Healthcare Benefits for National Benefit Fund Members
For Care in New York City, Long Island and Westchester
- Access to more than 30,000 Benefit Fund providers
- 21,000 providers affiliated with our network hospitals
- Mental and behavioral health coverage
For Care Outside New York City
- Choose providers from the Benefit Fund or the Aetna Choice POS II.
- All Aetna Signature providers accept the Benefit Fund’s payment for most services.
- No referrals and no out-of-pocket costs or deductibles for covered services.
Are you a National Benefit Fund retiree? See healthcare for retirees.
Your Benefits
Medical Benefit
Access to more than 30,000 Benefit Fund providers throughout New York City, Westchester and Long Island.
Mental and Behavioral Health
Comprehensive support through talk therapy, inpatient and outpatient treatment programs and coordinated care.
Prescription Benefit
Full prescription coverage with no co-payments when you use preferred drugs where available.
Dental Benefit
A choice of two plans—EmblemHealth or Aetna DMO—providing basic care, including cleanings, exams and restorative services.
Vision Benefit
Eye exams and glasses or contact lenses every two years.
Life Insurance
Life insurance benefit based on Wage Class.
Keeping Your Coverage
COBRA Continuation Coverage
COBRA allows you to extend your health benefits when your Benefit Fund coverage ends due to a “qualifying event.”
Disability
This benefit provides a financial cushion if you are temporarily unable to work due to non-work-related accidents, injury or illness.
Paid Family Leave
New York State’s Paid Family Leave (PFL) benefit is administered at no cost to NBF members.
Workers' Compensation
Provided through your employer, this benefit provides health and wage benefits if you are injured or become ill at work.
Benefits Overview
Overview of Wage Class I and II Benefits
Wage Classes
Wage Class I: Full-time or part-time members who earn 100% of the minimum full-time wage
Wage Class II: Part-time members who earn at least 60%, but less than 100%, of the minimum full-time wage
Hospital Care
You must call 1199SEIU CareReview at (800) 227-9360 before going to the hospital, or within two business days of an Emergency admission.
Inpatient Hospital Care
- This benefit is for the hospital’s charge for the use of its facility only. Coverage for services rendered by doctors, labs, radiologists or other services that are billed separately by these providers may be covered, as described in Section II.H of your Summary Plan Description (SPD).
- Up to 365 days per year
- Semi-private room and board
- Acute care for medically necessary services
- Inpatient admissions
- Up to 30 days per year for inpatient physical rehabilitation in an acute care facility
- Benefits are not provided for care in a sub-acute nursing home or skilled nursing facility
Outpatient Hospital Care
- Ambulatory care
- Observation care and services
Hospice Care
You must call 1199SEIU CareReview at (800) 227-9360 for Prior Authorization of inpatient hospice care.
- Coverage for a combined total of up to 210 days per lifetime in a Medicare-certified hospice program in a hospice center, hospital, skilled nursing facility, or at home.
Emergency Department Visits
Call the Benefit Fund at (646) 473-9200 for more information.
- This benefit is for the hospital’s charge for the use of its facility only. Coverage for services rendered by doctors, labs, radiologists or other services that are billed separately by these providers may be covered, as described in Section II.H.
- Use of the Emergency Department must be for a legitimate medical emergency within 72 hours of an accident, injury, or the onset of a sudden and serious illness
- Observation care and services
- Benefit Fund pays negotiated rate at Participating Hospital or reasonable charge at Non-participating Hospital
Programs for Mental and Behavioral Health
You must call 1199SEIU CareReview at (800) 227-9360 to Pre-certify inpatient care.
You must call the Benefit Fund at (646) 473-6868 to Pre-certify PHP and IOP services.
Mental Health
- Outpatient care
- Intensive Outpatient Programs (IOP)
- Inpatient care
- Partial Hospitalization Programs (PHP)
Alcohol/Substance Abuse
Surgery
You must call 1199SEIU CareReview at (800) 227-9360 before having non-Emergency surgery.
Call the Benefit Fund at (646) 473-9200 to make sure your surgeon is a Participating Provider.
- Inpatient or outpatient (ambulatory) surgery
- Benefits based on the Fund’s allowance for the surgical procedure
- Participating Surgeons bill the Benefit Fund directly and accept the Fund’s payment as payment in full
Anesthesia
Call the Benefit Fund at (646) 473-9200 to make sure your anesthesiologist is a Participating Provider
- Benefits based on the Fund’s Schedule of Allowances
Maternity Care
Call the Wellness Department at (646) 473-8962 to register for the Prenatal Program.
Call the Benefit Fund at (646) 473-9200 for information about breast pump options.
- An allowance which includes all prenatal and postnatal visits and delivery charges
- Hospital Benefit for the mother and newborn, if the mother is you or your spouse
- Disability Benefit for you, if you are the mother
- Lactation consulting by a certified provider
- Breast pump
Medical Services
- Treatment in a doctor’s office, clinic, hospital, Emergency Department or your home
- Well-child care for dependent children
- Immunizations
- Acupuncture: up to 25 visits per year, when performed by a licensed medical physician or licensed acupuncturist
- Allergy: up to 20 visits per year, including up to two testing visits
- Chiropractic: up to 12 visits per year
- Dermatology: up to 20 visits per year
- Physical/Occupational/Speech therapy: up to 25 visits per discipline per year
- Podiatry: up to 15 visits per year for routine foot care
- X-rays and laboratory tests
- Durable medical equipment and appliances
- Hospice care
- Ambulance services
- Participating Providers bill the Benefit Fund directly and accept the Fund’s payment as payment in full
Telehealth Visits
Call the Benefit Fund at (646) 473-9200 for information on how to access the Fund’s telehealth provider.
- Through telehealth, you can have an office visit by phone or video with your own Participating Provider or with the Benefit Fund’s telehealth provider, who can diagnose, recommend treatment and prescribe medication for many of your medical or mental health needs.
- If your doctor is unavailable, use the Benefit Fund’s telehealth provider for on-demand non-Emergency visits by phone or video (available 24 hours a day, 7 days a week), with doctors and pediatricians licensed in your state.
- If you prefer to access a licensed mental health professional through the Benefit Fund’s telehealth provider, you can schedule a phone or video appointment (available 7 days a week), and choose from a variety of board-certified counselors, therapists, psychologists and psychiatrists. You must be age 18 or older to use this benefit.
Services Requiring Prior Authorization
You must call the Prior Authorization Department at (646) 473-9200 for Prior Authorization of services, except Emergency ambulance and the services listed below.
You must call eviCore healthcare at (888) 910-1199 for Prior Authorization of radiological tests, molecular and genomic testing, radiation therapy and medical oncology services.
Call One Call Care Management at (800) 398-8999 for a referral to a preferred radiology facility.
You must call 1199SEIU CareReview at (800) 227-9360 for Prior Authorization of inpatient hospice care, ambulatory surgery or inpatient admissions.
You must call CareContinuum at (877) 273-2122 for Prior Authorization of certain infusion drugs administered on an outpatient basis.
- Home health care
- Long-term acute care hospital services
- Hospital transfer ambulance services
- Durable medical equipment and appliances
- Medical supplies
- Cellular and gene therapy
- Specific medications, including specialty drugs
- MRI, MRA, PET and CAT scans, and certain nuclear cardiology tests
- Molecular, genomic and other diagnostic laboratory tests
- Radiation therapy and medical oncology services
- Hospice care
- Ambulatory surgery or inpatient admissions
- Certain mental health and alcohol/substance abuse services
- Certain infusion drugs administered on an outpatient basis
Vision Care
Call the Benefit Fund at (646) 473-9200 for a referral to a Participating Provider
- One eye exam every two years
- One pair of eyeglasses every two years; In lieu of eyeglasses, one order of contact lenses every two years
- No out-of-pocket costs when using a Participating Provider for lenses and frames included in the Benefit Fund’s vision program
Hearing Aids
Call the Benefit Fund at (646) 473-9200 for a referral to a Participating Provider.
- Once every three years
- Co-payments may apply when using Participating Providers
Dental Benefits
Call the Benefit Fund at (646) 473-9200 for a referral to a Participating Provider.
- Coverage through a Plan Network for basic and preventive services, major restorative care and orthodontia treatment
- Annual benefit limits or network restrictions may apply
- Network Dentists bill the Benefit Fund’s Plan Network Administrator directly and accept the Network Administrator’s Schedule of Allowances as payment in full for Covered Services
- For certain upgrades and materials, co-payments may apply
Prescription Drugs
Call Express Scripts at (800) 818-6720 for more information.
- Coverage of FDA-approved prescription medications for FDA-approved indications, except Plan exclusions
- No co-payments when you use Preferred Drugs where available
- Use Participating Pharmacies
- Use The 1199SEIU 90-Day Rx Solution (Mandatory Maintenance Drug Access Program) for chronic conditions
- Comply with the Benefit Fund’s prescription drug programs, including Prior Authorization where required
- Up to 30 days per year for inpatient physical rehabilitation in an acute care facility
- Please refer to “What Is Not Covered” in Section II.L of your Summary Plan Description (SPD).
Life Insurance
Call the Benefit Fund at (646) 473-9200 for more information
- Wage Class I: During your first year of service, amount is $1,250. After your first year, benefit is based on your Wage Class and annual base pay up to a maximum amount of $50,000.
- Wage Class II: During your first year of service, amount is $1,250. After your first year, maximum amount is $2,500.
Disability
You must submit a Disability Claim Form to the Benefit Fund within 30 days of your accident, injury or the start of your illness. To get this form, or to make sure you are eligible before you stop working, call the Fund’s Member Services Department at (646) 473-9200.
- This benefit is a partial salary replacement. Coverage is only for accidents, injuries or illnesses that are not work-related.
- Amount is based on your Average Weekly Earnings or on statutory minimums
- Maximum weekly benefit is $385
- Maximum duration of 26 weeks leave within a 52-week period
- Your Benefit Fund coverage for all other benefits will continue while you are receiving Benefit Fund Disability Benefits
Paid Family Leave
Before you stop working, call the Benefit Fund’s Member Services Department at (646) 473-9200 to make sure you are eligible for benefits.
You must submit a Paid Family Leave Benefit Request Form to the Fund within 30 days of your qualifying event. To get this form, call (888) 447-9055 (toll-free), email [email protected] or visit the Paid Family Leave page.
- This benefit is a partial salary replacement. Your Benefit Fund coverage for all other benefits may continue while you are receiving Benefit Fund Paid Family Leave Benefits.
- Maximum weekly benefit is 67% of your average weekly earnings or the New York State average weekly wage, whichever is less.
- The length of time that you are eligible to receive benefits is based on verified need, up to a maximum of 12 weeks leave within a 52-week period.
Accidental Death and Dismemberment
Call the Benefit Fund at (646) 473-9200 for more information.
- For accidental death or dismemberment
- Equal to, or half of, your life insurance amount, depending on the loss suffered
Burial
Call the Benefit Fund at (646) 473-9200 for more information.
- If available, a free burial plot with permanent care or a $75 payment to your beneficiary
- Plots located in New York and New Jersey
Anne Shore Sleep-Away Camp Program
Call the Anne Shore Sleep-Away Camp Program at (212) 564-2220 for more information.
- For eligible children of Benefit Fund members (ages 9 to 15)
- Summer sleep-away camp program provided at no cost to you, except administrative fee
- FICA taxes and applicable withholdings paid for by the Benefit Fund (you will be responsible for taxable earnings)
Joseph Tauber Scholarship Program
Call the Joseph Tauber Scholarship Program at (646) 473-8999 for more information
- For eligible children of Benefit Fund members (age 22 or younger)
- Scholarships provided to attend accredited schools after high school
Social Services
Member Assistance Program (MAP)
Call MAP at (646) 473-6900 for more information.
- Help for personal and family problems
Citizenship Program
Call the Citizenship Program at (646) 473-8915 for more information.
- Assistance in applying for United States citizenship
Earned Income Tax Credit (EITC) Assistance Program
Call the EITC Assistance Program at (646) 473-9200 for more information.
- Tax preparation help
Financial Wellness and Homebuyer Education Program
Call the Financial Wellness and Homebuyer Education Program at (646) 473-9200 for more information.
- Help with home ownership, managing credit and financial wellness
Monday Night Legal Clinic
Call the Monday Night Legal Clinic at (646) 473-6488 for more information.
- Access to attorneys for free legal consultations regarding various personal legal matters
Weekly Workers’ Compensation Legal Clinic
Call the Weekly Workers’ Compensation Legal Clinic at (646) 473-6717 for more information.
- Assistance to members suffering from a work-related injury or illness