate licensed medical care provider, have worked for your employer for at least four weeks, and send the Fund written notice of your claim within 30 days of the event that caused your disability. Benefit payments begin when you have reached the first day of accidental injury disability, the eighth calendar day of sickness, or after your doctor disables you due to pregnancy. Benefits are payable at the weekly rate of 66²/3 percent of regular compensation up to a maximum of $215 per week for a maximum of 26 weeks within a 52-week period.

Follow the link to obtain a short-term disability claim form, or you may be able to get one from your employer or by calling the Fund at (877) RN BENEFITS [762-3633]. You fill out Part A, ask your physician to complete Part B, and have your employer fill out Part C. When the form is complete, mail it to the Benefits Fund at PO Box 12430, Albany, NY 12212-2430.

Click here for more information about your short-term disability benefit.

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Q: How does my long-term disability benefit work?

A: You're eligible for the Benefits Fund's long-term disability benefit if you become totally disabled by an accidental injury, sickness, or pregnancy while covered by the Fund. You must complete a qualifying period of six consecutive months; file for and receive a determination of benefits from the Social Security Administration; and be under the regular care of a licensed medical professional.

You will be considered totally disabled if you are completely and continuously unable to perform each and every duty required in your employment. This requirement will apply for the first two years of disability. After two years, you must be unable to perform any work for compensation or profit for which you are, or may become, reasonably fitted by training, education, or experience. You are not totally disabled during any period in which you  perform any work for compensation or profit.

The monthly benefit while totally disabled is 50 percent of your monthly base compensation, up to a maximum of $350 per month. Since the Fund's long-term disability benefit is offset by Social Security and other mandated or group disability policies, you cannot collect both at the same time. However, if you have a private disability policy, it is not affected by your Benefits Fund long-term disability.

You're responsible for completing a long-term disability form in full and submitting it to the Benefits Fund. Forms also are available by calling the Benefits Fund at (877) RN BENEFITS. Complete the participant and employer portions first; then give it to the attending physician. Please type or print clearly, and date and sign it before sending the completed form to the Fund office for processing.

Click here for more information about your long-term disability benefit.

Q: What is my life insurance benefit?

A: The life insurance benefit provided to each participant is computed by taking 150 percent of your base annual compensation, up to a maximum of $50,000. This benefit amount is reduced by 35 percent when your reach age 65 and by 50 percent at age 70.You may name one or more beneficiaries. You must submit a notarized letter to the Benefits Fund if you wish to change your beneficiary designation.

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