Who is Eligible? Employees, Retirees, and their Dependents may be eligible for coverage under this Plan. However, eligibility, participation, and contributions to the Plan are variable and depend upon the policy or your particular school district, their personnel policies and contractual agreements. For information on the specific eligibility requirements of your Employer, contact your school’s insurance clerk. 

Demonstrating Your Eligibility. The Plan requires that Employees submit appropriate official documentation of eligibility when enrolling themselves or their family members in the Plan. Coverage will not begin until documentation of eligibility (such as marriage or birth certificates, tax returns, etc.) has been submitted as requested by the Plan. 

Employees. An Employee is eligible for Plan benefits if he meets the following minimum requirements. He must be hired by a participating Employer for an anticipated period of at least 3 months; he must be working a regularly scheduled work week of at least 20 hours; and he must be paid an annual salary of at least $5,000.00. (Individual Employers may increase the anticipated employment eligibility requirement for up to six months. They may also require a work week of more than 20 hours to qualify for coverage, and they may set a higher minimum annual salary rate for eligibility. In addition, certain classes or categories of Employees may not be eligible for coverage. Check with your Employer to determine specific eligibility requirements.) 

Transfer of Employment between Participating Employers. If you transfer employment from one Employer participating in the Plan to another Employer participating in the Plan, you must reenroll with the new Employer within 30 days of the transfer, and there will be no lapses in your coverage. In addition, credit will be transferred from the old to the new Employer for any deductibles previously satisfied.  

Employment by Two or More Employers. If an individual is employed by two or more Employers who each participate in the Plan, the individual may elect coverage as an Employee with only one of them.  

Husband and Wife Employees. If both husband and wife each qualify as an Employee of a participating Employer, each may choose to be covered as an Employee under the Plan of their respective Employers, and each may elect family coverage, if desired. Some participating districts, however, may have limited eligibility for dual coverage through their collective bargaining agreement with employee unions. Please see your local school district’s insurance clerk for details on your school district’s policy. 

Employees on Active Military Duty. Employees going into or returning from active military service may elect to continue Plan coverage as mandated by the Uniformed Services Employment and Reemployment Rights Act and Article 4305(g) of the New York State Insurance Law. These rights apply only to Employees and their Dependents covered under the Plan immediately before leaving for service. Employees have 60 days from being ordered to active duty to elect continued coverage under this section or coverage will be suspended during the period of active duty. An Employee who elects to continue coverage during a period of active duty must pay the required group premium payment once monthly in advance.

If the Employee suspends coverage while on active duty, coverage under this Plan will continue when he or she returns to employment and will be retroactive to the date of termination of the period of active duty. The Employee must request continuation of this Plan’s coverage within 31 days of termination from active duty, or from discharge from hospital incident to such active duty (as long as the hospitalization continues for no longer than 12 months after discharge from active duty). No exclusionary or waiting period will be imposed in connection with the reinstatement of coverage under reemployment unless the condition arose during a period of active duty that has been determined by the secretary of veterans’ affairs to have been incurred in the line of duty. 

Employees on Approved Leaves of Absence. If an Employee goes on an approved leave of absence (without pay) for other than medical reasons, coverage for the Employee and his covered Dependent(s) may be continued for the duration of the approved leave, provided all required contributions are made by the Employee when due. (This provision applies only if approved as general policy for the Employee’s particular participating Employer.) If an Employee goes on an approved leave of absence (without pay) due to Total Disability for more than three months, coverage for the Employee and his covered Dependent(s) will be continued for the duration of the approved leave of absence, not to exceed one year. All required contributions must be made by the Employee when due.

 

Employees Involuntarily Terminated from Employment. If an Employee is terminated because of a service-connected disability retirement, coverage for the Employee and his covered Dependent(s) may be continued indefinitely, provided the Employee has completed the number of years of service required before the disability retirement, and provided he pays all required contributions when they are due.

If an Employee dies, and his death was due either to a work-related accident, or his death occurred after he completed at least 10 years of service, coverage for his covered Dependent(s) may be continued, provided that his former Employer continues to participate in the Plan. For the first three months after the Employee’s death, there will be no cost for continued coverage. Coverage will continue as long as the Dependent is eligible as long as the required contributions are made. Benefits will end if the Dependent ceases to qualify as an eligible Dependent for any reason other than lack of the deceased Employee’s principal support. (Once the Dependent becomes enrolled in the Plan as a result of survivorship, he or she may not add Dependents other than those who were eligible when the survivor first qualified for coverage.) 

Retirees. To be eligible for Plan enrollment, retired Employees of a participating school district must

have satisfied all requirements to collect an allowance/benefit from the applicable New York State

Employee’s or Teacher’s Retirement System, and they must pay any required contributions. In addition:

• A retired Employee (who was enrolled in the Plan immediately prior to retirement) may continue, at the option of the Employer, to be covered under the Plan as if an active Employee, until he becomes eligible for Medicare. If an Employer provides retiree coverage, the Employer may establish service requirements for its retired Employee’s eligibility.
• An Employee who does not maintain coverage under the OU Plan upon retirement may not re enroll in the Orange-Ulster Health Plan later.
• Retirees who are prohibited from participating in the Orange-Ulster School District’s Health Plan because of a non-duplication of coverage clause in their contractual agreement may enroll or re enroll if they lose coverage later under the plan that prevented them from participating in the OU Plan at retirement. In that case, the Retiree must enroll within 30 days of the loss of the other coverage. If there are reasonable circumstances that prevented the Retiree from enrolling within 30 days after losing his other coverage, the time for enrollment may be extended for up to one year, but no longer. In cases of legal incompetence, the one-year maximum time period for enrollment will begin after the incompetence ends. 

Vested Employees. A vested Employee is an ex-Employee who does not qualify as a Retiree, but was employed for a sufficient length of time to have satisfied the minimum requirements for vesting of retirement allowance/benefits. A vested Employee shall be considered to be a Retiree for the purpose of establishing eligibility to participate in the Plan, provided the Employee was covered under the Plan during the entire time he was in a vested status, and provided the Employee makes all required contributions during the period of vesting. (The Employer may require that the Employee be within five (5) years of retirement at the time he becomes vested.) 

Dependents. If an Employee has family coverage, the following members of his family may also be covered as Dependents:

(1) An Employee’s legal Spouse.

(2) An Employee’s children, step-children, adopted or pre-adoptive children, and eligible foster children (those who are placed with the employee by an authorized agency or order of a court of competent jurisdiction). Eligibility ends when the child reaches his or her 26th birthday. Until 2014, this option is only available if the dependent is not eligible for other employer-sponsored health plan coverage.

(3) Other children supported by the Employee or Spouse of the Employee who live in the Employee’s home may also be eligible under some circumstances; however, in the case of children who do not meet the definition of “child” under IRS152 (f)(1), and where no blood or legal relationship to the Employee or Spouse of the Employee exists, the support must be at least 50% to be eligible for coverage, and they are eligible only until the age of 19 (or 25 if they are full-time students).

(4) An unmarried Dependent child, regardless of age, who is incapable of self-sustaining employment because of physical handicap, mental retardation, mental illness, or developmental disability as defined in the New York Mental Hygiene Law, and who is eligible to be claimed as a dependent (“qualifying relative”) under IRS rules and regulations (which means the employee must provide more than half the dependent’s support). The condition must have occurred before the child reached the age at which coverage under the Plan would otherwise have terminated. The child’s disability must be certified by a physician within 31 days after he reaches the age at which coverage would have terminated in order for coverage to continue under the Plan. The Plan has the right to check whether a child is and continues to qualify under this paragraph.

To qualify for student coverage after a child’s 19th birthday, a child who does not meet the definition of child under IRS 152(f)(1), must be dependent on his parent(s) for support, and be enrolled as a full time student as determined by the institution, at an accredited institution of higher learning (post-secondary education). Proof of enrollment during each semester must be submitted to the Claims Administrator as requested in order to ensure continued coverage; otherwise benefits may be reduced or denied. Coverage will be continued during school vacation periods provided the child intends to resume full-time student status at the end of the vacation period. If a dependent student is granted a medical leave from school, coverage will continue for a maximum of 12 calendar months following the month in which the child withdraws from school, plus the time between the end of that period and the beginning of the next regular semester.

Time spent in military service, not to exceed four years, may be deducted from the Dependent’s age for the purpose of establishing eligibility for coverage.

A child who lives with an Employee on a temporary basis, such as an exchange student is not eligible for benefits. We have the right to request and be furnished with any proof we need to determine eligibility status of prospective Dependents as they pertain to eligibility under this Plan.

Young Adult Coverage to Age 30.

If an Employee has a child under the age of 30 who wishes to continue coverage under this plan with single coverage, this plan offers the Young Adult Option explained below. In order to qualify for this option, the Employee must be covered under this plan. In addition:

Requirements for the Young Adult to Enroll:

1. Be unmarried;

2. Be 29 years of age or under (up to 30th birthday);

Not be insured by or eligible for comprehensive (i.e. medical and hospital) health insurance

through his or her own employer;

4. Live, work or reside in New York State or the Plan’s service area; and

5. Not be covered under Medicare.

Note: The young adult is not required to live with the employee, be financially dependent on the employee, nor be a student to be eligible for this coverage.

Enrollment Dates for Coverage:

1. Loss of Coverage under the Plan. If the person is currently covered under the employee’s policy, he may enroll within 60 days of the date that coverage would otherwise end due to reaching the maximum age for dependent coverage. Coverage will be retroactive to the date that coverage would otherwise have terminated (similar to COBRA election period).

Note: Coverage will be retroactive only if elected within 60 days of the date the young adultwould otherwise age off a parent’s policy. In all other cases, coverage will be prospective and will start no more than 30 days from the date that the Plan receives notice of election and premium payment.

2. Changes in Circumstances. The person may enroll within 60 days of newly meeting the eligibility requirements because of a change in circumstance. Coverage will be prospective and will start within 30 days of when the Plan receives notice of the election and premium payment. Examples of changes in circumstances would be a young adult moving back to New York State after living outside the state or losing health insurance coverage sponsored by his own employer.

3. During an Annual 30-Day Open Enrollment Period. The Plan has an open enrollment period each year, during which the person can elect coverage if eligibility requirements are met. Coverage will be prospective and will start within 30 days of when the Plan receives notice of the election and premium payment.

4. During the Initial 12-Month Open Enrollment Period. There is an initial 12-month open enrollment period, which will begin July 31, 2010 during which adults can enroll if they meet the eligibility requirements. Coverage will be prospective and will start within 30 days of when the Plan receives notice of the election and premium payment.

Cost of Coverage. The young adult or his or her parent will be responsible for a separate premium for the young adult option (over and above what the parent pays for the group coverage). However, the cost will not exceed that which is charged for other single coverage.

Loss of Eligibility if Employee Loses Coverage. If the employee separates from his or her employer or group and is no longer eligible for health insurance, the young adult would also lose coverage. HOWEVER, if the employee elects COBRA, the adult remains eligible until COBRA is exhausted.

Dropping Coverage and Re-enrolling Later. If a young adult drops the coverage (perhaps because he obtains a job that has employer-sponsored coverage) and then loses that coverage (perhaps because he loses the job), he can sign up again as long as he meets the eligibility requirements.

When Does Coverage End? Coverage will end when one of the following occurs:

1. Coverage is terminated pursuant to the terms of the policy.

2. The employee is no longer enrolled in the Plan or receiving COBRA.

3. The young adult no longer meets the eligibility requirements.

4. The premium for coverage in not paid within a 30-day grace period.

5. The group insurance policy is terminated and not replaced.

Extended Plan Benefits. Plan benefits will be extended during a period of Total Disability caused by

injury, sickness or pregnancy, or for hospital confinements beginning (or surgery performed) during 31 days following termination of coverage. This extension of benefits is provided without cost to the disabled Covered Person only for treatment of the injury, sickness or pregnancy that that caused the disability. This extension of benefits for the specific cause of disability will be provided for up to 12 months subsequent to termination of coverage, unless coverage is available for the total disability under another group plan. 

When Coverage Begins.

Employees. A new Employee’s effective date of coverage is established by his Employer. Coverage may begin on the first day of employment or at a later date. Check with your Employer for his policy regarding effective dates of coverage under the Plan.

An Employee who waives coverage for himself and/or his Dependents when he is first eligible, or loses coverage for failure to pay required contributions, may elect coverage as a late enrollee. His benefits will begin on the first day of the month following enrollment, or on the first day of the month following the Employer’s waiting period, whichever is later. If the late enrollee is covered within 30 days prior to the late enrollment by another group health plan, coverage under this Plan will begin immediately.

Dependents (other than newborns). Employees may elect family (Dependent) coverage when (1) they acquire a Spouse or child who meets the definition of Dependent, or (2) they wish to enroll a previously eligible but un-enrolled Spouse or child who meets the definition of Dependent.

An Employee must apply for family coverage within 30 days after his coverage becomes effective, or the date he acquires a Dependent, in order for coverage to become effective on the first day of the month following application. Otherwise, family coverage will not begin until the first day of the third month following application. (In some cases, coverage may begin on the date of marriage, or the date the Employee acquires a Dependent child. Application for first day  coverage must be made in advance).

An unborn child will not be eligible for coverage as a Dependent until the date of the child’s birth. However, medical and/or surgical intervention of the unborn child to prevent or correct a congenital defect will be considered a maternity expense, as long as the maternity expenses related to that child are Covered Expenses under the Plan, and the treatment is not Experimental or Investigational as defined in the Plan. 

Newborn Coverage. If an Employee has family coverage, his newborn Dependent child will automatically become covered as a Dependent on the date of his birth. However, the newborn’s eligibility for coverage will terminate 30 days after birth unless the Claims Administrator has received enrollment materials by that date.

If the Employee does not have family coverage at the time of the infant’s birth, the infant will still be covered if the Employee elects Dependent medical coverage, effective as of the first day of the month in which the child was born, and he submits enrollment materials to your school district’s health plan representative, not later than 30 days after the birth. The contribution payment must be received by the Employer on or before the 30th day of the month following the month in which the birth occurs.

Newborn coverage will be provided to the same extent as it is for other covered Dependent children. The Plan pays Covered Expenses for Medically Necessary care and treatment of medically diagnosed congenital defects, birth abnormalities and prematurity, as well as Hospital charges for routine nursery care.

A newborn adopted child is covered from birth provided that the Employee takes physical custody of the child as soon as he is released from the Hospital after birth, and that the Employee files a petition for adoption (pursuant to the New York State Domestic Relations Law, Section 115-C) within 60 days of the infant’s birth. In addition, coverage will be provided only if no notice of revocation of the adoption has been filed and only if consent to the adoption has not been revoked. In no instance will the Plan pay for the adopted infant’s Hospital stay if either of the biological parents has medical coverage available for the infant. 

When Coverage Ends.

Employees. Coverage as an Employee under this Plan ends on the date the Plan terminates, or at 11:59:59 p.m. on the last day of the month in which the first of the following events occurs (except as provided in any extension of coverage provision):

(1) The day of the month in which your employment ceases; or

(2) The day your status as an eligible Employee ends; or

(3) The last day of the month immediately preceding the month in which you, or your

Employer on your behalf, made any required contribution*; or

(4) The day your Employer stops participating in the Plan or otherwise terminates

your coverage; or

(5) The day you enter the armed forces of any country, except as otherwise required by Section 4317 of the Uniformed Services Employment and Reemployment Rights Act (USERRA) (membership in the reserves is not deemed entry into the armed forces).

*For example, if your employer’s contribution is due July 15, and the employer fails to make the July payment, your insurance is cancelled retroactive to June 30th. 

Dependents. Coverage as a Dependent ends on the day the Plan terminates or at 11:59:59 p.m. on the last day of the month in which the first of the following events occurs (except as provided in any extension of coverage provision):

(1) The day the Employee’s coverage under the Plan ends; or

(2) The day the Employee ceases to be in a class of Employees eligible for

Dependent coverage; or

(3) The last day of the month immediately preceding the month in which the Employee, or the Employer on behalf of the Employee and covered Dependent, made any required contribution*; or

(4) The day Dependent coverage is canceled; or

(5) The day you no longer qualify as a Dependent (or student Dependent) under the

Plan; or

(6) The day you enter the armed forces of any country, except as otherwise required by Section 4317 of the Uniformed Services Employment and Reemployment Rights Act (USERRA) (membership in the reserves is not deemed entry into the armed forces); or

(6) The date of the Employee’s death.

*For example, if your employer’s contribution is due July 15, and the employer fails to make the July payment, your insurance is cancelled retroactive to June 30th. 

Retirees. Coverage for Retirees and their Dependents ends when the first of the following events occurs (except as provided in any extension of coverage provision):

(1) The Retiree or the former Employer fails to timely pay the applicable cost of the Retiree’s coverage; or

(2) The Plan terminates; or

(3) The Dependent coverage terminates under the Plan; or

(4) The Retiree dies.

 

Enrollment in the OU Plan. Enrollment in the OU Plan is not automatic. You are required to enroll yourself and your Dependents, and advise the Plan when you have changes that affect enrollment. You may enroll for individual or for family coverage if you have eligible Dependents. If certain changes occur that affect your current enrollment, it’s your responsibility to notify the Plan of enrollment changes; for example, you must notify the Plan of the following:

1. Adding a newly acquired Spouse or Dependent child;

2. Adding an existing Spouse previously enrolled as an Employee or Retiree;

3. Adding a previously eligible but unenrolled Spouse or Dependent child;

4. Changing from individual to family coverage any time you acquire or elect to

enroll a previously eligible Spouse or Dependent child;

5. Changing from family to individual coverage when you no longer have or wish to

cover eligible Dependents;

6. Changing, adding, or removing a Dependent from family coverage; or

7. Reporting other group plan(s) and Medicare coverage information and changes. 

Open Enrollment Period. You and your eligible Dependents may also enroll in the Plan during the Plan’s “open enrollment” period that takes place each year between October 1st and December 31st. If you enter during the open enrollment period, you will not be considered late enrollees, and your coverage will begin the following January 1st