PEF Dental Plan
This dental plan provides benefits for most types of dental services. Your level of dental benefits is known as the GHI Preferred Dental Plan. This document is your Certificate of Insurance.
Who Is Eligible?
This section explains eligibility requirements for the GHI Preferred Dental Plan for you (the enrollee) and your dependents.
You; the enrollee
To be eligible for benefits you must work at least half time on a regularly scheduled basis. You must also be an employee of New York State whose position is represented by the Public Employees Federation (PEF).
The following dependents are eligible for coverage:
Your spouse, including a legally separated spouse, is eligible. If you are divorced or your marriage has been annulled, your former spouse is not eligible, even if a court orders you to maintain coverage. However, an ex-spouse may be eligible to purchase a contract under COBRA, as offered by your group. Please refer to the COBRA section of this certificate.
Domestic partner coverage
You may cover your same or opposite sex domestic partner as your dependent. A domestic partnership, for eligibility under the dental plan, is one in which you and your partner are 18 years of age or older, unmarried and not related in a way that would bar marriage. You must be living together, involved in a lifetime relationship and financially interdependent. To enroll a domestic partner, you must have been in the partnership for one year. Agency Health Benefits Administrators have complete information on eligibility, enrollment procedures and coverage dates.
Note on Tax Implications: Under the Internal Revenue Service (IRS) rules for domestic partners, the fair market value of dental insurance benefits is treated as income for tax purposes. Ask your tax consultant how enrolling your domestic partner will affect your taxes.
Note on Dual Coverages: If you and your spouse or domestic partner are both eligible, you and your spouse or domestic partner may be covered under the dental plan as an employee and as a dependent. Your eligible dependents may also be covered under both plans.
Your child under age 19
Your unmarried dependent children are eligible until the end of the month in which they reach age 19. This includes your natural children, legally adopted children, including children in a waiting period prior to finalization of adoption, and your dependent stepchildren. Other children who reside permanently with you in your household who are chiefly dependent on you for support and for whom you have assumed legal responsibility in place of the parent are also eligible.
Your child age 19 or over who is a full-time student
Your unmarried dependent children who are age 19 or over, but under age 25 are eligible if they are full-time students at an accredited secondary or preparatory school, college or other educational institution which grants a degree or diploma. They must also not be otherwise eligible for employer group coverage. They continue to be eligible until the first of the following dates: the end of the third month following the month in which they complete course requirements for graduation, or the end of the month in which they reach age 25. For children other than your natural children, legally adopted children or dependent stepchildren, supported by you, as described in the previous paragraphs, must have commenced before the child reached age 19.
If your child reaches age 19 during a school vacation period, coverage will continue, as long as the child is enrolled in an accredited secondary or preparatory school or college or other accredited educational institution and plans to resume classes on a full-time basis at the end of the vacation period. Proof of enrollment for the upcoming semester will be required.
Students age 19 or over who want to continue dental insurance during the summer must be enrolled as full-time students for the fall semester. If a child is not enrolled in a school for the fall semester, coverage will terminate on the last day of the month in which the child was a full-time student. To be eligible for COBRA the child must apply for coverage within 60 days of the termination date by contacting the New York State Department of Civil Service, Employee Benefits Division.
If a dependent child age 19 or over is seeking admission to a school over the summer, the child should enroll for COBRA coverage. If the child later enrolls in school for the fall semester, COBRA payments will be refunded and dependent student status will be retroactively reinstated.
If the enrollee informs the New York State Department of Civil Service Employee Benefits Division that a dependent who enrolled in school for the fall semester will not return to school, group dental coverage for that dependent will terminate at the end of the month in which the decision is made.
When an enrollee applies for dependent student coverage for a dependent child who is not currently a student, coverage will begin on the first day of the month in which attendance in class actually starts.
When a dependent student withdraws from school after classes have begun for the semester, coverage will end on the last day of the month in which the dependent attended classes as a full-time student.
If a dependent child who is enrolled as a full-time student voluntarily drops a course and becomes a part-time student, coverage will end on the last day of the month in which the dependent child was considered a full-time student. If a dependent child becomes a part-time student because the school has canceled a course and the dependent child cannot register in another course to continue full-time status, coverage as a dependent student will continue through that semester as if the dependent child was a full-time student.
Certain students completing graduation requirements
Your unmarried dependent children who are age 19 or over, but under age 25 who need less than a full-time course load to satisfy requirements for graduation may also be eligible. They must:
- Otherwise qualify.
- Have been a full-time student in the term immediately preceding the semester or trimester in which course requirements will be completed.
- Be able to provide a statement from their school or college administrator which verifies the student's status. They continue to be eligible for up to three months after the end of the month in which they complete course requirements for graduation. A dependent child may be granted a second semester of coverage during part-time attendance if there are unusual, extenuating circumstances, which, through no fault of the student, prevent that student's timely graduation. Requests for this continued coverage must be submitted in writing to:
NYS Department of Civil Service
Employee Benefits Division
Program Services Unit
Alfred E. Smith State Office Building
Albany, N.Y. 12239
Medical leave for students age 19 or over
If your dependent child is granted a medical leave by the school, dental insurance coverage will continue for a maximum of one year from the month in which the student withdraws from classes, plus any time before the start of the next regular semester. You must be able to provide written documentation from the school and doctor.
For purposes of eligibility for dental insurance coverage as a student dependent, you may deduct from your dependent's age up to four years for service in a branch of the U.S. Military.
Your unmarried dependent children age 19 or over who are incapable of supporting themselves because of a mental or physical disability acquired before termination of their eligibility for dental insurance are eligible.
If you have a child who qualifies for coverage as a disabled dependent, you must provide medical documentation. If you anticipate eligibility on this basis, you must file a PS-451, Statement of Disability. Contact your Agency Health Benefits Administrator (HBA) several months before your child's 19th birthday.
If your child is covered as a full-time student between the ages of 19 and 25, and becomes disabled while in that status, you will need to file a PS-451, Statement of Disability with your Agency Health Benefits Administrator at the time the disability occurs.
If you have any questions concerning eligibility, please contact your Agency Health Benefits Administrator who is usually located in your Personnel Office.
Enrollment And Effective Dates Of Coverage
How to enroll
You must have completed 56 calendar days of continuous employment to be eligible for coverage in the Preferred Dental Plan. Your Agency Health Benefits Administrator will give you an enrollment form (PS-404). The form should be completed by you and returned directly to your HBA so that you and your eligible dependents can be added to GHI's enrollment file. GHI will mail identification cards to your home.
When coverage begins
If you are a new employee eligible for coverage, your coverage will begin on the first day after you have completed 56 calendar days of continuous employment. Newly eligible employees have the same 56-day waiting period. ("Newly eligible employees" are employees who are not eligible for coverage under the GHI Preferred Dental Plan when they are hired, but become eligible later. For example, their work schedule increases from 30 percent to 50 percent). However, you may have satisfied the 56-day period of employment while you were working in a non-eligible position. [In this event, your effective date is the first day following the date you were employed in an eligible position.]
No coverage during waiting period
Dental expenses incurred or services rendered during your waiting period will not be covered. Be sure to keep any other insurance you may have, if possible, to cover dental expenses until your GHI Preferred Dental coverage becomes effective.
Termination Of Coverage
Your eligibility to participate in the Plan will cease 28 days after the last day of the last payperiod in which you are separated from active state service, or are transferred out of a position for which this plan has been negotiated or administratively extended. In the event of your death, your dependents' coverage will end 28 days after the last day of your last payperiod worked.
If you wish to continue coverage, you or your dependent may elect COBRA within the required period or convert to a GHI direct payment dental plan. (See COBRA).
How Changes In Your Status Affect Coverage
Special circumstances, such as changes in your payroll status, may affect your enrollment. You need to make sure that you continue to be eligible for dental insurance coverage. Consult your Agency Health Benefits Administrator when your work or payroll status changes.
Leave without pay: continuing coverage when on leave
If you are on authorized Leave Without Pay, or otherwise leave the payroll temporarily, you may be eligible to continue your dental insurance coverage.
Coverage not automatic
Coverage while you are on leave is not automatic. You must arrange for coverage with your Agency Health Benefits Administrator before you go on leave. If you are going on leave because of military duty, special provisions may apply. Please contact your Agency Health Benefits Administrator for more information.
To continue your dental insurance coverage while on leave without pay, you must pay the full share premium. Your Agency Health Benefits Administrator will notify you of the cost for your coverage. After you enroll, the New York State Department of Civil Service Employee Benefits Division will bill you on a monthly basis for your dental insurance premiums.
If you do not choose to continue coverage or do not pay your premium, your coverage will end 28 days after the last day of the last payperiod in which you were placed on leave without pay.
Coverage may not be reinstated until you return to the payroll. If your coverage was canceled while you were on leave, you may re-enroll when you return to work, provided you still meet the eligibility requirements. Contact your Agency Health Benefits Administrator to reactivate your coverage. Your coverage will begin on the first day of the month in which you return to work.
If you are laid off, you may be eligible under COBRA to apply for continuation of coverage for up to 18 months, or up to 29 months if you are totally disabled (See COBRA).
Please contact your Agency Health Benefits Administrator for further information regarding your eligibility to continue benefits in the event you are affected by a layoff.
If you retire, your dental benefits will end 28 days after the last day of the last payperiod worked. You will be eligible to continue dental benefits for up to 18 months or up to 29 months if you are totally disabled by enrolling in COBRA or you may enroll in the GHI Retiree Dental Plan offered to you by GHI at the time you retire. If you enroll in COBRA, you must continue coverage for the entire 18 months; then you will again have the option to convert to the Retiree Dental Plan at the end of the COBRA period.