These questions and answers are provided as an outline of the health benefits (medical, dental, vision, and prescription drug) and supplemental benefits (life insurance, long- and short-term disability) provided for participants in the New York State Nurses Association Benefits Fund. Participants may call the Fund office toll-free at (877) RN BENEFITS [762-3633] for any additional information regarding the benefits covered under your plan, proper procedures, claims, and eligibility. You also may e-mail the Fund at benefit@rnbenefits.org. For even more detailed information, click here to view our most recent Summary Plan Description.

General Questions

How do I add a new dependent?

Answer:
You have 60 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, marriage, adoption, and placement for adoption. If notification is not received within 60 days of the event, the dependent will need to wait until the next open enrollment period (between November 1 and December 31) to be eligible for coverage with the Fund with an effective date of January 1 of the following year.

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 and certified copy of guardianship appointment for your legal ward.

Who qualifies as a Benefits Fund covered dependent?

Answer:
Eligibility for dependents varies, according to their age and relationship to you:

  • Your spouse is eligible for medical, dental, vision, and prescription drug benefits through the Benefits Fund.
  • Your children, stepchildren, foster children, and legal wards also are eligible for medical, dental, vision, and prescription drug benefits from birth until their 26th birthday.
  • Dependent children living with you while awaiting your legal adoption are eligible for these benefits until their 26th birthday.

How do I know which Benefits Fund plan I have?

Answer:
The fastest way is to check on Pages 11-12 of your Summary Plan Description. There you'll find a list of hospitals, plan numbers, and eligibility dates. However, please reference your NYSNA contract for the most updated information.

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

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

Answer:
Federal 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. New York's state continuation benefit extends that period an additional 18 months for medical only.

An RN's spouse and dependents who lose eligibility can receive federal COBRA continuation coverage (medical, vision, prescription drug, and dental benefits) for up to 18 months, followed by another 18 months of New York state continuation coverage (medical only) if needed.

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.

Are my children covered under my plan or my spouse's?

Answer:
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.  

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

Answer:
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.  

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

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

I lost my ID card. What should I do?

Answer:
Call the Benefits Fund at (877) RN BENEFITS [762-3633] to get a new one. If you need to see a Oxford provider before the new one arrives, he or she can call the Benefits Fund to verify that you're a participant. You and each covered family member should have an individual ID card from Oxford.

What's the difference between a copayment and coinsurance?

Answer:
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 Oxford (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 Oxford (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.

Medical Questions

How do I find an in-network medical care provider?

Answer:
Thanks to two helpful Web sites, finding a participating service provider is as easy as clicking a few buttons and navigating a mouse!

If you live in the Oxford service area (NYC and LI, CT, NJ, and Dutchess, Orange, Westchester, Rockland, and Ulster Counties) a list of in-network medical providers can be found on the Oxford Web site, www.oxhp.com.

If you live outside of the Oxford service area, you should go to www.uhc.com to find a UnitedHealthcare Choice Plus provider. Select “Find a Doctor” then search by Zip code or location. Don't forget to choose "Choice Plus Network."

It's always a good idea to ask your doctor if he/she participates with your insurance plan when you're scheduling an appointment.

You also can locate a provider by calling the Benefits Fund at (877) RN BENEFITS [762-3633]. 

Oxford's UnitedHealth Premium designation program was designed to provide additional information to participants looking to make the most informed choices about where they receive medical care. The program evaluates and recognizes doctors who meet national industry standards for quality and local market benchmarks for cost efficiency. For help finding a UnitedHealth Premium doctor, go online to www.oxfordhealth.com or call the Benefits Fund at (877) RN BENEFITS [762-3633].

Do I need a referral to see a medical specialist?

Answer:
No. As a Benefits Fund participant in the Oxford Freedom Plan, you have unrestricted access to in- and out-of-network specialists.

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

Answer:
When an out-of-network claim is denied by Oxford, 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 180 days of the notification.

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

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

How long will it take for me to receive my out-of-network claims reimbursement from Oxford?

Answer:
It generally takes 12 business days from the day Oxford 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.

Who's responsible for getting any necessary preauthorizations?

Answer:
Oxford contracts with the following vendors for preauthorization of certain medical services:

  • United Behavioral Health - mental health 
  • OrthoNet - orthopedic services
  • eviCore - radiology and radiation services
  • Optum HealthCare Solutions - chiropractic, physical therapy, and occupational therapy.

When you see an in-network provider, he takes care of contacting Oxford for preauthorization, which should take no longer than 48 hours, excluding weekends.

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

All out-of-network outpatient procedures needing preauthorization require that you, not your provider, obtain preauthorization. If you're planning an inpatient procedure with an out-of-network provider, you may want to ask your provider if he will call for preauthorization. If he won't make the arrangements, call the toll-free preauthorization phone number at (800) 666-1353.

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

Vision Care Questions

Do my vision benefits cover laser eye surgery?

Answer:
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 at www.davisvision.com.

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

Answer:
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.

How do I find an in-network provider?

Answer:
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.  

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

Answer:
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.

Dental Questions

How do I locate an Aetna provider?

Answer:
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.

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

Answer:
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.

How often can I have my teeth cleaned each year?

Answer:
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.

Prescription Drug Questions

Where can I fill my prescription?

Answer:
Most major pharmacy retailers participate with Express Scripts (ESI), including CVS Pharmacy, Duane Reade, Walgreens, and Rite Aid Pharmacy, in addition to an extensive selection of independent pharmacies. Go to www.express-scripts.com to search for a participating pharmacy closest to you. ESI will allow for an initial 34-day supply of medication and one refill at a retail pharmacy. Maintenance medications taken for chronic conditions are dispensed in 90-day supplies either from ESI's mail service pharmacy and mailed directly to your home or you may fill these prescriptions through Walgreens, Duane Reade, and select Rite Aid retail pharmacies only. (Visit www.express-scripts.com, click on "Prescriptions," then "Find a Pharmacy" for a list of Smart90 pharmacies.)

How can I get a replacement for my Express Scripts prescription identification card?

Answer:
Participants can order new prescription drug ID cards by contacting the Benefits Fund office between 8:30 am and 4:30 pm Monday through Friday at (877) RN BENEFITS [762-3633] or calling Express Scripts at (855) 521-0777. You may also print a copy of your ESI identification card by registering online at ESI's Website, www.express-scripts.com, and going to the "Forms & Cards" page of the site under the "Benefits" tab on the main menu.

What happens if I fill my prescription at an out-of-network retail pharmacy?

Answer:
If you fill a monthly (up to 34-day) supply of medication at a pharmacy that doesn't participate with Express Scripts, you will most likely need to pay the cost upfront and will be reimbursed at the average wholesale cost minus the applicable in-network copay. Click here for an Express Scripts direct member reimbursement form or go to the Forms page on this Web site.

Do I have to pay for my prescription drugs?

Answer:
Benefits Fund participants may have copays for prescription medications as part of your prescription drug benefit provided through Express Scripts. The program is a three-tiered formulary design with different pricing for generic drugs (Tier 1), preferred brand drugs (Tier 2), and non-preferred brand drugs (Tier 3). No deductibles apply. Participants will pay anywhere from $0 to $40 depending on your plan and the specific drug ordered. Click here for detailed information regarding drug copays for your plan.

I heard there's a Mandatory Generic program in place. What does that mean?

Answer:
The mandatory generic program targets the 60 percent of brand-name drugs that have direct generic equivalents, including drugs labeled "dispense as written." If you choose to fill a brand-name drug that has a direct generic equivalent available, you'll be required to pay the brand-name copay plus the cost difference between the brand-name drug and the generic drug. If there isn't a direct generic equivalent for the brand-name drug you've been prescribed, in most cases you'll pay the Tier 2 preferred drug copay.

How does the High Performance Step Therapy program work?

Answer:
This plan encourages participant use of generic drugs and the most cost-effective brand-name drugs within certain classes of prescription drugs before all other brands are covered. For more information, please contact a participant service representative here at the Benefits Fund office by calling (877) RN BENEFITS [762-3633].

Supplemental Benefits Questions

Does the Benefits Fund offer Paid Family Leave coverage during my pregnancy?

Answer:
No. New York State Paid Family Leave, offered through the Benefits Fund, is not available for prenatal conditions. It may be used for bonding after the birth of your baby. For more information regarding NYS PFL and Federal Family Medical Leave, please click here.

How does my long-term disability benefit work?

Answer:
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. Click here for a long-term disability form. 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.

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

Answer:
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 66 2/3 percent of regular compensation up to a maximum of $215 per week for a maximum of 26 weeks within a 52-week period. Click here 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.

What is my life insurance benefit?

Answer:
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.