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Summary of Material Modifications (SMM)

 


Effective July 1, 2014

 


Infertility Treatment General Plan Exclusion ALL PLANS

 


The following language will be added to the General Plan Exclusion that addresses infertility treatment, which is found in the General and Administrative Section of the Summary Plan Description:

 


Any services, testing or procedures (whether or not related to infertility treatment) on an embryo prior to its transfer to a mother’s uterus, including but not limited to a biopsy procedure, pre-implantation genetic testing, and/or pre-implantation genetic diagnosis (regardless of whether either parent has an inherited disease or is a documented carrier of a genetically-linked inheritable disease).”

 


Suspension and Disqualification of Benefits ALL PLANS

 


The filing of a false, inaccurate or misleading application for eligibility or claim for Benefits is a violation of the rules of the Fund and may result in all or part of the following:

 


     A. Denial of the claim;
     B. Member or dependent repayment, collection proceedings, deduction of the excess amounts from future claims, or litigation to recover Benefit

payments made to you or on your behalf to the extent permitted by law; and/or

 

     C. Penalties
        
· First violation - suspension of coverage under the Fund for a period of one year
            beginning on the date of a final determination that a false, inaccurate or misleading claim has been filed.
        
§ If the member agrees to enter into a repayment agreement with the Fund, the member’s coverage will be reinstated so long as the member            adheres to all of the terms of the agreement. The member’s failure to adhere to the terms of the repayment agreement will result in

           suspension of coverage and litigation.
        
· Second violation permanent disqualification from the Fund.

 

In addition to the above remedies, the Trustees may determine, in their sole and absolute discretion, any remedy it deems appropriate to the extent permitted by law.

 


Out-of-Network Inpatient Plan Language PLATINUM PLUS PLAN ONLY

 


Out-of-Network, Inpatient Benefits (i.e. Maternity/Birthing Centers, Maternity/Nursery, and Mental Health Care) are no longer subject to deductible.

 


Effective January 1, 2015

 


Out-of-Pocket Maximum BRONZE PLUS AND BRONZE ESSENTIAL PLANS ONLY

 


The Out-of-Pocket Maximums for both the Bronze Plus and Bronze Essential Plans have been reduced to $5,000 per person/$10,000 per family.

 


Effective July 1, 2015

 


School Injury Claims ALL PLANS

 


Because the Trustees have the authority to compromise and settle all matters in accordance  with the terms of its Declaration of Trust, the Trustees have granted the Fund’s Legal Department Director the authority to approve settlement of certain claims originating from injuries at Educational and Sports Facilities when both the facility insurance and the NOITU Insurance are both claiming Secondary status and the amount of all related claims in question do not exceed $1,500.

 


Effective December 8, 2015

 


Sexual/Erectile Dysfunction drugs ALL PRESCRIPTION DRUG PLANS.

 


There is a $350 monthly cap on payments related to Sexual/Erectile Dysfunction drugs. The Member will pay the full cost of the drug after the cap has been met.

 


Effective January 1, 2016

 


Five (5) Annual, In-Network Office Visits with NO Deductible; NO Co-pay; and NO Co-insurance
FOR ALL EMPLOYEES WHO FORMERLY HAD THE HRA CARD BENEFIT

 


The NOITU Insurance Trust Fund has replaced the HRA Benefit with the “5 office visit program”, which allows a member to receive Five (5) Annual, In-Network Office Visits with no deductible, no co-pay and no-co-insurance. The “5 office visit program” provides for primary care only and NOT for visits to a specialist (except when the office visit is provided by one of the following fields of specialty: Family Medicine, General Practice, Gynecology, Internal Medicine, Pediatrics and Podiatry).

 


Retail Purchases Refill Restrictions for Maintenance Drugs, Mail Order Services for Maintenance Drugs and Maintenance choice $7.50/$30/$50 PRESCRIPTION DRUG PLAN ONLY

 

Mail Order is optional for Maintenance Drugs and there is no penalty for a 30-day Maintenance Drugs retail refills.

 


Death Benefit

 


Base value Death Benefit will increase to $20,000 for eligible Full-Time Members.
Base value Death Benefit will increase to $7,500 for eligible Part-Time Members.
Base value Death Benefit will increase to $5,000 for eligible Direct Pay Members.

 


Effective June 14, 2016

 


Adaptive Behavioral Treatment for Autism Spectrum Disorder General Plan Exclusion ALL PLANS

 


The following language will be added to the General Plan Exclusion which is found in the General and
Administrative Section of the Summary Plan Description:

 


All assessment, observations and other related procedures associated with Adaptive Behavioral
Treatment (ABT) for Autism Spectrum Disorder (ASD). Therapy for learning disabilities, developmental
delays, Autism and/or treatment that is not restorative in nature.

 


Effective June 14, 2017

 


Authorized Representative
ALL PLANS

 


The following language will replace the “Authorized Representative” definition which is found in subsection 6.2 of the General and Administrative Section of the Summary Plan Description:

Authorized Representative

 

Except as expressly provided in the Plan, a Claimant may not transfer or assign, in whole or in part, in any manner or to any extent, to any person or entity any of his rights or interests under the Plan, including but not limited to, the right to: (i) receive Benefits or reimbursement or payment for Benefits under the Plan; (ii) initiate any legal proceeding (including an action under Section 502(a) of ERISA or an arbitration) against the Fund, the Trustees or any individual Trustee; (iii) seek statutory penalties under Section 502(c) of ERISA; or (iv) request information under Section 104(b) of ERISA.

 


Notwithstanding the preceding paragraph, a Claimant may designate a representative (including a treating health care professional) to act on his or her behalf to seek reimbursement or  payment with respect to a Benefit Claim under the Plan. If the Claimant satisfies the requirements set forth below, the representative shall be recognized as an “Authorized Representative” under the Plan. For purposes of these Claim procedures, a Claimant’s assignment of his Benefit Claim to a third party (e.g., to a health care professional) does not constitute an appointment of an Authorized Representative. An assignee can be designated to act as an Authorized Representative only if such person or entity is appointed as an Authorized Representative in accordance with the provisions below.

 


An Authorized Representative shall have the right to act for or on behalf of the Claimant to seek payment or reimbursement from the Trust Fund with respect to a Benefit Claim in any internal administrative claims and appeal process established under the Fund (i.e., filing a Benefit Claim with the plan administrator or an appeal with the Trustees). An Authorized Representative shall have no authority to act for or on behalf of a Claimant in any arbitration or judicial proceeding against the Trust Fund, the Trustees or any individual Trustee.

 


In order to appoint an Authorized Representative, a Claimant must complete and sign an approved “Appointment of Authorized Representative” form furnished by the Fund Office. The completed form must be submitted to:

 


NOITU Insurance Trust Fund
Member Services Department
148-06 Hillside Avenue
Jamaica, NY 11435-9977

 


The Trust Fund will not accept any Authorized Representative designation unless the appointment is made through an Appointment of Authorized Representative form furnished by the Trust Fund. A Claimant may terminate the appointment of an Authorized Representative at any time by so advising the Trust Fund in writing. The Claimant may then appoint another person or entity to serve as the Authorized Representative. A Claimant may only make one such appointment at a time. A Claimant who appoints an Authorized Representative to act on his behalf with respect to a Benefit Claim or appeal agrees to be bound by the actions of the Authorized Representative. An Authorized Representative cannot appoint another person or entity to act as the Claimant’s Authorized Representative.

 


The Trust Fund will rely on the duly signed and filed Authorized Representative form. Once an
Authorized Representative is appointed, the Trust Fund shall direct all information, notifications, etc., regarding the Benefit Claim to the Authorized Representative. The Claimant shall be copied on all correspondence regarding the Benefit Claim, unless the Claimant provides specific written direction otherwise.

 


Any reference in these Claims procedures to Claimant includes the Authorized Representative duly appointed by the Claimant under these Procedures.”

 

 

 

 

 

 

 

 

 

 

 

 



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