Frequently Asked Questions
Below are some answers to some
common questions we encounter. As always, if you need more information
feel free to contact us.
The CSEA Employee Benefit Fund is a Trust
Fund managed by a Board of Trustees comprised of CSEA members and
chaired by CSEA President Danny Donohue. Since its inception in 1979,
the Fund's mission is to provide the best possible benefits and an Ever
Better Future to our members. To facilitate this mission, the Fund's
Benefit Specialists attend Membership Meetings, Information Days, Health
Fairs, Conferences and Workshops to assist our membership at their place
of work, while our Customer Service Department is open weekdays 7:30
a.m. to 5:00 p.m. to help with claim inquiries or questions. Our union
staffed offices are located at One Lear Jet Lane, Latham, New York.
The EBF is
committed to protecting the personal medical information it collects
from its members during the regular course of business. To download a
No. Your union dues do not pay for your dental and vision
benefits with the CSEA Employee Benefit Fund. These benefits are
negotiated on your behalf with your employer and provided pursuant to
the CSEA contract.
employers have negotiated for EBF benefits in their collective
After your employer informs the EBF that you are eligible for EBF benefits, a "Welcome Aboard" package is sent to you with an enrollment form which must be fully completed and returned to the EBF. Eligible employees may also use the "Enroll Online" button on the home page to complete the form. A direct link is located here.
After the form is processed an EBF Member ID Card is sent with your EBF ID Number. This number is different than your CSEA ID Number. When you have the EBF ID number you can call and schedule an appointment with a participating provider. Participating providers can be located using the "Provider Search" button on the home page. A direct link is located here.
Participating providers agree to accept EBF payments for covered services as full payment for most services.
The best way to determine the amount of
benefits you have used is to save, review and tally your Explanation of
Benefits (EOB) statements. Each time a claim is processed for you, the
EBF sends you a statement that shows what services were submitted by the
provider and the amount of benefit that was paid on those services. If
you are having extensive work done, or are being treated by more than
one provider, it is important to know what treatment you have had done
that has not yet been processed and reflected in the EOB. You may also
call an EBF Customer Service Representative at 1-800-323-2732 and
request the amount of benefits that have been paid out to date.
Please remember that the information provided by the EBF will
only reflect information available in our claims system as of the time
of your call. Our records would not take into account work that has
been done that has not yet been submitted to the EBF for processing. It
is the member's responsibility to be aware of the treatment that has
been provided. If the treatment that you require totals an amount that
is over your annual maximum, you are responsible for paying the
difference to your provider.
The CSEA EBF accepts the American Dental Association (ADA) claim form. This claim form should be available at your provider's office. Providers should be advised that the EBF also accepts electronic claims from Change Healthcare, Tesia, and DentalXChange clearinghouse. Our payor number is CX054. In addition, CSEA EBF dental claim forms are also available for download at: CSEA EBF Dental Claim Form
The EBF accepts electronic claims from Change Healthcare, Tesia, and DentalXChange clearinghouse. Our payor number is CX054.
If you reside
outside of New York State, please use the following guidelines for
submitting dental or vision claims to the Fund for reimbursement. Dental
Dental coverage does
not require use of a participating dentist. When using a
non-participating dentist, services will be reimbursed based upon your
dental plan fee schedule. The dentist has the right to bill the
difference between his/her charges and the fee schedule. The Fund
provides a list of providers outside of New York State who accept our
dental plan fee schedule as payment in full for services covered in the
plan. A printed list of participating providers is available by calling
1-800-323-2732 or by visiting our Provider Search Utility. When
searching for dental providers on our website, choose "Dental" from the
Provider Type. Choose "Out of State" from the Region pull-down menu. In
the County box, choose "All Counties". When the search is performed all
dental providers outside of New York State will be listed. Completed
dental claims must be submitted on a universal ADA claim form. The claim
should include the patients name, address, EBF ID#, date of service,
service rendered, the ADA code for the procedure and the dentist's name,
address and license number. Claims can be submitted electronically or
mailed to the CSEA Employee Benefit Fund, P.O. Box 489, Latham, NY
vision care benefits provide you with fee scheduled reimbursement for
eye care services outside of New York State when a non-participating
provider is used. Call the Fund at 1-800-323-2732 or visit Download Forms
and select "Vision Care
Reimbursement Form" from the menu. You must have this form with you when
you have vision services provided. A signed, itemized receipt from the
provider must be attached to the claim form, along with the doctor's
signature. Vision care reimbursement forms can be mailed to CSEA
Employee Benefit Fund, P.O. Box 516, Latham, NY 12110-0516. Should you
have any questions regarding any of the above information, please
contact the Fund toll free from throughout the United States at
1-800-323-2732 and press 5 on the phone menu for a customer service
representative in the Member Services Department.
To change your address with the EBF,
please complete our online Change
of Address Form
OR call the Member Services Department directly at
1-800-323-2732 and press 5 on the phone menu to update your information.
To order a replacement ID
card, go here
. Enter the required
information and you can print your card right from the screen. You can
also select "Mail me the ID Card" to have a card mailed to you but
processing will take 5 to 7 days to arrive. There is no charge for
replacement ID cards and your number will not change.
State EBF Members: You are covered
for 28 days after the last day you worked. Unless you elect COBRA
option, your eligibility will be terminated after this 28 day period.
COBRA (Consolidated Omnibus Reconciliation Act of 1986) is a federal
regulation that gives you the right to continue benefits for a period of
36 months in an event of a member's retirement, termination, layoff,
leave without pay or reduction in hours. You will receive 36 months in
the event of divorce, legal separation or child losing dependency
status. You will receive 29 months if a member is permanently disabled.
Since you will no longer be working for the State to receive these
benefits for free, they are on a direct pay basis either monthly or
Local Government EBF Members: Local
Government units must check with their personnel department. Once our
system shows your termination date on our system you will receive a
COBRA application from us and you have 60 days to fill it out and mail
it back to us. Coverage terminates based on the termination date the
If you become ineligible for CSEA Employee
Benefit Fund coverage because of retirement, termination, layoff, leave
without pay or a reduction in hours, you may have certain rights to
continue Plan coverage through COBRA.
termination of a members employment status, the member is covered for
28 days after the last day worked. Unless a terminated employee elects
the COBRA option, the eligibility will be ended after this 28 day
period. COBRA refers to the Consolidated Omnibus Reconciliation Act of
1986, a federal regulation that gives you the right to continue
benefits for a period of 36 months in the event of a change in a
members employment status. In the event of the death of the member,
divorce, legal separation, or a child losing dependency status, a
dependent could receive up to 36 months of coverage. Because the member
is no longer working for New York State, the benefits must be paid
for by the employee on a direct pay basis, either monthly or
Once the EBF shows a members termination date
on our system, the member will receive a COBRA application and is
provided 60 days to file it with the EBF.
Local Government EBF Members
Please Note: There are separate provisions in your
CSEA contract agreement with regard to your eligibility for health
insurance. In relation to COBRA, the CSEA EBF administers only dental
and vision benefits.
members employed by local governments generally have the same
provisions applying to the continuation of benefits but should check
with their personnel department with regard to the 28 day continuation
period since many local governments have waived such
Local government members are eligible for
COBRA continuation for dental and vision if such coverage was available
to them during the course of their active employment.
Previously, if you were
married in a jurisdiction that allows same-sex marriage, you were able
to enroll your spouse in the CSEA EBF. That remains the same now. To
enroll your spouse, download the CSEA EBF enrollment form and complete
the applicable sections. When sending the form to us, please include a
copy of your marriage certificate as proof of the location you were
You should consult your tax advisor as to
how the benefits provided to your spouse will be treated for purposes of
Federal and New York State income tax.
EBF strives to provide quality benefits to eligible CSEA members and
their dependents. If the EBF determines that a CSEA member, or a
dependent of a CSEA member, receives a benefit for which he/she is not
eligible, the EBF contacts the member and requests that the member
reimburse the EBF for the amount of the improper benefit. If the member
fails to provide the requested reimbursement, the EBF reserves the right
to offset that amount which the member fails to reimburse against any
other payment which the member would otherwise be entitled to receive
from the EBF.
In the event that you become legally
separated (a) by living separate and apart from your spouse pursuant to
a written agreement of separation or (b) by the issuance of a decree of
legal separation, you may remove your spouse from coverage. A copy of
the fully signed and dated separation agreement or the separation decree
signed by the Court, whichever is applicable, must be provided to the
EBF in order to remove your spouse. If you become divorced, you are
required to notify the EBF within five business days of the date of the
divorce decree. Failure to notify the EBF of a divorce within such
five business day period may result in a collection against the member
(or suspension of a member's benefits) if an ex-spouse improperly
continues to use EBF benefits.
A name change can occur for different reasons.
If you have recently married and would like to update your name, please complete an EBF Enrollment Form.
If you have recently married and would like to add your spouse if you have family coverage, please complete an enrollment form and send in a copy of your marriage certificate.
The Enrollment Form is located here.
If you have recently divorced, please complete a Remove Dependent Form, update your last name, and attach a copy of the divorce decree. Only send the first page stating that the decree is a divorce as well as the signature pages.
The Remove Dependent Form is located here.
If you have legally changed your name for any other reason, please complete the EBF Enrollment Form and attach documentation from the court updating your name.
Yes. The EBF's dental plan has been reviewed by
accredited ACA experts and has been determined to be fully compliant
with the new health care reform provisions. The provisions that
specifically relate to the EBF are the pediatric dental requirements
affecting the claims of dependent children up to age 19. The EBF
has taken all of the required steps to be compliant with the new dental
requirements that took effect for cases initiated after January 1, 2014.
The CSEA EBF is fully compliant with the pediatric dental
requirements of the ACA.
The EBF has a guide for HBA's that will assist them and answer any questions they have regarding the EBF. The guide can be downloaded here
The EBF calculates the fair market value of benefit payments made for domestic partners or anyone that is not a dependent as defined by the Internal Revenue Service. This is also known as imputed income.
When a 1099 is applicable, the EBF makes this calculation in January for the previous year. It is sent by January 31st automatically to the address of the member on file.
You should consult your tax professional (accountant, tax service, tax software provider, etc.) for questions about the 1099 when working on filing your taxes.
If you go to a participating vision provider and select a
frame from your plan collection, you will have no out-of-pocket expense
for the cost of your frame. If you choose a frame that is
outside of your plan collection, you will be provided a $30 allowance
and you must pay the difference in the price to the participating
Members and eligible dependents who wish
to purchase lenses and coatings not currently covered by their vision
program are entitled to a set co-pay schedule. Please consult your
specific plan book for details.
Yes, we have a Retiree Dental Program available to retirees
who were previously covered by an EBF dental plan. Members meeting
eligibility criteria have a maximum of 90 days from their retirement
date or COBRA expiration to elect the EBF Retiree Dental Plan.
Participants pay a monthly fee. Participating dental providers accept
the Retiree Dental Plan as payment in full for covered services.
Yes. CSEA members who were covered by an EBF vision program and retire on or after June 1, 2016 may be eligible for participation. A separate Retiree Vision Memorandum of Agreement must be signed by the employer and in place on the date of retirement to access this program. Members meeting eligibility criteria have a maximum of 90 days from their retirement date to elect the Retiree Vision Program. A national provider network of over 10,000+ participate in the program. Participants pay a monthly fee for this program.
Co-Pay Reimbursements & Other Miscellaneous Benefits
Benefits other than vision and
dental, negotiated by an employer for its members.
Members whose employers have negotiated for these
Miscellaneous Benefits in their contract with CSEA EBF are eligible for
Please click on your
Prescription Drug Co-Pay - $150 per family, per calendar
year - Download Form
New York State Employees are not eligible for miscellaneous benefits.
Part-time Unified Court System employees are not eligible for miscellaneous benefits.
Prescription drug co-pay - $200 per family, per calendar
year - Download Form
Maternity - $200 per child - Download Form
Benefit - $1,000 annual benefit - see plan brochure for guidelines - Download Form
Aid Benefit - $450 per ear/3 years - Download Form
Prescription Drug Co-Pay - $100 per family, per calendar
year - Download Form
Prescription drug co-pay - $500 per
family, per calendar year - Download
Physician co-pay - $120 per family, per
calendar year - Download Form
Prescription drug co-pay - $500 per family, per calendar year - Download
Physician co-pay - $120 per family, per
calendar year - Download Form
Prescription drug co-pay - $250 per
family, per calendar year - Download
All of our forms can be downloaded through our "Download Forms" button located on the home page. Here is a direct link
. Due to the time sensitivity regarding the filing of claims please contact us at 800-323-2732 if you have any questions.
You should receive your payment within 4-6 weeks.
All prescription and physician co-pays
are due by March 31st of the following calendar year.
hearing aid, annual physical exam, maternity and legal claims are due by
December 31st of the following calendar year.
Contact your local pharmacy and/or mail order company and ask for a complete, itemized printout for yourself and all eligible dependents. The printout must contain the patient's name, prescription name and co-pay charged.
Contact your health insurance carrier and ask for EOB's for all eligible dependents or log into your online health insurance account and print the EOB's yourself. If you have CDPHP, please click here
for a step-by-step guide to printing your EOB's.
Dependent Coverage for a Child
The federal health care reform act required
employers and insurers to implement many changes in health care benefits
and eligibility for coverage. One provision of the Act permitted adult
children to remain on their parent's health plan until age 26. A
provision of New York state law extended that even further. Dental and
Vision benefits are not affected by the changes in the Federal Law. The
CSEA EBF plan provides coverage for dependent children from age 19 to
age 25 if the child remains in full time student status. The EBF
requires that current proof of student status be provided annually in
order to qualify for benefits.
Live Chat allows our members to
communicate directly with a trained CSEA EBF customer service
representative via the Live Chat button on our website. Due to the high
volume of online inquiries please try to keep your questions as concise
Live Chat can
answer basic questions about EBF dental and vision plans, send contact
links for our dental and vision books and forms. Live Chat can also send
links to other contact businesses such as Pearl Carroll & Associates and
other departments within CSEA.
Questions that require technical answers for
specific plan questions such as the balance left on a dental cap, the
status of a dental claim or predetermination, eligibility for specific
services under a Fund sponsored program or status of payment of the Rx
Co-pay Benefit cannot be answered by a Live Chat operator. Live Chat
cannot verify patient eligibility. Questions regarding insurance
coverage from other carriers such as Pearl Carroll or GHI cannot be
answered by Live Chat. Please contact the carrier directly.
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