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PENNSYLVANIA FACULTY |
P.O. Box 60430
Harrisburg, Pennsylvania 17106-0430 |
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| HEALTH AND WELFARE FUND |
Telephone: (717) 233-4776 |
PART-TIME FACULTY
Preventive Care Benefit Package Claim Form
Print or Clearly Type |
| Faculty Member: |
______________________________________________________ |
| Birth Date: |
______________________________________________________ |
| Social Security Number: |
______________________________________________________ |
| Spouses' Member: |
______________________________________________________ |
| Birth Date: |
______________________________________________________ |
| Social Security Number: |
______________________________________________________ |
| Mailing Address: |
______________________________________________________ |
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______________________________________________________ |
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______________________________________________________ |
I am applying for reimbursement for:
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_______ Member
_______ Spouse |
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I have appended detailed receipts for:
Vision Examination: $
Wellness Examination:
Mammography Examination:
Dental Expenses:
Total $ |
Amount
_______________
_______________
_______________
_______________
_______________ |
I understand that benefits provided to Part-Time Faculty and their eligible spouses are to be paid only after all other group insurance plans have made payment. I certify that my spouse and I have not received or submitted for payment for any benefits for which I am applying for reimbursement that has not been disclosed to the Pennsylvania Faculty Health and Welfare Fund. In no case shall benefits be paid in excess of actual charges taken together with other payments for which I may qualify. I understand that reimbursement will be paid to me only after completing this claim form in full, attaching detailed receipts and signing below as indicated (see page 2 for eligibility requirements and benefits description).
By: ___________________________________ Date: ______________________
Faculty Member Signature
Append detailed claim receipts and copies of payments from any other group insurance plan for which your spouse and you qualify for reimbursement. It is your responsibility to obtain payment from all other group insurance plans before submitting benefit claims to the Pennsylvania Health and Welfare Fund for consideration. |
| ELIGIBILITY REQUIREMENTS AND BENEFIT DESCRIPTION |
Part-time Faculty shall be defined as any member of the APSCUF bargaining unit who works less than 100% of full-time in any academic year beginning the 1993-94 academic year. Benefit claims will be reimbursed for services rendered on and after January 1, 1994.
Part-time Faculty in order to qualify for benefit reimbursement, must have worked at least 25% of full-time in any one (1) of the preceding three (3) semesters. The benefit package shall be provided after the initial waiting period of one (1) semester is served, and thereafter, so long as benefit claims are incurred while part-time Faculty are employed by the State System of Higher Education.
The initial eligibility waiting period of one (1) semester shall only be served once by part-time Faculty who work continuously for at least one (1) semester each academic year.
Part-time Faculty who work 25% to 49% of full-time are eligible for member only benefits. Part-time Faculty who work 50% to 99% of full-time are eligible for member benefit AND their lawful spouses are also eligible for benefits.
The Part-Time Faculty Preventive Care Benefit Package includes reimbursement for the following services:
1. A vision examination one every two (2) calendar years. The Fund will reimburse up to $65.00 for vision examinations.
2. A wellness examination once every two (2) calendar years. The Fund will reimburse up to $125.00 for wellness examinations.
3. A mammography examination once every two (2) calendar years. The Fund will reimburse up to $100 for mammography examinations.
4. Dental services will be reimbursed according to a schedule of dental services. These services include yearly examinations, X-rays, reimbursement of dental cleanings and restorative services.
Part-Time Faculty must properly complete and submit claims for reimbursement on the Pennsylvania Faculty Health and Welfare Funds claim form designed especially for Part-Time Faculty. Claim filing procedures and other requirements for obtaining reimbursement are those in current use by the Fund. BEFORE any claim is reimbursed, Part-Time Faculty must certify that they meet the Fund's eligibility criteria for Part-Time Faculty and that all benefit claims were actually incurred during the semester(s) employed by the State System of Higher Education as Part-Time Faculty. DETAILED RECEIPTS ARE REQUIRED WHEN FILING FOR REIMBURSEMENT.
NO PAYMENT WILL BE MADE BY THE FUND FOR BENEFIT SERVICES RENDERED ON DATES PART-TIME FACULTY ARE OTHERWISE INELIGIBLE FOR THE PLAN OF BENEFITS.
The Part-Time Faculty Preventive Care Benefit Package is a supplemental benefit plan. It should be regarded under all circumstances as a "third-payor plan." This plan of benefits shall coordinate payment, to the extent possible, with Faculty and spouses' primary and secondary health care plans.
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